Gait and participation outcomes in adults with cerebral palsy: a series of case studies using mixed methods

Social participation in adults with cerebral palsy: a systematic review of the evidence-base

PURPOSE

To identify and synthesise the current evidence on social participation in adults with cerebral palsy (CP).

METHODS

Four databases (PubMed, CINAHL Plus, PsycINFO, Web of Science) were systematically searched between December 2021 and February 2022. Pre-specified eligibility criteria were applied to all identified studies resulting in the inclusion of 16 articles. Data extraction was performed using a standardised tool and quality appraisal was assessed using the Mixed Methods Appraisal Tool. A narrative synthesis approach was taken for data analysis.

RESULTS

The 16 included studies were rated as high (n = 11) and medium quality (n = 5). Numbers of participants included in the studies ranged from 7 to 335. Definitions of social participation were discussed. Common themes were identified: the impact of home and work environments on social participation, the importance of age-appropriate support and interventions, and the impact of limited autonomy on social participation.

CONCLUSIONS

Adults with CP experience limited social participation due to lack of appropriate support in childhood, issues across the lifespan including physical limitations when ageing, and factors such as societal expectations and inaccessible environments which limit opportunities for autonomy. Social participation may be improved by supporting families to provide opportunities in childhood, providing timely interventions, and by enhancing autonomy.

Residual Deformity and Outcome of Ambulatory Adults With Cerebral Palsy: A Long-term Longitudinal Assessment

BACKGROUND

Advances in pediatric orthopaedic care have improved mobility and function for children with cerebral palsy (CP) as mobility declines from adolescence into adulthood. The long-term effectiveness of modern orthopaedic care is not widely reported. This study aimed to report the pediatric orthopaedic surgical burden, residual deformities, and outcomes using objective evidence of mobility in ambulatory adults with CP.

METHODS

An institutional review board-approved prospective cohort study was performed in ambulatory adults with CP between 25 and 45 years, who had an adolescent gait analysis. Orthopaedic interventions were reviewed, and adolescent and adult gait analyses were compared using paired 2-tailed t tests. Adults were categorized by the presence of no, mild, or severe residual deformities in rotation, crouch, stiff knee, equinus, and foot deformity.

RESULTS

Of 106 adults with CP, Gross Motor Function Classification System (GMFCS) distribution was grade I (22%), II (50%), III (23%), and IV (5%). Sixty-one males and 45 females were tested. The average age was 30±4 years with follow-up of 13±4 years since previous analysis; 279 surgical events (1165 procedures) were performed with a mean per patient of 2.6 events and 11 procedures. Comm on procedures were gastrocsoleus complex (88%) and hamstring lengthening (79%). The mean gait deviation index at adolescent and adult visit were 72.7±13 and 72.3±13 (P=0.78). Mean gait velocity at the adolescent visit was 85±27 and 79±31 cm/s at adult visit (P=0.02). Both gait deviation index and gait velocity change were clinically insignificant. Fifty-seven adults (81 limbs, 54%) had mild residual deformities. Residual hip internal rotation, pes planovalgus, and crouch gait were common. Severe deformities impacting function or causing pain were present in 11 participants (14 limbs, 10%). Seven of the 11 adults with severe deformities were worse compared with their adolescent evaluation; 4 were unchanged.

CONCLUSIONS

Correcting deformities before adulthood has lasting stability with little functional loss in most ambulatory young adults with CP. Increasing deformity after adolescence can occur in young adults but is uncommon.

LEVEL OF EVIDENCE

Level III.

Mobility and gait in adults with cerebral palsy: Evaluating change from adolescence

BACKGROUND

Previous studies have looked at the short-term effectiveness of conservative and surgical treatment of children with cerebral palsy (CP), but few have explored the long-term outcomes into adulthood using gait analysis and patient-reported outcome measures.

RESEARCH QUESTION

How do gait, mobility, and patient-reported outcomes in adults with CP who received specialized pediatric orthopedic care change from adolescence?

METHODS

We identified 645 adults with 1) CP, 2) age 25-45 years, and 3) an adolescent instrumented gait analysis (IGA) at our center. Measurement outcomes included physical examination, IGA, and select domains of the Patient-Reported Outcomes Measurement Information System (PROMIS).

RESULTS

Participants included 136 adults with CP; Gross Motor Function Classification System levels I (21 %), II (51 %), III (22 %), and IV (7%); 57 % males; and average age 16 ± 3/29 ± 3 years (adolescent/adult visits). There was no significant difference in gait deviation index, stride length, or gross motor function between adolescent and adult visits. There were statistically significant but not clinically meaningful declines in gait velocity. At adulthood, PROMIS results revealed limitations in physical function compared with a normative sample but no differences in depression, participation, or pain interference.

SIGNIFICANCE

In this relatively homogeneous group of adults with CP who received orthopedic care from one center, gait and gross motor function showed no clinically meaningful change from adolescence, which differs from recent reports of declining mobility in adulthood. Expert orthopedic care, guided by IGA, may prevent losses in functional mobility for adults with CP.

Determining the most effective exercise for gluteal muscle activation in children with cerebral palsy using surface electromyography

BACKGROUND

Reduced lumbo-pelvic postural control is a common feature of gait in children with Cerebral Palsy (CP). These features are commonly attributed to insufficiency of the hip musculature as well as underlying bony geometry. Exercises aimed at strengthening the hip muscles are frequently prescribed in children with Cerebral Palsy (CP). There is a lack of evidence indicating the most effective exercises in targeting gluteal muscle activation in this population.

RESEARCH QUESTION

To determine the most effective exercise for gluteal muscle activation in children with CP.

METHODS

This was a cross-sectional study of children with CP. Surface EMG data from the gluteus medius (GMed) and maximus (GMax) on the more involved limb were recorded as participants completed 6 commonly prescribed gluteal strengthening exercises. EMG was assessed for peak activation, normalised to functional reference values.

RESULTS

Data from ten children (5 males, 5 females; mean +- SD age, 13+-3 years) were included for final analysis. The single leg bridge and step up were the most effective exercises for gluteal muscle activation. Differences in activation were found to be statistically significant using Friedman's rank test (GMax p = 0.0001, GMed p = 0.0023).

SIGNIFICANCE

This study is the first to show clear differences in activation across gluteal strengthening exercises in a CP population. Exercises which involve weight bearing through a single limb appear most effective in activating the target muscles i.e the single leg bridge and the step up. Exercises involving double limb support or open-chain movements were less effective. The results of this study indicate that careful exercise selection is required to achieve targeted muscle activation in a paediatric CP population. The results of this study will provide guidance for exercise prescription for gluteal strengthening in this population and will inform future research studies on the effectiveness hip muscle strengthening programmes in CP.

Participation Patterns of Preschool Children With Intellectual Developmental Disabilities

We aim to examine the pattern of participation of children with intellectual developmental disabilities (IDD) or global developmental delay (GDD) in comparison with typically developing preschoolers. In addition, to identify environmental and personal factors associated with their participation, 20 children with mild to moderate GDD or IDD, and 24 age- and gender-matched controls, aged 3 to 6 years, were assessed using the Assessment of Preschool Children's Participation and the Environmental Restriction Questionnaire. Significant differences were found between the groups, both for general scales of participation and for each activity area. For the IDD/GDD group, participation was significantly negatively correlated with environmental restrictions at home. For the control group, participation was correlated with demographic variables. Typically developing children participate at a higher frequency and in a more diverse range of activities compared with children with IDD/GDD. Associations between participation and contextual factors varied depending on the child's health condition.

Meaningfulness of mean group results for determining the optimal motor rehabilitation program for an individual child with cerebral palsy

As research on the efficacy or effectiveness of interventions to improve motor functioning in cerebral palsy (CP) has accumulated and been incorporated into systematic reviews, the foundation for evidence-based practice in CP is growing. To determine whether an intervention is effective, clinical trials report mean group differences. However, even if a statistically significant mean group effect is found, this does not imply that this intervention was effective for each study participant or ensure positive outcomes for all with CP. A personalized approach to medical care is currently being advocated based primarily on increasingly recognized genetic variations in individual responses to medications and other therapies. A similar approach is also warranted, and perhaps more justifiable, in CP which includes a heterogeneous group of disorders. Even interventions deemed highly effective in CP demonstrate a range of individual responses along a continuum from a negative or negligible response to a strong positive effect, the bases for which remain incompletely understood. This narrative review recommends that the next critical step in advancing evidence-based practice is to implement research strategies to identify patient factors that predict treatment responses so we can not only answer the question 'what works', but also 'what works best, for whom'.