Gait deficits and dynamic stability in children and adolescents with cerebral palsy: A systematic review and meta-analysis

Are challenging walking environments linked to falls or risk of falling in children with cerebral palsy? A systematic review

BACKGROUND

Children with cerebral palsy (CP) regularly fall over and this has negative effects on their physical and psychosocial wellbeing (e.g., reduced activity participation). However, the reasons for falls are not well understood. The way in which children negotiate challenging walking environments (e.g., uneven surfaces), may reveal more about how falls occur as these environments require gait modifications to maintain stability. Stability in challenging walking environments has been explored for children with CP; however, it remains unclear how these lead to falls.

RESEARCH QUESTION

Do challenging walking environments that mimic those faced in the real-world, contribute to increased fall occurrence and fall risk in children with CP?

METHODS

Five databases were searched, and 1386 records screened to include ambulatory children with CP, aged 5-18 years old, investigating dynamic walking in challenging environments, with outcomes of fall occurrence or fall risk. The full protocol for this review was registered on PROSPERO (CRD42021290456).

RESULTS

Sixteen studies met the inclusion criteria. One study reported occurrence of stumbles, two reported no falls. Fifteen studies identified gait alterations used by children with CP in challenging environments. Twenty-four gait characteristics were identified to be indicative of cautious walking strategies and seven gait characteristics identified to increase fall risk, suggesting a potential link. However, limited evidence exists as to whether this reflects falls faced in the real-world.

SIGNIFICANCE

Investigations into stability over challenging walking environments for children with CP are lacking any measures of fall occurrence. Investigations into the mechanisms that may contribute to high fall risk, or fall avoidance when negotiating obstacles, uneven surfaces, steep declines and stairs may reveal further causes of real-world falls, and in doing so inform future fall prevention techniques. Finally, understanding the multifaceted causes of falls in real-world challenging environments from the perspectives of children with CP is key for future research.

A continuum of balance performance between children with developmental coordination disorder, spastic cerebral palsy, and typical development

BACKGROUND

Balance deficits are one of the most common impairments in developmental coordination disorder (DCD) and cerebral palsy (CP), with shared characteristics between both groups. However, balance deficits in DCD are very heterogeneous, but unlike in CP, they are poorly understood.

AIM

To unravel the heterogeneity of balance performance in children with DCD by comparing them with CP and typical development (TD).

DESIGN

Cross-sectional case-control study.

SETTING

Different outpatient settings and the community.

POPULATION

Children aged 5-10.9 years with TD (N.=64, boys: 34, mean [SD] age: 8.1 [1.6]), DCD (N.=39, boys: 32, mean [SD] age: 8.1 [1.5], formal diagnosis [N.=27]), and CP (N.=24, boys: 14, mean [SD] age: 7.5 [1.4], GMFCS level I [N.=14]/II [N.=10], unilateral [N.=13]/bilateral [N.=11]).

METHODS

We evaluated balance performance with the extended version of the Kids-Balance Evaluation Systems Test (Kids-BESTest). Between-group differences in domain and total scores (%) were assessed via ANCOVA (covariate: age), with Tukey post-hoc analyses (P≤0.01).

RESULTS

Children with DCD and CP performed poorer than TD children on total and domain scores with large effects (domains: η2=0.25-0.66 [P<0.001], total: η2=0.71 [P<0.001]). Still, post hoc comparisons revealed that DCD children scored significantly better than CP on the total score and four domains (P≤0.009), while performing similarly on tasks related to stability limits (P=0.999) and gait stability (P=0.012).

CONCLUSIONS

There is a continuum of balance performance between children with TD, DCD and CP, but with great inter- and intra-individual heterogeneity in DCD and CP. DCD and CP children have difficulties with tasks requiring anticipatory postural adjustments, fast reactive responses, and with tasks that require complex sensory integration, suggesting an internal modeling deficit in both groups. This implies that these children must rely on slow conscious feedback-based control rather than fast feedforward control and fast automatic feedback. The performance of both DCD and CP children on their stability limits/verticality is similarly poor which further emphasizes a potential deficit in their sensory input and/or integration. Future research must focus on unraveling the control mechanisms, to further understand the heterogeneity of these balance deficits.

CLINICAL REHABILITATION IMPACT

The heterogeneous balance performances in both children with DCD and CP underscore the importance of comprehensively evaluating balance deficits in both groups. This comprehensive assessment contributes to a better understanding of individual balance deficits, thereby facilitating more tailored treatment programs.

Effects of interval treadmill training on spatiotemporal parameters in children with cerebral palsy: A machine learning approach

Quantifying individualized rehabilitation responses and optimizing therapy for each person is challenging. For interventions like treadmill training, there are multiple parameters, such as speed or incline, that can be adjusted throughout sessions. This study evaluates if causal modeling and Bayesian Additive Regression Trees (BART) can be used to accurately track the direct effects of treadmill training on gait. We developed a Directed Acyclic Graph (DAG) to specify the assumed relationship between training input parameters and spatiotemporal outcomes during Short Burst Locomotor Treadmill Training (SBLTT), a therapy designed specifically for children with cerebral palsy (CP). We evaluated outcomes after 24 sessions of SBLTT for simulated datasets of 150 virtual participants and experimental data from four children with CP, ages 4-13 years old. Individual BART models were created from treadmill data of each step. Simulated datasets demonstrated that BART could accurately identify specified responses to training, including strong correlations for step length progression (R2 = 0.73) and plateaus (R2 = 0.87). Model fit was stronger for participants with less step-to-step variability but did not impact model accuracy. For experimental data, participants' step lengths increased by 26 ± 13% after 24 sessions. Using BART to control for speed or incline, we found that step length increased for three participants (direct effect: 13.5 ± 4.5%), while one participant decreased step length (-11.6%). SBLTT had minimal effects on step length asymmetry and step width. Tools such as BART can leverage step-by-step data collected during training for researchers and clinicians to monitor progression, optimize rehabilitation protocols, and inform the causal mechanisms driving individual responses.

Motor function and gait decline in individuals with cerebral palsy during adulthood: a narrative review of potential physiological determinants

Cerebral palsy (CP) is the most common childhood-onset disability. The evolution of gait according to severity is well known amongst children and thought to peak between 8 and 12 years of age among those walking without assistive devices. However, among adults, clinical experience as well as scientific studies report, through clinical assessments, questionnaires and interviews, increasing walking difficulties leading to an increased dependency of assistive devices in everyday ambulation. For many individuals with CP, this change will occur around 30-40 years, with the risk of losing mobility increasing with age. This narrative review aims to first provide objective evidence of motor function and gait decline in adults with CP when ageing, and then to offer mechanistic hypotheses to explain those alterations. Many studies have compared individuals with CP to the typically developing population, yet the evolution with ageing has largely been understudied. Comorbid diagnoses comprise one of the potential determinants of motor function and gait decline with ageing in people with CP, with the first manifestations happening at an early age and worsening with ageing. Similarly, ageing appears to cause alterations to the neuromuscular and cardiovascular systems at an earlier age than their typically developing (TD) peers. Future studies should, however, try to better understand how the physiological particularities of CP change with ageing that could pave the way for better strategies for maintaining function and quality of life in people with CP.

The FeetMe® Insoles System: Repeatability, Standard Error of Measure, and Responsiveness

BACKGROUND

Three-dimensional motion analysis using optoelectronic cameras and force platforms is typically used to quantify gait disorders. However, these systems have various limitations, particularly when assessing patients in an ecological environment. To address these limitations, several wearable devices have been developed. However, few studies have reported metrological information regarding their repeatability and sensitivity to change.

METHODS

A healthy adult performed 6 min walking tests with FeetMe® system insoles under different walking conditions overground and on a treadmill. The standard error of measurement (SEM), the minimum detectable differences (MDDs), and the effect size (ES) were calculated for spatio-temporal parameters, and the ground reaction force was calculated from the 16,000 steps recorded.

RESULTS

SEM values were below 3.9% for the ground reaction force and below 6.8% for spatio-temporal parameters. ES values were predominantly high, with 72.9% of cases between overground and treadmill conditions with induced asymmetry, and 64.5% of cases between treadmill conditions with and without induced asymmetry exhibiting an ES greater than 1.2. The minimum detectable differences ranged from 4.5% to 10.7% for ground reaction forces and 2.1% to 18.9% for spatio-temporal parameters.

CONCLUSION

Our study demonstrated that the FeetMe® system is a reliable solution. The sensitivity to change showed that these instrumented insoles can effectively reflect patient asymmetry and progress.

Neural Correlates of Mobility in Children with Cerebral Palsy: A Systematic Review

Recent advances in brain mapping tools have enabled the study of brain activity during functional tasks, revealing neuroplasticity after early brain injuries and resulting from rehabilitation. Understanding the neural correlates of mobility limitations is crucial for treating individuals with cerebral palsy (CP). The aim is to summarize the neural correlates of mobility in children with CP and to describe the brain mapping methods that have been utilized in the existing literature. This systematic review was conducted based on PRISMA guidelines and was registered on PROSPERO (n° CRD42021240296). The literature search was conducted in the PubMed and Embase databases. Observational studies involving participants with CP, with a mean age of up to 18 years, that utilized brain mapping techniques and correlated these with mobility outcomes were included. The results were analyzed in terms of sample characteristics, brain mapping methods, mobility measures, and main results. The risk of bias was evaluated using a checklist previously created by our research group, based on STROBE guidelines, the Cochrane Handbook, and the Critical Appraisal Skills Programme (CASP). A total of 15 studies comprising 313 children with CP and 229 with typical development using both static and mobile techniques met the inclusion criteria. The studies indicate that children"with'CP have increased cerebral activity and higher variability in brain reorganization during mobility activities, such as gait, quiet standing, cycling, and gross motor tasks when compared with children with typical development. Altered brain activity and reorganization underline the importance of conducting more studies to investigate the neural correlates during mobility activities in children with CP. Such information could guide neurorehabilitation strategies targeting brain neuroplasticity for functional gains.

The efficacy of 3D gait analysis to evaluate surgical (and rehabilitation) outcome after degenerative lumbar surgery

BACKGROUND

Lumbar degenerative conditions are a major cause of back pain and disability in individuals aged 45 and above. Gait analysis utilizes sensor technology to collect movement data, aiding in the evaluation of various gait aspects like spatiotemporal parameters, joint angles, neuromuscular activity, and joint forces. It is widely used in conditions such as cerebral palsy and knee osteoarthritis. This research aims to assess the effectiveness of 3D gait analysis in evaluating surgical outcomes and postoperative rehabilitation for lumbar degenerative disorders.

METHODS

A prospective self-controlled before-after study (n = 85) carried out at our Hospital (Sep 2018 - Dec 2021) utilized a 3D motion analysis system to analyze gait in patients with lumbar degenerative diseases. The study focused on the multifidus muscle, a crucial spinal muscle, during a minimally invasive lumbar interbody fusion surgery conducted by Shandong Weigao Pharmaceutical Co., Ltd. Pre- and postoperative assessments included time-distance parameters (gait speed, stride frequency, stride length, stance phase), hip flexion angle, and stride angle. Changes in 3D gait parameters post-surgery and during rehabilitation were examined. Pearson correlation coefficient was employed to assess relationships with the visual analog pain scale (VAS), Oswestry Disability Index (ODI), and Japanese Orthopedic Association (JOA) scores. Patient sagittal alignment was evaluated using "Surgimap" software from two types of lateral radiographs to obtain parameters like pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS), lumbar lordosis (LL), intervertebral space height (DH), posterior height of the intervertebral space (PDH) at the operative segment, and anterior height of the intervertebral space (ADH).

RESULTS

By the 6th week post-operation, significant improvements were observed in the VAS score, JOA score, and ODI score of the patients compared to preoperative values (P < 0.05), along with notable enhancements in 3D gait quantification parameters (P < 0.05). Pearson correlation analysis revealed a significant positive correlation between improvements in 3D gait quantification parameters and VAS score, JOA score, and ODI value (all P < 0.001).

CONCLUSION

3D gait analysis is a valuable tool for evaluating the efficacy of surgery and rehabilitation training in patients.

Factors associated with gait efficiency in children with cerebral palsy: association between gait abnormality and balance ability

[Purpose] Children with cerebral palsy require more gait energy than healthy children. The association between gait abnormalities and gait efficiency remains unclear. We investigated the association between gait abnormalities, balance, and maximum step length to determine contributors to gait efficiency in children with cerebral palsy. [Participants and Methods] The study included 33 patients with cerebral palsy, who could walk without the use of walking aids. All participants were instructed to walk for 6 min, and the Total Heart Beat Index was calculated as a measure of walking efficiency. The Edinburgh Visual Gait Score was used to assess gait abnormalities. Additionally, the maximum step length was recorded, and all participants performed the Berg Balance Scale. Correlation analysis and stepwise multiple regression analysis were used to confirm the association between the aforementioned parameters and the Total Heart Beat Index. [Results] The Edinburgh Visual Gait Score was correlated with the heel lift during the stance, knee position during the terminal swing of gait as factors associated with the Total Heartbeat Index. The Berg Balance Scale was correlated with turning 360°, standing with feet together. [Conclusion] Our findings emphasize the need for treatment strategies focused on gait abnormalities and balance.

Effects of tai chi on postural balance and quality of life among the elderly with gait disorders: A systematic review

BACKGROUND

Tai Chi is good for improving the physical fitness of older adults. But few studies have reported the effects of Tai Chi on the postural balance and quality of life of older adults with gait disorders.

OBJECTIVE

This review aimed to assess the influence of tai chi on postural stability and quality of life in older adults with abnormal gait.

METHOD

According to the literature retrieval principles, the works published from the inception date to May 2023 were retrieved, including the following databases: PubMed, Scopus, Web of Science, China National Knowledge Infrastructure, EBSCOhost, and Google Scholar. Subsequently, literature screening and quality assessment were performed.

RESULTS

A total of 16 randomized controlled trials were included in this study, Tai Chi intervention can affect populations with Parkinson's disease (PD), no exercise, mild cognitive impairment (MCI), chronic stroke, sedentary, fear of falling, or history of falling. Postural instability is associated with balance, gait, the Unified Parkinson's Disease Rating Scale Motor Subscale 3 (UPDRS III), mobility, lower body strength, and falls. Only two articles looked at quality of life. The Yang style is the most commonly used in the intervention. Nonetheless, most studies were performed on female participants, hence, more research on older male populations is needed.

CONCLUSION

Tai Chi intervention benefits postural balance in patients with gait disorders. 12 weeks is the most common intervention period for patients with gait disorders. The frequency of intervention is seven articles twice a week, and the intervention time is about 60 minutes. The Tai Chi intervention methods in this study involve Yang Style, Sun Style, Taoist Tai Chi, and Health Qigong Tai Chi, but the Yang Style Tai Chi intervention is the most widely used.

Evidence-based management and motor rehabilitation of cerebral palsy children and adolescents: a systematic review

Background

Evidence regarding the management of several aspects of cerebral palsy improved in recent years. Still, discrepancies are reported in clinical practice. Italian professionals and stakeholders expressed the need of setting up updated, evidenced-based, shared statements, to address clinical practice in cerebral palsy rehabilitation. The objective of the present study was to provide an updated overview of the state of knowledge, regarding the management and motor rehabilitation of children and young people with cerebral palsy, as the framework to develop evidence-based recommendations on this topic.

Methods

Guidelines and systematic reviews were searched, relative to evidence-based management and motor treatment, aimed at improving gross motor and manual function and activities, in subjects with cerebral palsy, aged 2-18 years. A systematic search according to the Patients Intervention Control Outcome framework was executed on multiple sites. Independent evaluators provided selection and quality assessment of the studies and extraction of data.

Results

Four guidelines, 43 systematic reviews, and three primary studies were included. Agreement among guidelines was reported relative to the general requirements of management and motor treatment. Considering the subject's multidimensional profile, age and developmentally appropriate activities were recommended to set individual goals and interventions. Only a few approaches were supported by high-level evidence (i.e., bimanual therapy and constraint-induced movement therapy to enhance manual performance). Several task-specific active approaches, to improve gross motor function and gait, were reported (mobility and gait training, cycling, backward gait, and treadmill), based on low-level evidence. Increasing daily physical activity and countering sedentary behavior were advised. Based on the available evidence, non-invasive brain stimulation, virtual reality, action-observation therapy, hydrotherapy, and hippotherapy might be complementary to task or goal-oriented physical therapy programs.

Conclusion

A multiple-disciplinary family-centered evidence-based management is recommended. All motor rehabilitation approaches to minors affected by cerebral palsy must share the following fundamental characteristics: engaging active involvement of the subject, individualized, age and developmentally appropriate, goal-directed, skill-based, and preferably intensive and time-limited, but suitable for the needs and preferences of the child or young person and their family, and feasible considering the implications for themselves and possible contextual limitations.

The effect of walking with reduced trunk motion on dynamic stability in healthy adults

BACKGROUND

Most people with Parkinson's disease (PD) walk with a smaller mediolateral base of support (BoS) compared to healthy people, but the underlying mechanisms remain unknown. Reduced trunk motion in people with PD might be related to this narrow-based gait. Here, we study the relationship between trunk motion and narrow-based gait in healthy adults. According to the extrapolated center of mass (XCoM) concept, a decrease in mediolateral XCoM excursion would require a smaller mediolateral BoS to maintain a constant margin of stability (MoS) and remain stable.

RESEARCH QUESTION

As proof of principle, we assessed whether walking with reduced trunk motion results in a smaller step width in healthy adults, without altering the mediolateral MoS.

METHODS

Fifteen healthy adults walked on a treadmill at preferred comfortable walking speed in two conditions. First, the 'regular walking' condition without any instructions, and second, the 'reduced trunk motion' condition with the instruction: 'Keep your trunk as still as possible'. Treadmill speed was kept the same in the two conditions. Trunk kinematics, step width, mediolateral XCoM excursion and mediolateral MoS were calculated and compared between the two conditions.

RESULTS

Walking with the instruction to keep the trunk still significantly reduced trunk kinematics. Walking with reduced trunk motion resulted in significant decreases in step width and mediolateral XCoM excursion, but not in the mediolateral MoS. Furthermore, step width and mediolateral XCoM excursion were strongly correlated during both conditions (r = 0.887 and r = 0.934).

SIGNIFICANCE

This study shows that walking with reduced trunk motion leads to a gait pattern with a smaller BoS in healthy adults, without altering the mediolateral MoS. Our findings indicate a strong coupling between CoM motion state and the mediolateral BoS. We expect that people with PD who walk narrow-based, have a similar mediolateral MoS as healthy people, which will be further investigated.

Efficacy of Robot-Assisted Gait Therapy Compared to Conventional Therapy or Treadmill Training in Children with Cerebral Palsy: A Systematic Review with Meta-Analysis

BACKGROUND

Motor, gait and balance disorders reduce functional capabilities for activities of daily living in children with cerebral palsy (CP). Robot-assisted gait therapy (RAGT) is being used to complement conventional therapy (CT) or treadmill therapy (TT) in CP rehabilitation. The aim of this systematic review is to assess the effect of RAGT on gait, balance and functional independence in CP children, in comparison to CT or TT.

METHODS

We have conducted a systematic review with meta-analysis. A search in PubMed Medline, Web of Science, Scopus, CINAHL, PEDro and SciELO has been conducted for articles published until October 2022. Controlled clinical trials (CCT), in which RAGT was compared to TT or CT and assessed gait speed, step and stride length, width step, walking distance, cadence, standing ability, walking, running and jumping ability, gross motor function and functional independence in children with CP, have been included. Methodological quality was assessed with the PEDro scale and the pooled effect was calculated with Cohen's Standardized Mean Difference (SMD) and its 95% Confidence Interval (95% CI).

RESULTS

A total of 15 CCTs have been included, providing data from 413 participants, with an averaged methodological quality of 5.73 ± 1.1 points in PEDro. The main findings of this review are that RAGT shows better results than CT in the post-intervention assessment for gait speed (SMD 0.56; 95% CI 0.03 to 1.1), walking distance (SMD 2; 95% CI 0.36 to 3.65) and walking, running and jumping ability (SMD 0.63; 95% CI 0.12 to 1.14).

CONCLUSIONS

This study shows that the effect of RAGT is superior to CT on gait speed, walking distance and walking, running and jumping ability in post-intervention, although no differences were found between RAGT and TT or CT for the remaining variables.

Effectiveness of virtual reality on functional mobility during treadmill training in children with cerebral palsy: a single-blind, two-arm parallel group randomised clinical trial (VirtWalkCP Project)

INTRODUCTION

Treadmill training and virtual reality have been investigated in children with cerebral palsy. However, few studies have assessed the effectiveness of the combination of both treatments on children's functional and balance activities. The project aims to compare the effects of treadmill training with and without virtual reality on walking endurance and speed, static and dynamic balance, gross motor function, functional independence, quality of life and occupational participation in children with spastic cerebral palsy between the ages of 4 and 12 years classified at levels I, II and III of the Gross Motor Function Classification System.

METHODS AND ANALYSIS

This study is a single-blind, two-arm parallel group, randomised, controlled clinical trial. Participants will be recruited at the Pediatric Department of the Vic Hospital Consortium, and the research will be conducted at the University of Vic - Central University of Catalonia. The participants will be randomly allocated into two groups: (1) the experimental group, which will receive the treadmill training at the same time as the virtual reality; and (2) the control group, which will undertake treadmill gait training alone. The training will be provided in 10 sessions over 2 weeks with 30 min for each session. Assessments will be performed on three occasions: 1 week before the intervention, 1 week following the intervention and 1 month after the end of the intervention. The evaluations will involve the 6 min walk test, stabilometry, the Berg Balance Scale, the 10 m walk test, the Gross Motor Function Measure, the Functional Independence Measure, the paediatric quality of life inventory and the Children Participation Questionnaire. For between-within group comparison, a mixed-effect linear model will be used.

ETHICS AND DISSEMINATION

The study has been approved by the Clinical Research Ethics Committee of the Osona Foundation for Health Research and Education (2021061). Results will be published in peer-reviewed journals and presented at international conferences.

TRIAL REGISTRATION NUMBER

NCT05131724.

Effect of Functional Electrical Stimulation on Gait Parameters in Children with Cerebral Palsy: A Meta-Analysis

Objective

At present, there are controversies on the effectiveness of functional electrical stimulation devices in gait improvement in the clinic, and the results reported in limited literature are contradictory. This paper summarizes and analyzes the relationship between functional electrical stimulation treatment and gait parameter changes in children with cerebral palsy, thus exploring the above controversies' results.

Methods

Two researchers conducted a detailed search of the literature from the establishment of the database to June 2022. Literature retrieved from databases, including PubMed, Embase, Ovid, Cochrane Library, and Web of Science and the search process followed the principles of Cochrane. The search keywords were “cerebral palsy”, “functional electrical stimulation”, “gait”, or “walk”. Gait and balance parameters were extracted from the literature. Gait parameters, such as walking speed and step length, were included in the meta-analysis. The study used standard mean difference (STD) and 95% confidence interval (CI) to calculate the mean difference between the two groups. The statistic I² was used to evaluate the heterogeneity between the evaluation studies. Begg's test detected publication bias and the funnel chart was used for visual analysis. Furthermore, Review Manager software was used to make a risk bias map for literature publication bias analysis.

Results

9 literatures were included in the analysis, with a total of 282 children with cerebral palsy, including 142 patients in the functional electrical stimulation treatment group and 140 patients in the comfort treatment, general nursing, or other physical therapy. The randomization scheme and result report used in most studies were low risk, which was important for the credibility of this study. Most studies have limitations in the blinding method of participants and subjects, and most of them were single-blind studies, which might have a high risk. The results showed that functional electrical stimulation could increase the walking speed of children with cerebral palsy (SMD = 0.82, P < 0.0001) and increase the walking step length of children with cerebral palsy (SMD = 1.34, 95%CI = 1.07, 1.60, Z = 9.91, P < 0.0001). Funnel plot analysis showed that the literature distribution was uniform and symmetrical, and Begg's test showed no publication bias in included literature.

Conclusion

This study compared the effects of the functional nerve stimulation treatment group and control group on improving gait parameters of children with cerebral palsy. The results indicated that functional nerve stimulation treatment could increase the gait speed and step length of children with cerebral palsy, which could improve the walking of children with cerebral palsy. Furthermore, this study needs more research data to support our findings. The results of this study might better guide the clinical practice and better use of health as well as financial resources.

Reliability and discriminant validity of the quantitative timed up and go in typically developing children and children with cerebral palsy GMFCS levels I-II

PURPOSE

The purpose of this study was to examine the reliability, and discriminant validity of the Quantitative Timed up and Go (QTUG) in typically developing (TD) children and children with cerebral palsy (CP).

METHODS

Twenty-eight TD children and 8 with CP (GMFCS I-II) completed 3 TUG trials while wearing QTUG sensors. Test-retest reliability and discriminative ability were examined for the 57 constituent parameters of the TUG. Relationships between age and these parameters were also examined.

RESULTS

Forty-four of the parameters demonstrated moderate to excellent test-retest reliability, with measures of angular velocity being the most reliable. Twenty-six parameters were different between TD children and those with CP, and twenty-eight gait parameters demonstrated correlations with age, further supporting its discriminative ability.

CONCLUSION

The QTUG is a clinically feasible tool that is capable of both reliably measuring and discriminating many of the movement parameters with the TUG mobility task in TD children and those with CP GMFCS I-II. The results of the present study provide preliminary evidence that the QTUG can discriminate between children on several of the gait parameters within the TUG.

Effects of Dynamic Suit Orthoses on the Spatio-Temporal Gait Parameters in Children with Cerebral Palsy: A Systematic Review

Dynamic suit orthoses (DSO) are currently used as a complementary treatment method in children with Cerebral Palsy (cwCP). The aim of this review was to assess the effects of interventions with DSO on the altered spatio-temporal gait parameters (STGPs) in cwCP. An electronic search was conducted in the Web of Science, Scopus, PEDro, Cochrane Library, MEDLINE/PubMed, and CINAHL databases up to July 2021. We included a total of 12 studies, which showed great heterogeneity in terms of design type, sample size, and intervention performed (two employed a Therasuit, three employed the Adeli suit, three employed Theratogs, one employed elastomeric tissue dynamic orthosis, one employed a full-body suit, one employed external belt orthosis, and one employed dynamic orthosis composed of trousers and T-shirt). The Cochrane collaboration’s tool and the Checklist for Measuring Study Quality were used to assess the risk of bias and the methodological quality of the studies. It was variable according to the Checklist for Measuring Study Quality, and it oscillated between eight and 23. The studies of higher methodological quality showed significant post-intervention changes in walking speed (which is the most widely evaluated parameter), cadence, stride length, and step length symmetry. Although the evidence is limited, the intervention with DSO combined with a programme of training/physical therapy seems to have positive effects on the STGPs in cwCP, with the functional improvements that it entails. Despite the immediate effect after one session, a number of sessions between 18 and 60 is recommended to obtain optimum results. Future studies should measure all STGPs, and not only the main ones, such as gait speed, in order to draw more accurate conclusions on the functional improvement of gait after the use of this type of intervention.

Kinect V2-Based Gait Analysis for Children with Cerebral Palsy: Validity and Reliability of Spatial Margin of Stability and Spatiotemporal Variables

Children with cerebral palsy (CP) have high risks of falling. It is necessary to evaluate gait stability for children with CP. In comparison to traditional motion capture techniques, the Kinect has the potential to be utilised as a cost-effective gait stability assessment tool, ensuring frequent and uninterrupted gait monitoring. To evaluate the validity and reliability of this measurement, in this study, ten children with CP performed two testing sessions, of which gait data were recorded by a Kinect V2 sensor and a referential Motion Analysis system. The margin of stability (MOS) and gait spatiotemporal metrics were examined. For the spatiotemporal parameters, intraclass correlation coefficient (ICC_2,k) values were from 0.83 to 0.99 between two devices and from 0.78 to 0.88 between two testing sessions. For the MOS outcomes, ICC_2,k values ranged from 0.42 to 0.99 between two devices and 0.28 to 0.69 between two test sessions. The Kinect V2 was able to provide valid and reliable spatiotemporal gait parameters, and it could also offer accurate outcome measures for the minimum MOS. The reliability of the Kinect V2 when assessing time-specific MOS variables was limited. The Kinect V2 shows the potential to be used as a cost-effective tool for CP gait stability assessment.

The gait is less stable in children with cerebral palsy in normal and dual-task gait compared to typically developed peers

There is limited evidence about gait stability and its alteration by concurrent motor and cognitive tasks in children with cerebral palsy (CP). We examined gait stability and how it is altered by constrained cognitive or motor task in CP and their typically developed (TD) controls. Gait kinematics were recorded using inertial-measurement units (IMU) from 18 patients with hemiplegia (13.5 ± 2.4 years), 12 with diplegia (13.0 ± 2.1 years), and 31 TD controls (13.5 ± 2.2 years) during unconstrained gait, and motor (carrying a tray) and cognitive (word naming) task constrained gait at preferred speed (~400 steps/task). Step duration, its standard deviation and refined-compound-multiscale entropy (RCME) were computed independently for vertical and resultant horizontal accelerations. Gait complexity was higher for patients with CP than TD in all tasks and directions (p < 0.001-0.01), being pronounced in vertical direction, cognitive task and for diplegic patients (p < 0.05-0.001). The gait complexity increased more (i.e. higher dual-task cost) from the unconstrained to the constrained gait in CP compared to TD (p < 0.05). Step duration was similar in all groups (p > 0.586), but its variation was higher in CP than TD (p < 0.001-0.05), and during the constrained than unconstrained gait in all groups (p < 0.01-0.001). The gait in children with CP was more complex and the dual-task cost was higher primarily for children with diplegic CP than TD during cognitive task, indicating that attentional load hinders their gait more. This raises the hypothesis that more attention and cortical resources are needed to compensate for the impaired gait in children with CP.

The effect of dual-task conditions on gait and balance performance in children with cerebral palsy: A systematic review and meta-analysis of observational studies

Dual-task conditions are commonly experienced in daily routines. The aim of the present systematic review is to investigate the effect of dual-task conditions on gait and balance performance in children with cerebral palsy (CP) and to perform meta-analyses where applicable. Five databases, "ProQuest", "PubMed", "OTSeeker", "Scopus", and "PEDro" from the incipient date of databases up to Aug 24, 2020 were searched for studies focusing on the effects of dual-task conditions on gait and balance performance in children with CP. After removing irrelevant articles and applying inclusion and exclusion criteria, nine articles were included in the present systematic review and meta-analysis. The results of the meta-analysis showed that walking speed was slower during dual-task conditions compared to single-task conditions in children with CP (WMD = -0.29 m/s, 95% CI = -0.34, -0.24, P ≤ 0.001) and walking speed decreased in children with CP during dual-task conditions in comparison with the typical development (TD) control group (WMD = -0.19 m/s, 95% CI = -0.23 to -0.15, P ≤ 0.001). The results of subgroup analysis based on the type of task indicated that adding concurrent tasks to walking degrades walking speed under varied dual-task conditions. Additionally, theoretical synthesis of the literature demonstrated that other gait and balance variables are changed by performing cognitive and motor secondary tasks differently. Although these changes may be compensatory strategies to retain their stability, there was not sufficient evidence to reach a firm conclusion. Research gaps and recommendations for future studies are discussed.

Automatic Diagnosis of Cerebral Palsy Gait Using Computational Intelligence Techniques: A Low-Cost Multi-Sensor Approach

Automatic diagnosing of Cerebral Palsy (CP) gait is crucial in quantitative evaluation of a therapeutic intervention. Existing systems for such gait assessment are expensive and require user intervention. This study proposes a low-cost gait assessment system equipped with multiple Kinect sensors. Forty subjects (20 CP patients and 20 normal) were recruited for the experiment. To remove outlier frames from the combined gait signal of multiple sensors a data driven algorithm was proposed. Different supervised classifiers along with extreme learning machine were investigated to diagnose CP gait. In addition, a feature level analysis was also performed. Several spatio-temporal features (i.e. step length, stride length, stride time, etc.) were extracted. The strength of walking ratio, a speed invariant feature, to detect CP gait was thoroughly analyzed. The proposed system outperformed state-of-the-art with ≈98% of accuracy (sensitivity: 100%, and specificity: 96.87%). Results indicate a substantial improvement in abnormality detection performance after outlier removal. Based on ReliefF feature ranking algorithm, walking ratio ranked the best among other classical gait features. Performance of all classifiers increased substantially using walking ratio as a feature. Extreme learning machine demonstrated a competing performance in all cases. The higher classification accuracy of this low-cost system using only a single feature makes it attractive for CP gait detection.

Modified desk height helps children with cerebral palsy perform sit-to-stand

Aim: Children with cerebral palsy (CP) have difficulties performing activities that require the use of fundamental motor skills such as sit-to-stand (STS). In this study, we used a height adjustable chair and desk to investigate the role of desk support in STS and how it might benefit children with CP. Methods: Seventeen typically developing children (TDC), average age = 9.7 years, and 28 children with CP (Gross Motor Function Classification System [GMFCS] I and II), average age = 10.3 years, participated in the test. Elapsed time and body sway were measured using a pressure mat and load cell while each child performed a STS task. Two different desk heights were tested for time consumption and sway under the condition of hands-on-desk and arms-crossed. Results: We found that the elapsed time of hands-on-desk with the elbow flexion height was the shortest (p < 0.05). Sway amount was also significantly reduced for all children when they used the table for STS (p < 0.05). Conclusion: Results of this study may be a useful reference in rehabilitation training and designing a desk height beneficial for children with CP.Implications for RehabilitationBetter performance of sit-to-stand for a child with cerebral palsy could be made by a desk supportElapsed time during preparation period for sit-to-stand could be reduced by desk support for all CP childrenSway amount during sit-to-stand could be reduced by desk support, especially for the CP children with GMFCS level IIDesk height is an important parameter and should be studied in detail.

Gait Abnormality Detection in People with Cerebral Palsy Using an Uncertainty-Based State-Space Model

Assessment and quantification of feature uncertainty in modeling gait pattern is crucial in clinical decision making. Automatic diagnostic systems for Cerebral Palsy gait often ignored the uncertainty factor while recognizing the gait pattern. In addition, they also suffer from limited clinical interpretability. This study establishes a low-cost data acquisition set up and proposes a state-space model where the temporal evolution of gait pattern was recognized by analyzing the feature uncertainty using Dempster-Shafer theory of evidence. An attempt was also made to quantify the degree of abnormality by proposing gait deviation indexes. Results indicate that our proposed model outperformed state-of-the-art with an overall \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$87.5\%$$\end{document} of detection accuracy (sensitivity \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$80.00\%$$\end{document}, and specificity \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$100\%$$\end{document}). In a gait cycle of a Cerebral Palsy patient, first double limb support and left single limb support were observed to be affected mainly. Incorporation of feature uncertainty in quantifying the degree of abnormality is demonstrated to be promising. Larger value of feature uncertainty was observed for the patients having higher degree of abnormality. Sub-phase wise assessment of gait pattern improves the interpretability of the results which is crucial in clinical decision making.