Cerebral Palsy Gait Research Articles

The Effects of Treadmill Training with Visual Feedback and Rhythmic Auditory Cue on Gait and Balance in Cerebral Palsy: A Randomized Controlled Trial

The Effects of Treadmill Training with Visual Feedback and Rhythmic Auditory Cue on Gait and Balance in Cerebral Palsy: A Randomized Controlled Trial

Machine learning approaches for predicting Ankle Dorsi Plantar Moments in Cerebral Palsy gait analysis: A comparative study

Machine learning approaches for predicting Ankle Dorsi Plantar Moments in Cerebral Palsy gait analysis: A comparative study

Collagen architecture and biomechanics of gracilis and adductor longus muscles from children with cerebral palsy.

Cerebral palsy (CP) describes some upper motoneuron disorders due to non-progressive disturbances occurring in the developing brain that cause progressive changes to muscle. While longer sarcomeres increase muscle stiffness in patients with CP compared to typically developing (TD) patients, changes in extracellular matrix (ECM) architecture can increase stiffness. Our goal was to investigate how changes in muscle and ECM architecture impact muscle stiffness, gait and joint function in CP. Gracilis and adductor longus biopsies were collected from children with CP undergoing tendon lengthening surgery for hamstring and hip adduction contractures, respectively. Gracilis biopsies were collected from TD patients undergoing anterior cruciate ligament reconstruction surgery with hamstring autograft. Muscle mechanical testing, two-photon imaging and hydroxyproline assay were performed on biopsies. Corresponding data were compared to radiographic hip displacement in CP adductors (CPA), gait kinematics in CP hamstrings (CPH), and joint range of motion in CPA and CPH. We found at matched sarcomere lengths muscle stiffness and collagen architecture were similar between TD and CP hamstrings. However, CPH stiffness (R2=0.1973), collagen content (R2=0.5099) and cross-linking (R2=0.3233) were correlated to decreased knee range of motion. Additionally, we observed collagen fibres within the muscle ECM increase alignment during muscular stretching. These data demonstrate that while ECM architecture is similar between TD and CP hamstrings, collagen fibres biomechanics are sensitive to muscle strain and may be altered at longer in vivo sarcomere lengths in CP muscle. Future studies could evaluate the impact of ECM architecture on TD and CP muscle stiffness across in vivo operating ranges. KEY POINTS: At matched sarcomere lengths, gracilis muscle mechanics and collagen architecture are similar in TD patients and patients with CP. In both TD and CP muscles, collagen fibres dynamically increase their alignment during muscle stretching. Aspects of muscle mechanics and collagen architecture are predictive of in vivo knee joint motion and radiographic hip displacement in patients with CP. Longer sarcomere lengths in CP muscle in vivo may alter collagen architecture and biomechanics to drive deficits in joint mobility and gait function.

A systematic review and meta-analysis of long-term outcomes of femoral derotation surgery for intoeing gait in cerebral palsy

BackgroundFemoral derotation osteotomy is treatment of choice in intoeing gait secondary to cerebral palsy (CP). Research questionThe aim of this study was to critically appraise the literature regarding the long-term outcomes of femoral derotation surgery in CP. MethodsElectronic databases of PubMed and Scopus was used for the literature review by two researchers independently (SB, SC). The study population included patients of cerebral palsy undergoing femoral derotation surgery. The keywords used were “cerebral palsy”, “intoeing gait”, “femur anteversion”, “hip anteversion”, “femur derotation” and “femur osteotomy”. ResultsNine studies which included 657 limbs in 407 patients were selected for this study of which eight were retrospective in nature. The improvement in hip rotation at stance at last follow up (more than five years) maintained a statistical significance (SMD 1.67 95 %CI 1.12–2.22). Similar statistically significant outcomes were noted for foot progression angle (SMD 1.19 95 %CI 0.92–1.47), anteversion (SMD 2.75 95 %CI 1.49–4.01) and total passive internal rotation (SMD 1.71 95 %CI 1.19–2.22). SignificanceFemoral derotation surgery is the procedure of choice for correction of intoeing gait in CP. Even though, there is deterioration of results on long-term as compared to short term, majority of the patients shall maintain overall correction without recurrence of an intoeing gait. Future studies with uniform criteria for defining recurrence on the basis of functional limitations shall provide better idea about the natural course of this procedure.

Wearable Sensor‐Based Multi‐modal Fusion Network for Automated Gait Dysfunction Assessment in Children with Cerebral Palsy

Gait, fundamental to human movement, becomes compromised in cerebral palsy (CP), a childhood‐onset central nervous system motor disorder. Precise assessment of patients’ gait is crucial for tailored rehabilitation interventions. Currently, clinical scales assessing CP gait dysfunction mostly, while valuable, rely on subjective clinician observations. To enhance objectivity and efficiency in CP diagnosis and rehabilitation, there is a need for more objective assessment procedures. This study introduces a multi‐modal and multi‐scale feature fusion (MMFF) framework, a new framework for automating gait dysfunction assessment in children with CP. By utilizing surface electromyography and acceleration signals recorded during children's walking, MMFF generates a feature vector enriched with adaptively refined feature maps, cross‐mode correlations, and both local and global information. Validation of MMFF's effectiveness is evident through an accomplished classification accuracy of 99.13%. The mean values for precision, recall, and F1‐score in Gross Motor Function Classification System (GMFCS)‐1, GMFCS‐2, and GMFCS‐3, reaching 99.00%, 99.00%, and 98.33%, respectively, further reflect the accuracy of functional assessments at each level. This study underscores MMFF's potential as an objective, streamlined tool for clinicians, promising improved gait assessment and well‐informed rehabilitation strategies for children with CP.

The Effect of a New Generation of Ankle Foot Orthoses on Sloped Walking in Children with Hemiplegia Using the Gait Real Time Analysis Interactive Lab (GRAIL).

Cerebral palsy poses challenges in walking, necessitating ankle foot orthoses (AFOs) for stability. Gait analysis, particularly on slopes, is crucial for effective AFO assessment. The study aimed to compare the performance of commercially available AFOs with a new sports-specific AFO in children with hemiplegic cerebral palsy and to assess the effects of varying slopes on gait. Eighteen participants, aged 6-11, with hemiplegia, underwent gait analysis using GRAIL technology. Two AFO types were tested on slopes (uphill +10 deg, downhill -5 deg, level-ground). Kinematic, kinetic, and spatiotemporal parameters were analyzed. The new AFO contributed to significant changes in ankle dorsi-plantar-flexion, foot progression, and trunk and hip rotation during downhill walking. Additionally, the new AFO had varied effects on spatiotemporal gait parameters, with an increased stride length during downhill walking. Slope variations significantly influenced the kinematics and kinetics. This study provides valuable insights into AFO effectiveness and the impact of slopes on gait in hemiplegic cerebral palsy. The findings underscore the need for personalized interventions, considering environmental factors, and enhancing clinical and research approaches for improving mobility in cerebral palsy.

Transcranial Direct Current Stimulation for Improving Spasticity, Gross Motor Functions, Balance and Gait in Spastic Cerebral Palsy: Systematic Review of Clinical Trials.

Context: Cerebral palsy is known as a non-progressive neuromotor disorder that is characterized by abnormalities of muscular tonicity, gross and fine motor skills, balance, posture and gait. Transcranial direct current stimulation (tDCS) has emerged as a rather promising therapeutic tool for the management of the above-mentioned symptoms and to possibly to optimize the rehabilitation strategies. Purpose: This review study evaluates the effectiveness of tDCS on spasticity, gross motor function, balance, and gait; it also tends to summarize the beneficial protocols of tDCS for spastic cerebral palsy patients. Methods: Comprehensive searches were performed on three electronic databases including PubMed, PEDro, and Cochrane. The inclusion criteria for considered articles were (1) English-language publications available in full text between 2000 and 2023.(2), The PEDro scale, where a score of at least 5 out of 10 was acceptable, (3) Human studies using the tDCS intervention with control group , and (4) Study design (PICOS) method, where P = spastic CP; I = transcranial direct current stimulation; C = conventional physical Therapy; O = muscle strength, spasticity, , and gait kinematics; and S = RCT. Results: Nine RCTs were included based on the inclusion criteria. This systematic review showed transcranial direct current stimulation is a non-invasive safe modality, and well-tolerated brain stimulation technique with positive effects on gross motor function, spasticity, balance, muscle strength, and gait. Besides, it can be used in conjunction with different modalities as well as conventional physical therapy. Conclusion: It can be concluded that transcranial direct current stimulation is a novel, fairly simple, low cost and low risk therapeutic modality that can be easily administered in a clinic as well as at home to produce a significant change in spasticity, balance, gross motor function, and gait.

Effect of Kinesio Taping on Posture, Balance and Gait in Spastic Cerebral Palsy – A Systematic Review

ABSTRACT Background: Cerebral palsy (CP) is a nonprogressive developmental disorder characterized by motor deficits, such as abnormal posture, balance, and gait impairments leading to deformities, affecting activities daily and, therefore, the quality of life. The application of Kinesio taping (KT) in patients with CP has emerged as a choice of adjunct treatment. Therefore the objective of this review was to evaluate the effectiveness of KT as an addition to conventional physiotherapy (CPT) interventions on posture, balance, and gait in spastic cerebral palsy. Materials and Methods: A bibliographic search was done in various databases. Only randomized controlled trials on KT in CP were included. The risk of bias in included studies was evaluated by using the RoB 2.0 tool. Downs and Black checklist was used to determine the overall quality of studies. Results: A total of five studies were eligible, out of which two studies reported a low risk of bias and three studies reported some concerns on RoB 2.0. The overall methodological quality of the studies ranged from fair to good. Out of five studies in three studies, KT was more effective as adjunct CPT than CPT alone on sitting posture, balance, and standing balance. In one study, KT was equally effective as ankle foot orthosis on gait. Lastly, one study showed a significant improvement with KT application over CPT alone, but the effects of neuromuscular electrical stimulation were more significant than KT on postural control and sitting. Conclusion: KT is a noninvasive, inexpensive, and compliant adjunct to physiotherapy in patients with spastic CP for better outcomes regarding posture, balance, and gait.

ISB clinical biomechanics award winner 2023: Medial gastrocnemius muscle and Achilles tendon interplay during gait in cerebral palsy

BackgroundThe interplay between the medial gastrocnemius muscle and the Achilles tendon is crucial for efficient walking. In cerebral palsy, muscle and tendon remodelling alters the role of contractile and elastic components. The aim was to investigate the length changes of medial gastrocnemius belly and fascicles, and Achilles tendon to understand their interplay to gait propulsion in individuals with cerebral palsy. MethodsTwelve young individuals with cerebral palsy and 12 typically developed peers were assessed during multiple gait cycles using 3D gait analysis combined with a portable ultrasound device. By mapping ultrasound image locations into the shank reference frame, the medial gastrocnemius belly, fascicle, and Achilles tendon lengths were estimated throughout the gait cycle. Participants with cerebral palsy were classified into equinus and non-equinus groups based on their sagittal ankle kinematics. FindingsIn typically developed participants, the Achilles tendon undertook most of the muscle-tendon unit lengthening during stance, whereas in individuals with cerebral palsy, this lengthening was shared between the medial gastrocnemius belly and Achilles tendon, which was more evident in the equinus group. The lengthening behaviour of the medial gastrocnemius fascicles resembled that of the Achilles tendon in cerebral palsy. InterpretationThe findings revealed similar length changes of the medial gastrocnemius fascicles and Achilles tendon, highlighting the enhanced role of the muscle in absorbing energy during stance in cerebral palsy. These results, together with the current knowledge of increased intramuscular stiffness, suggest the exploitation of intramuscular passive forces for such energy absorption.

Medial gastrocnemius and achilles tendon interplay is not optimally exploited during gait in cerebral palsy

Medial gastrocnemius and achilles tendon interplay is not optimally exploited during gait in cerebral palsy

Botulinum toxin type A for spasticity in cerebral palsy patients: Which impact on popliteal angle to hamstring length? A proof-of-concept study.

Cerebral palsy (CP) is the most common physical disability in childhood. It is a heterogeneous condition in terms of etiology, motor type and severity of impairments. Clinical impairments, such as increased muscle tone (spasticity), muscle weakness and joint stiffness contribute to the abnormal development of functional activities, including gait. The objective of this study was to investigate the popliteal angle to hamstring length after ultrasound guided Incobotulinum toxin A injections for spasticity in CP patients. In this proof-of-concept study, we included outpatients with CP and crouch gait correlated to hamstrings spasticity referred to the Pediatric Rehabilitation outpatient clinic of Umberto I University Hospital, Sapienza University of Rome, in the period between February and October 2018. Modified Ashworth Scale (MAS) of hamstring muscles, Popliteal Angle and Modified Popliteal Angle, Passive Knee Extension and 10 Meter Walk Test (10MWT) were assessed at baseline (T0) and three weeks after ultrasound guided injection (T1) of Incobotulinum Toxin A (dose weight and site dependent). Thirteen patients (5 male and 8 female), mean aged 9.91 ± 3.59, were included. The clinical evaluation at T0 showed hamstring muscles spasticity, with MAS of 2.4 ± 0.6, popliteal angle -51.7∘± 11.0∘, modified popliteal angle of -39.5∘± 11.0∘, passive knee extension of -14.0∘± 8.7∘ and 10MWT of 14.3 ± 4.6 seconds. At T1, hamstring muscles MAS mean value was 1.7 ± 0.6 (p< 0.01), popliteal angle 41.3∘± 7.0∘ (p< 0.001), modified popliteal angle -32.9∘± 10.4∘ (p< 0.001), passive knee extension -4.0∘± 4.2∘ (p< 0.05) and 10MWT 12.6 ± 4.8 seconds (p< 0.05). None of the treated patients reported any adverse event related to Incobotulinum Toxin A injection. Incobotulinum toxin A treatment has been proven to be safe and effective for hamstring muscles spasticity management in CP patients. Further studies with larger samples and longer follow-up are warranted to assess the efficacy of this treatment on the popliteal angle.

Physical Therapy Interventions in Children With Cerebral Palsy: A Systematic Review.

Cerebral palsy is a group of disorders affecting individuals already from birth. It enormously impacts an individual's physical and emotional life and can bring many challenges to the individual, caregivers, and families. Therefore, it is crucial to investigate interventions that could improve various symptoms in children with cerebral palsy. Our systematic review intends to assess the effect of different exercise and physical therapy interventions in children with cerebral palsy. We used three databases for our article search: PubMed, Medical Literature Analysis and Retrieval System Online (MEDLINE), and PubMed Central (PMC). The combined number of papers found in all databases was 65,412. We then applied our inclusion and exclusion criteria, filters, key terms, and Medical Subheadings (MeSH). After applying our quality assessment tools, we included nine papers in our systematic review. The studies included in our review used various interventions to assess for improvement in symptoms in individuals with cerebral palsy. Interventions included stretching and resistance exercises, horse riding, biking, core stability exercises, slackline training, a home exercise program using an online tool, sit-to-stand exercise program, and functional training. Many studies have shown that interventions improved symptoms like balance, coordination, gait, and cardiovascular endurance in cerebral palsy. This review suggests that some of the included interventions have great potential to improve the symptoms of cerebral palsy and, therefore, can be a great addition to existing training and rehabilitation programs. Given that studies included a relatively small number of participants and were conducted over a short time, more research with a more significant number of participants over a longer time is necessary.

A prospective assessment of gait kinematics and related clinical examination measures in cerebral palsy crouch gait.

Background While prospectively assessed crouch gait in cerebral palsy (CP) does not necessarily progress, prospective changes in clinical examination measures have not been reported. This study prospectively examined the association between selected clinical examination variables and change in crouch gait in a cohort with bilateral CP. Methods Inclusion criteria were a diagnosis of ambulant bilateral CP, knee flexion at mid-stance >19 0 and a minimum of two-years between gait analyses. The change in kinematic variables was assessed using Statistical Parameter Mapping (SPM) and changes in clinical measures using appropriate paired tests. Linear regression examined the association between progression of crouch and clinical examination variables. Results There was no mean change in crouch in 27 participants over 3.29 years. However, there was significant variability within this group. Clinical hamstring tightness (60.00 0 to 70.48 0, p<0.01) and external knee rotation during stance (SPM analysis, p<0.001) increased but there was no association between changes in clinical examination variables and changes in crouch (p-values 0.06 - 0.89). Conclusions This prospective study found no association between the changes in clinical examination variables and changes in crouch highlighting the likely multi-factorial aetiology of this gait pattern and the need for larger prospective studies. The variability crouch gait progression among the 27 participants highlights the pitfall of group mean values in such a heterogeneous population.

Rehabilitation of Gait and Balance in Cerebral Palsy: A Scoping Review on the Use of Robotics with Biomechanical Implications.

Cerebral palsy (CP) is a congenital and permanent neurological disorder due to non-progressive brain damage that affects gross motor functions, such as balance, trunk control and gait. CP gross motor impairments yield more challenging right foot placement during gait phases, as well as the correct direction of the whole-body center of mass with a stability reduction and an increase in falling and tripping. For these reasons, robotic devices, thanks to their biomechanical features, can adapt easily to CP children, allowing better motor recovery and enjoyment. In fact, physiotherapists should consider each pathological gait feature to provide the patient with the best possible rehabilitation strategy and reduce extra energy efforts and the risk of falling in children affected by CP.

Perspectives on ankle-foot technology for improving gait performance of children with Cerebral Palsy in daily-life: requirements, needs and wishes

BackgroundAnkle-foot orthoses (AFOs) are extensively used as a primary management method to assist ambulation of children with Cerebral Palsy (CP). However, there are certain barriers that hinder their prescription as well as their use as a mobility device in all kinds of daily-life activities. This exploratory research attempts to further understand the existing limitations of current AFOs to promote a better personalization of new design solutions.MethodsStakeholders’ (professionals in CP and end-users with CP) perspectives on AFO technology were collected by two online surveys. Respondents evaluated the limitations of current assistive solutions and assessment methods, provided their expectations for a new AFO design, and analyzed the importance of different design features and metrics to enrich the gait performance of these patients in daily-life. Quantitative responses were rated and compared with respect to their perceived importance. Qualitative responses were classified into themes by using content analysis.Results130 survey responses from ten countries were analyzed, 94 from professionals and 36 from end-users with CP. The most highly rated design features by both stakeholder groups were the comfort and the ease of putting on and taking off the assistive device. In general, professionals preferred new features to enrich the independence of the patient by improving gait at functional levels. End-users also considered their social acceptance and participation. Health care professionals reported a lack of confidence concerning decision-making about AFO prescription. To some degree, this may be due to the reported inconsistent understanding of the type of assistance required for each pathological gait. Thus, they indicated that more information about patients’ day-to-day walking performance would be beneficial to assess patients’ capabilities.ConclusionThis study emphasizes the importance of developing new approaches to assess and treat CP gait in daily-life situations. The stakeholders’ needs and criteria reported here may serve as insights for the design of future assistive devices and for the follow-up monitoring of these patients.

Analysis of cerebral palsy gait based on movement primitives

BackgroundCerebral palsy is the most prevalent motor disorder among children. Despite extensive studies on motor modularity of gait of children with cerebral palsy, kinematic modularity of their gait has not been addressed which is the main goal of this study. MethodsThe kinematics of the gait of 13 typical development children and 188 children with cerebral palsy was captured and analyzed, where the cerebral palsy children were grouped into True, Jump, Apparent, and Crouch. Non-negative matrix factorization method was used to extract the kinematic modulus of each group, which were then clustered to find their characteristic movement primitives. The movement primitives of groups were then matched based on the similarity of their activation profiles. FindingsThe number of movement primitives was three for the Crouch group, four for the other cerebral palsy groups, and five for the typical development group. Compared to the typical development children, the kinematic modules and activations of the cerebral palsy groups involved higher variability and co-activation, respectively (P < 0.05). Three temporally matched movement primitives were shared by all groups, but with altered structures. InterpretationThe gait of children with cerebral palsy involved lower complexity and higher variability due to the reduced and inconsistent kinematic modularity. Three basic movement primitives were sufficient to prodcue the overall gait kinematics, as observed in the Crouch group. Other movement primitives, were responsible for providing smooth transitions between basic movement primitives, as seen in more complex gait patterns.

The Complex Relationship between Gait and Balance in Cerebral Palsy

The Complex Relationship between Gait and Balance in Cerebral Palsy

Deep Learning Models for Stable Gait Prediction Applied to Exoskeleton Reference Trajectories for Children With Cerebral Palsy

Gait trajectory prediction models have several applications in exoskeleton control; they can be used as feed-forward input to low-level controllers and to generate reference/target trajectories for position-controlled exoskeletons. In our study, we implement four deep learning models (LSTM, FCN, CNN and Transformer) that perform one-step-ahead gait trajectory prediction after training on gait patterns of typically developing children. We propose a methodology that optimises for stability in long-term forecasts, and evaluate the performance of the models on typically developing (TD) and Cerebral Palsy (CP) gait during recursive prediction of 200 time-steps in the future (which may lead to propagation of errors) and in the presence of varying levels of Gaussian noise (1%-5%). Results on TD gait show that the FCN and Transformer, with mean absolute errors (MAEs) for one-step-ahead predictions between 1.17°-1.63°, are the most suitable for the intended application. We also proposed an approach for generating adaptive trajectories that can be used as reference trajectories for position-controlled exoskeletons. Gait patterns from children with Cerebral Palsy were fed into gait trajectory prediction models trained on typically developing gait only, to generate corrective patterns. Preliminary results show that the gait patterns of typically developing children were introduced onto the generated trajectories.

A prospective assessment of gait kinematics and related clinical examination measures in cerebral palsy crouch gait

Background While prospectively assessed crouch gait in cerebral palsy (CP) does not necessarily progress, prospective changes in clinical examination measures have not been reported. This study prospectively examined the association between selected clinical examination variables and change in crouch gait in a cohort with bilateral CP. Methods Inclusion criteria were a diagnosis of ambulant bilateral CP, knee flexion at mid-stance &gt;190 and a minimum of two-years between gait analyses. The change in kinematic variables was assessed using Statistical Parameter Mapping (SPM) and changes in clinical measures using appropriate paired tests. Linear regression examined the association between progression of crouch and clinical examination variables. Results There was no mean change in crouch in 27 participants over 3.29 years. However, there was significant variability within this group. Clinical hamstring tightness (60.000 to 70.480, p&lt;0.01) and external knee rotation during stance (SPM analysis, p&lt;0.001) increased but there was no association between changes in clinical examination variables and changes in crouch (p-values 0.06 - 0.89). Conclusions The variability crouch gait progression highlights the pitfall of group mean values in such a heterogeneous population. The lack of association between changes in clinical examination variables and changes in crouch highlights the multi-factorial aetiology of this gait pattern and the need for larger prospective studies.

Auditory Stimulation Improves Gait and Posture in Cerebral Palsy: A Systematic Review with Between- and Within-Group Meta-Analysis.

The past decade has seen an increased interest in the implementation of auditory stimulation (AStim) for managing gait and postural deficits in people with cerebral palsy. Although existing reviews report beneficial effects of AStim on the spatiotemporal and kinematic parameters of gait, there are still numerous limitations that need to be addressed to correctly interpret these results. For instance, existing reviews have failed to characterize the effects of AStim by conducting separate between and within-group meta-analyses, these reviews have not evaluated the influence of AStim on postural outcomes, and nor have included several high-quality existing trials. In this study, we conducted between- and within-group meta-analyses to establish a state of evidence for the influence of AStim on gait and postural outcomes in people with cerebral palsy. We searched the literature according to PRISMA-P guidelines across 10 databases. Of 1414 records, 14 studies, including a total of 325 people with cerebral palsy, met the inclusion criterion. We report a significant enhancement in gait speed, stride length, cadence, and gross motor function (standing and walking) outcomes with AStim compared to conventional physiotherapy. The findings from this analysis reveal the beneficial influence of AStim on the spatiotemporal and kinematic parameters of gait and postural stability in people with cerebral palsy. Furthermore, we discuss the futurized implementation of smart wearables that can deliver person-centred AStim rehabilitation in people with cerebral palsy.