Cerebral Palsy Gait Research Articles

Patella tendon shortening for the correction of flexed knee gait in cerebral palsy – A randomized controlled trial

Patella tendon shortening for the correction of flexed knee gait in cerebral palsy – A randomized controlled trial

Ability for stair climbing in patients with bilateral cerebral palsy and stiff gait

Ability for stair climbing in patients with bilateral cerebral palsy and stiff gait

Motorized versus manual instrumented spasticity assessment in children with cerebral palsy.

We compared the outcomes of manual and motorized instrumented ankle spasticity assessments in children with cerebral palsy (CP). Ten children with spastic CP (three males, seven females; mean age 11y [standard deviation 3y], range 6-14y; Gross Motor Function Classification System levels I-III) were included. During motorized assessments, fast (100°/s) rotations were imposed around the ankle joint by a motor-driven footplate; during manual assessments, rotations of comparable speed were applied by a therapist using a foot orthotic. Angular range of motion, maximum velocity, acceleration, work, and muscle activity (electromyography [EMG]) of the triceps surae and tibialis anterior were compared during passive muscle stretch between motorized and manual assessments. Both movement profiles were also compared to CP gait ankle movement profile. The imposed movement profile differed between methods, with the motorized assessment reaching higher maximum acceleration. Despite equal maximum velocity, the triceps surae were more often activated in motorized assessments, with low agreement of 44% to 72% (κ≤0) for EMG onset occurrence between methods. The manually applied ankle velocity profile matched more closely with the gait profile. The differences in acceleration possibly account for the different muscle responses, which may suggest acceleration, rather than velocity-dependency of the stretch reflex. Future prototypes of instrumented spasticity assessments should standardize movement profiles, preferably by developing profiles that mimic functional tasks such as walking.

“Children with cerebral palsy experience greater levels of loading at the low back during gait compared to healthy controls”

Excessive trunk motion has been shown to be characteristic of cerebral palsy (CP) gait. However, the associated demands on the lower spine are unknown. This study investigated 3-dimensional reactive forces and moments at the low back in CP children compared to healthy controls. In addition, the impact of functional level of impairment was investigated (GMFCS levels). Fifty-two children with CP (26 GMFCS I and 26 GMFCS II) and 26 controls were recruited to the study. Three-dimensional thorax kinematics and reactive forces and moments at the low back (L5/S1 spine) were examined. Discrete kinematic and kinetic parameters were assessed between groups. Thorax movement demonstrated increased range for CP children in all 3 planes while L5/S1 reactive forces and moments increased with increasing level of functional impairment. Peak reactive force data were increased by up to 57% for GMFCS I and 63% for GMFCS II children compared to controls. Peak moment data were increased by up to 21% for GMFCS II children compared to GMFCS I and up to 90% for GMFCS II compared to control. In addition, a strong correlation was demonstrated between thorax side flexion and L5/S1 lateral bend moment (r=0.519, p<0.01) and medial/lateral force (r=0.352, p<0.01). Children with CP demonstrated increased lower spinal loading compared to TD. Furthermore, GMFCS II children demonstrated significantly more involvement. Intervention should be aimed at reducing excessive thorax movement, especially in the coronal plane, in order to reduce abnormal loading on the spine in this population.

A Comparative Study on Effectiveness of Open Versus Closed Kinetic Chain Exercises to Improve Gait in Spastic Diplegic Cerebral Palsy

A Comparative Study on Effectiveness of Open Versus Closed Kinetic Chain Exercises to Improve Gait in Spastic Diplegic Cerebral Palsy

Quantitative Evaluation of the Effects of Ankle Foot Orthosis on Gait in Children with Cerebral Palsy Using the Gait Profile Score and Gait Variable Scores

Ankle foot orthoses (AFOs) are often used in children with Cerebral Palsy (CP) to facilitate and optimise their impaired gait pattern. The aim of this study was to assess quantitatively the effects of AFOs on gait in CP using a summary measure obtained by Gait Analysis (GA): the Gait Profile Score (GPS) with its Gait Variable Scores (GVSs).

Efficacy of supracondylar knee ankle foot orthosis for hyperextended knee and heel rise in spastic cerebral palsy: A pilot clinical trial

Background: Guidelines to assist with decision making for orthotic management of gait dysfunction in individual with cerebral palsy (CP) is difficult to derive and remain controversial. The research question is whether supracondylar knee ankle foot orthosis (SKAFO) is one of best options for knee hyperextension and heel rise for spastic diaplegic Cerebral palsy. Aim: The purpose of this study was to check the efficacy of bilateral molded SKAFO for knee hyperextension and heel rise for Cerebral palsy in terms of gait parameters and energy expenditure. Materials and Methods: Five individuals (mean age 3.5 years) were diagnosed as spastic diplegic and one with hemiplegic (age 5 years old) Cerebral palsy with delayed milestone presented with knee hyperextension and heel rise during mid-stance and were fitted with bilateral molded SKAFO with pair of shoes. Observational gait analysis by video recording was performed and gait parameters by 10 m walk test and energy expenditure using physiological cost index was recorded in bracing and non-bracing conditions. Results: The orthosis controlled knee hyperextension by not allowing the knee to go beyond neutral position. The gait was more natural with proper heel strike and better push off. There was improvement in temporal-spatial gait parameters and gait was energy efficient. Conclusion: The SKAFO was found to be effective in controlling knee hyperextension and resulted in stable, natural, satisfactory and energy efficient gait in spastic Cerebral palsy with knee hyperextension and heel rise. Similar study involving case series can be used to set the prognosis of ambulation and the kind of orthotic interventions needed to optimize the walking ability.

Leg and Joint Stiffness in Children with Spastic Diplegic Cerebral Palsy during Level Walking.

Individual joint deviations are often identified in the analysis of cerebral palsy (CP) gait. However, knowledge is limited as to how these deviations affect the control of the locomotor system as a whole when striving to meet the demands of walking. The current study aimed to bridge the gap by describing the control of the locomotor system in children with diplegic CP in terms of their leg stiffness, both skeletal and muscular components, and associated joint stiffness during gait. Twelve children with spastic diplegia CP and 12 healthy controls walked at a self-selected pace in a gait laboratory while their kinematic and forceplate data were measured and analyzed during loading response, mid-stance, terminal stance and pre-swing. For calculating the leg stiffness, each of the lower limbs was modeled as a non-linear spring, connecting the hip joint center and the corresponding center of pressure, with varying stiffness that was calculated as the slope (gradient) of the axial force vs. the deformation curve. The leg stiffness was further decomposed into skeletal and muscular components considering the alignment of the lower limb. The ankle, knee and hip of the limb were modeled as revolute joints with torsional springs whose stiffness was calculated as the slope of the moment vs. the angle curve of the joint. Independent t-tests were performed for between-group comparisons of all the variables. The CP group significantly decreased the leg stiffness but increased the joint stiffness during stance phase, except during terminal stance where the leg stiffness was increased. They appeared to rely more on muscular contributions to achieve the required leg stiffness, increasing the muscular demands in maintaining the body posture against collapse. Leg stiffness plays a critical role in modulating the kinematics and kinetics of the locomotor system during gait in the diplegic CP.

Kinematic differences in primary genu recurvatum gait in cerebral palsy – Early vs late onset

Kinematic differences in primary genu recurvatum gait in cerebral palsy – Early vs late onset

The role of altered proximal femoral geometry in impaired pelvis stability and hip control during CP gait: A simulation study

Children with cerebral palsy (CP) often present aberrant hip geometry, more specifically increased femoral anteversion and neck-shaft angle. Furthermore, altered gait patterns are present within this population. This study analyzed the effect of aberrant femoral geometry, as present in subjects with CP, on the ability of muscles to control hip and knee joint kinematics. Given the specific gait deficits observed during crouch gait, increased ability to abduct, externally rotate the hip and extend the knee and hip were denoted as beneficial effects. We ran dynamic simulations of CP and normal gait using two musculoskeletal models, one reflecting normal femoral geometry and one reflecting proximal femoral deformities. The results show that the combination of aberrant bone geometry and CP-specific gait characteristics beneficially increased the ability of gluteus medius and maximus to extend the hip and knee. In contrast, the potentials of the hamstrings to extend the hip decreased whereas the potentials to flex the knee increased. These changes closely followed the observed changes in the muscle moment arm lengths. In conclusion, this study emphasizes the concomitant effect of the presence of proximal femoral deformity and CP gait characteristics on the muscle control of hip and knee joint kinematics during single stance. Not accounting for subject-specific geometry will affect the calculated muscles’ potential during gait. Therefore, the use of generic models to assess muscle function in the presence of femoral deformity and CP gait should be treated with caution.

Femoral Derotation in Children with Cerebral Palsy - Does the Result Depend on the Age at Operation and the Kind of Surgery?

Patients with spastic cerebral palsy GMFCS I-III often develop gait dysfunctions. One of the most prevalent gait dysfunctions is the intoeing gait. Femoral derotation osteotomy is the common treatment for internal rotation gait in cerebral palsy. We now present 3D-gait analysis data of the hip rotation in gait before and after femoral derotation osteotomy. We analysed the influence of the age at the index operation on the risk of recurrence and the surgical technique. We included 48 patients treated with femoral derotation osteotomy during a single event of multi-level surgery. Mean hip rotation in standing was measured before and after femoral derotation osteotomy (FDO). The patients were divided into two groups of different age and in a second analysis into two groups with the osteotomy in different locations, either inter-trochanteric (DO proximal) or supracondylar (DO distal). Age at FDO and surgical technique had no influence on the results. However, the variance of the results was very high. Differences were found in the walking speed between the DO proximal and DO distal groups. The walking speed in the group of distal femoral osteotomy was higher. This difference was not significant, but there was a trend to proximal osteotomy in slower walkers. Significant improvements in IRG after FDO were found in our investigation. Our results indicate that FDO as a part of single-event multilevel surgery SEMLS provides a satisfactory mean overall correction of IRG. The results were independent of the age at the index operation and the location of the osteotomy.

Effect of Varus Rotational Osteotomy (VRO) on upper extremity motion during gait in cerebral palsy

Effect of Varus Rotational Osteotomy (VRO) on upper extremity motion during gait in cerebral palsy

Muscle weakness does not influence gait in unilateral cerebral palsy: A muscle strength and three-dimensional gait analysis study

Objective. The purpose of this cross-sectional study was to investigate muscle strength and possible influence on gait in high-functioning young individuals with unilateral cerebral palsy. Methods. Forty-four individuals with a mean age of 17.5 years (range 13.0–24.0 years) and 23 matched controls participated. Maximal voluntary isometric contraction was measured in a muscle strength chair. Maximal moments (torque) and muscle work were calculated from three-dimensional gait analysis. Results. The mean maximal voluntary isometric strength in knee extensors on the involved side was 1.56 Nm/kg, compared to 2.4 Nm/kg in the control group (p < 0.001). Plantar flexor strength was 1.29 compared to 2.30 Nm/kg (p < 0.001) and dorsiflexor strength was 0.18 compared to 0.47 Nm/kg (p < 0.001). Muscle strength did not correlate with muscle work performed during walking. The respective percentages of strength (Nm/kg) used during walking in relation to the strength chair measurements were 28% for knee extensors on the involved side, 102% for plantar flexors and 41% for dorsiflexors. The corresponding numbers in the control group were 33%, 66% and 48%. Conclusion. Muscle strength is decreased in the knee and ankle on the involved side in unilateral cerebral palsy, although this does not influence gait.

Patella lowering is effective in the treatment of crouch gait in cerebral palsy: A clinical and biomechanical retrospective comparative study

Patella lowering is effective in the treatment of crouch gait in cerebral palsy: A clinical and biomechanical retrospective comparative study

Trunk kinematics and lower lumbar spinal loading during paediatric cerebral palsy gait

The purpose of this study was to determine the contributions of strength, dorsiflexion range of motion (DFROM), plantar cutaneous sensation (PCS), and static postural control to Star Excursion Balance Test (SEBT) performance in individuals with chronic ankle instability (CAI). Forty individuals with CAI completed isometric strength, weight-bearing DFROM, PCS, static and dynamic balance assessments. Three separate backward multiple linear regression models were calculated to determine how strength, DFROM, PCS, and static postural control contributed to each reach direction of the SEBT. Explanatory variables included dorsiflexion, inversion, and eversion strength, DFROM, PCS, and time-to-boundary mean minima (TTBMM) and standard deviation (TTBSD) in the medial–lateral (ML) and anterior–posterior (AP) directions. Criterion variables included SEBT-anterior, posteromedial, and posterolateral directions. The strength of each model was determined by the R2-value and Cohen's f2 effect size. Regression models with an effect size ≥0.15 were considered clinically relevant. All three SEBT directions produced clinically relevant regression models. DFROM and PCS accounted for 16% of the variance in SEBT-anterior reach (f2 = 0.19, p = 0.04). Eversion strength and TTBMM-ML accounted for 28% of the variance in SEBT-posteromedial reach (f2 = 0.39, p < 0.01). Eversion strength and TTBSD-ML accounted for 14% of the variance in SEBT-posterolateral reach (f2 = 0.16, p = 0.06). DFROM and PCS explained a clinically relevant proportion of the variance associated with SEBT-anterior reach. Eversion strength and TTB ML explained a clinically relevant proportion of the variance in SEBT-posteromedial and posterolateral reach distances. Therefore, rehabilitation strategies should emphasize DFROM, PCS, eversion strength, and static balance to enhance dynamic postural control in patients with CAI.

Are clinical parameters sufficient to model gait patterns in patients with cerebral palsy using a multilinear approach?

The aim of this study was to evaluate whether clinical parameters are sufficient using, a multilinear regression model, to reproduce the sagittal plane joint angles (hip, knee, and ankle) in cerebral palsy gait. A total of 154 patients were included. The two legs were considered (308 observations). Thirty-six clinical parameters were used as regressors (range of motion, muscle strength, and spasticity of the lower). From the clinical gait analysis, the joint angles of the sagittal plane were selected. Results showed that clinical parameter does not provide sufficient information to recover joint angles and/or that the multilinear regression model is not an appropriate solution.

Factors associated with recurrence after femoral derotation osteotomy in cerebral palsy

Femoral derotation osteotomy (FDO) as gold standard treatment for internal rotation gait in cerebral palsy (CP) leads to satisfying short-term results, whereas rates of recurrence up to 33% are reported in long-term outcome studies. The purpose of this study was therefore to identify factors contributing to recurrence of internal rotation gait in patients with CP who were treated with FDO in childhood.70 patients (age: 10 (±3.3) years at surgery) with bilateral CP and internal rotation gait were examined pre-, one year and at least five years (mean 8±2 years) postoperatively after distal or proximal FDO, using standardized clinical examination and 3D gait-analysis. 27 patients had a good hip rotation one year postoperatively (between 5° external and 15° internal for both limbs) and were considered for the analysis of factors contributing to recurrence of internal rotation gait.Regarding all included patients both mean hip rotation and foot progression angle improved significantly (p<0.001) from pre- to postoperative. A significant deterioration in hip rotation (more involved side) (p<0.001) from one year postoperatively to the long-term follow-up can be observed. Younger age, reduced hip joint impulse, increased plantar flexion and internal foot progression angle postoperatively could be identified as factors for recurrence.FDO on average leads to a satisfactory correction of internal rotation gait. In order to improve the long-term outcome after FDO the time of multilevel surgery should be indicated as late as possible and the different factors leading to potential recurrence should be considered.

The effects of an ankle foot orthosis on cerebral palsy gait: A multiple regression analysis.

The aim of this study was twofold. Firstly, to develop a multiple regression normalization (MR) strategy to decorrelate physical properties and walking speed from spatiotemporal gait data in healthy children; and secondly, to use this MR approach to identify the effect of a solid ankle foot orthosis (AFO) on gait in children with cerebral palsy (CP). Spatiotemporal gait data during self-selected walking were obtained from 51 children with diplegic CP and 34 aged-matched healthy controls. Data were normalized using standard dimensionless equations (DS) and a MR approach. Stride length, stance time, swing time, and double support time were significantly different between children with CP and healthy controls using DS (p<;0.05); however, only stride length and swing time were significantly different when children with CP walked with and without an AFO. Normalizing gait data using DS demonstrated significant differences in cadence and step time in children with CP when wearing an AFO compared to the controls (p<;0.05). In contrast, MR normalization revealed significant differences in all spatiotemporal parameters between children with CP with and without an AFO, except double support time. After MR normalization, spatiotemporal parameters in children wearing an AFO became closer to those of the controls, except for double support time. The MR approach presented will assist in evaluating the effectiveness of conservative interventions such as AFOs in children with CP, as well as in surgery, and may be useful in gait classification using machine learning.

Muscle synergies and complexity of neuromuscular control during gait in cerebral palsy.

Individuals with cerebral palsy (CP) have impaired movement due to a brain injury near birth. Understanding how neuromuscular control is altered in CP can provide insight into pathological movement. We sought to determine if individuals with CP demonstrate reduced complexity of neuromuscular control during gait compared with unimpaired individuals and if changes in control are related to functional ability. Muscle synergies during gait were retrospectively analyzed for 633 individuals (age range 3.9-70y): 549 with CP (hemiplegia, n=122; diplegia, n=266; triplegia, n=73; quadriplegia, n=88) and 84 unimpaired individuals. Synergies were calculated using non-negative matrix factorization from surface electromyography collected during previous clinical gait analyses. Synergy complexity during gait was compared with diagnosis subtype, functional ability, and clinical examination measures. Fewer synergies were required to describe muscle activity during gait in individuals with CP compared with unimpaired individuals. Changes in synergies were related to functional impairment and clinical examination measures including selective motor control, strength, and spasticity. Individuals with CP use a simplified control strategy during gait compared with unimpaired individuals. These results were similar to synergies during walking among adult stroke survivors, suggesting similar neuromuscular control strategies between these clinical populations.

Effects of task-oriented training for Gross Motor Function Measure, balance and gait function in persons with cerebral palsy

Objective: This study was to investigate the effects of Task-oriented training for Gross Motor Function Measure (GMFM), gait and balance function in cerebral palsy. Design: Randomized controlled trials. Methods: Twenty four subjects were recruited by means of a convenience sampling from Kangseo-Gu G rehabilitation center. Subjects were 24 inpatients and were randomly divided into a task-oriented training group and a conventional group. Twelve patients were experimental group who executed the task-oriented training (5 times/wk) for 4 weeks. The task-oriented program mainly focused on the capabilities of independent walking, with the angle of inclination set at 0 degrees and walking at a self-selected comfortable speed. In addition, balance training included the one-legged standing with weight-shifting and task-oriented training. Twelve patients were control group who executed only general conventional therapy (5 times/wk) for 4 weeks. All subjects were evaluated about the motor function, gait and balance function. Subjects have conducted the measured variables, GMFM, GAITRite, PDM Multifunction Force Measuring Plate after treatment. Results: There was statistically significant increase of Gross Motor Function Measure scores of the experimental group and control group after 4 weeks (p