Lower limb functioning and its impact on quality of life in ambulatory children with cerebral palsy

Epidemiological predictors of quality of life and the role of early markers in children with cerebral palsy: A multi-centric cross-sectional study

BACKGROUND

More than 100 million children in the world have at least one type of disability. Among disabled children, approximately 25% of chronic disabilities are of neurological origin. Cerebral Palsy is the leading cause of chronic disability in children, making them not only physically and mentally handicapped but also socially aloof.

METHODS

This study was conducted among 200 eligible participants from three centers with Child Guidance or Cerebral Palsy clinics in the outpatient department. All the participants were included in the analysis of the epidemiological profile and the role of early markers. Of these, 70 participants were assessed for quality of life according to the age criteria of a pre-tested Cerebral Palsy Quality of Life questionnaire (CP-QOL).

RESULTS

Mean ± S.D. age in years was 3.7 ± 2.8. Birth history included 182 (39%) neonatal etiopathology, followed by 173 (38%) perinatal, and 106 (23%) antenatal causes. Mean ± S.D. birth weight was 2.3 ± 1.2 kg. The positive predictors of various domains of Quality of Life were an absence of any associated sensory, neurological, communication, or psychological disorder or disability. While, the negative predictors were decreasing functional capacity, involvement of number of limbs in increasing order, high therapeutic requirements, and dependency.

CONCLUSION

The association between early diagnosis of cerebral palsy and improved functional capacity, involvement of a lesser number of limbs, better quality of life, and absence of associated disabilities is established from the findings of our study.

Predicting Gait Patterns of Children With Spasticity by Simulating Hyperreflexia

Spasticity is a common impairment within pediatric neuromusculoskeletal disorders. How spasticity contributes to gait deviations is important for treatment selection. Our aim was to evaluate the pathophysiological mechanisms underlying gait deviations seen in children with spasticity, using predictive simulations. A cluster analysis was performed to extract distinct gait patterns from experimental gait data of 17 children with spasticity to be used as comparative validation data. A forward dynamic simulation framework was employed to predict gait with either velocity- or force-based hyperreflexia. This framework entailed a generic musculoskeletal model controlled by reflexes and supraspinal drive, governed by a multiobjective cost function. Hyperreflexia values were optimized to enable the simulated gait to best match experimental gait patterns. Three experimental gait patterns were extracted: (1) increased knee flexion, (2) increased ankle plantar flexion, and (3) increased knee flexion and ankle plantar flexion when compared with typical gait. Overall, velocity-based hyperreflexia outperformed force-based hyperreflexia. The first gait pattern could mostly be explained by rectus femoris and hamstrings velocity-based hyperreflexia, the second by gastrocnemius velocity-based hyperreflexia, and the third by gastrocnemius, soleus, and hamstrings velocity-based hyperreflexia. This study shows how velocity-based hyperreflexia from specific muscles contributes to different spastic gait patterns, which may help in providing targeted treatment.

Relationship between kinematic gait quality and caregiver-reported everyday mobility in children and youth with spastic Cerebral Palsy

BACKGROUND

3D gait analysis (3DGA) is a common assessment in Cerebral Palsy (CP) to quantify the extent of movement abnormalities. Yet, 3DGA is performed in laboratories and may thus be of debatable significance to everyday life.

AIM

The aim was to assess the relationship between kinematic gait abnormality and everyday mobility in ambulatory children and youth with spastic CP.

METHODS

73 paediatric and juvenile patients with uni- or bilateral spastic CP (N = 21 USCP, N = 52, BSCP, age: 4-20 y, GMFCS I-III) underwent a 3DGA, while the MobQues47 Questionnaire quantified caregiver-reported mobility. We calculated the Gait Profile Score (GPS), a metric that summarizes how far the lower limb joint angles during walking deviate from those of matched controls.

RESULTS

The GPS correlated well with indoor and outdoor mobility (rho = -0.69 and -0.70, both p < 0.001) and the relationships were not significantly different for USCP and BSCP. Still, mobility was lower in BSCP (p < 0.001) and more compromised outdoors (p = 0.002). Indoor mobility could be predicted by walking speed, GPS and age (adj. R² = 0.62). Outdoor mobility was best predicted by walking speed and GPS (adj. R² = 0.60). The additive explained variance by the GPS was even higher outdoors than indoors (17.1% vs. 11.4%).

CONCLUSIONS

Measuring movement deviations with 3DGA seems equally meaningful in uni- and bilaterally affected children and has considerable relevance for real-life ambulation, particurlarly outdoors, where children with spastic CP typically face greater difficulties. Therapeutic strategies that achieve faster walking and reduction of kinematic deviations may increase outdoor mobility.

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.

Gait stability in ambulant children with cerebral palsy during dual tasks

Aim

The aim of this cross-sectional study was to measure the effect of dual tasks on gait stability in ambulant children with cerebral palsy (CP) compared to typically developing (TD) children.

Methods

The children of the CP (n = 20) and TD groups (n = 20) walked first without a dual task, then while counting forward and finally while alternatively naming fruits and animals (DTf/a). They then completed the same cognitive exercises while sitting comfortably. We calculated the distance between the foot placement estimator (FPE) and the real foot placement in the anterior direction (DFPEAP) and in the mediolateral direction (DFPEML) as a measure of gait stability, in a gait laboratory using an optoelectronic system. Cognitive scores were computed. Comparisons within and between groups were analysed with linear mixed models.

Results

The dual task had a significant effect on the CP group in DFPEAP and DFPEML. The CP group was more affected than the TD group during dual task in the DFPEML. Children in both groups showed significant changes in gait stability during dual tasks.

Interpretation

The impact of dual task on gait stability is possibly due to the sharing of attention between gait and the cognitive task. All children favoured a ‘posture second’ strategy during the dual task of alternatively naming animals and fruits. Children with CP increased their mediolateral stability during dual task.

Effects of Robot-Assisted Therapy on Gait Parameters in Pediatric Patients With Spastic Cerebral Palsy

Background: Gait dysfunction is a crucial factor that restricts independence and quality of life in children with cerebral palsy (CP). Gait training based on robotic-assisted therapy (RAT) is widely used, but information about effectiveness and ideal patient profile is not sufficient. Aim of this study was to assess the effect of RAT on gait parameters in spastic children with CP, and to determine whether changes in gait parameters are different among patients on different ambulatory levels.

Method: A total of 26 children with bilateral spastic CP were divided into two groups based on their functional ability: non-assisted ambulator (NAS) or assisted ambulator (AS); and underwent a RAT program (30 training sessions of RAT during 10 weeks). Gait analysis was performed: before the therapy (t1), right after (t2), and 6 weeks later (t3).

Results: No significant changes in spatiotemporal parameters or gait deviation index at t2 or t3. Double support symmetry significantly improved (t1 vs. t3, p = 0.03) for the whole group (NAS + AS). Walking speed symmetry significantly improved (t2 vs. t3, p = 0.02) for group AS.

Conclusion: RAT based on our protocol did not change spatiotemporal parameters and kinematics of walking except limited improvement in some aspects of gait symmetry. We did not find differences in changes in selected objective gait parameters among children with CP in different ambulatory levels.

Effects of cane use on walking parameters and lower limb muscle activity in adults with spastic cerebral palsy: a cross-sectional study

[Purpose] Adults with cerebral palsy often use a cane as a walking aid because of their decreased gait ability. However, it is unclear whether this affects lower limb muscle activity during walking. The purpose of this study was to clarify the influence of using a cane during walking on the spatio-temporal parameters of walking, lower limb muscle activity, and lower limb muscle coactivation in adults with spastic cerebral palsy. [Participants and Methods] Eleven participants with cerebral palsy were included. The spatio-temporal parameters of walking, lower limb muscle activity, and coactivation of lower limb muscle were measured during a 10 m trial with no cane, one cane, and two canes. [Results] Walking speed was lower and the stride time longer when using two canes than when using no cane. All muscle activities significantly reduced when using two canes. No significant difference was observed between using no cane and one cane, except for walking speed. In addition, there was no significant difference in coactivation between the conditions. [Conclusion] This study revealed that when two canes were used, the walking speed was reduced, and lower limb muscle activity was reduced, reducing the burden. In contrast, the movement pattern was not suggested to have changed.

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.

Self-perceived gait quality in young adults with cerebral palsy

AIM

To explore how patients with cerebral palsy (CP) perceive their gait and evaluate associations between subjective gait perception and: objective gait parameters, endurance, pain, and fatigue.

METHOD

Sixty-two patients (21 females and 41 males; mean [SD] age 20y [5y 1mo], range 15-29y) performed a clinical gait analysis. Self-selected walking speed, Gait Profile Score, and Gait Variable Score were calculated. Subjective gait perception was assessed with a visual analogue scale using the question: 'On a scale from 0 (worst) to 10 (optimal), how would you describe your walking today?'. A 6-minute walk test (6MWT) measured endurance; the 36-Item Short Form Health Survey (SF-36) evaluated quality of life. T-tests, Pearson correlations, and univariate and multiple linear regression models were used to compare and find associations between the data.

RESULTS

Overall mean (SD) subjective gait perception was 7.5 (1.8) and was significantly higher for patients in Gross Motor Function Classification System (GMFCS) level I (7.9 [1.5]) than for patients in GMFCS levels II and III (5.9 [2.0]). Positive correlations were found between subjective gait perception and gait scores, walking speed, 6MWT distance, and SF-36 score. Only walking speed was a significant predictor of subjective gait perception.

INTERPRETATION

Subjective gait perception was influenced by GMFCS level and linked partially with the walking speed. The gait quality did not explain subjective gait perception. It is important to combine subjective and objective gait scores to develop personalized therapeutic goals.

WHAT THIS PAPER ADDS

Subjective gait perception is influenced by the physical impairment levels of patients with cerebral palsy. Subjective gait perception and objective gait scores are associated. Walking speed is the only predictor of gait perception.

Gait analysis for individually tailored interdisciplinary interventions in children with cerebral palsy: a randomized controlled trial

AIM

To test the hypothesis that improvements in gait and function following individualized interdisciplinary interventions consisting of physical therapy, orthotics, spasticity management, and orthopaedic surgery using instrumented gait analysis are superior to 'usual care' in children with cerebral palsy (CP).

METHOD

This was a prospective, single-blind, parallel-group, randomized controlled trial investigating the effectiveness of interventions based on the use of gait analysis. Primary outcome was gait (Gait Deviation Index) and secondary outcomes were walking and patient-reported outcome measures of function, disability, and health-related quality of life. Follow-ups were done at 26 weeks (questionnaires) and at the primary end point of 52 weeks (all outcomes).

RESULTS

Sixty participants with CP (39 males, 21 females, mean age 6y 10mo, standard deviation 1y 3mo, range 5y-9y 1mo) in Gross Motor Function Classification System levels I or II, were randomized to interventions with or without gait analysis. No significant or clinically relevant between-group differences in change scores of the primary or secondary outcomes were found. The recommended categories of interventions were dominated by non-surgical interventions and were applied in 36% to 86% of the participants.

INTERPRETATION

Interventions using gait analysis were not superior to 'usual care' on gait, walking, or patient-reported outcomes in a sample of relatively young and independently walking children with CP not expected to need surgery.

WHAT THIS PAPER ADDS

Gait analysis in children with cerebral palsy in Gross Motor Function Classification System levels I or II recommends interdisciplinary interventions. Compliance to interventions recommended after gait analysis was low. No statistically significant advantages were identified for the intervention group versus the control group.

Validation of the Caregiver Priorities and Child Health Index of Life with Disabilities (CPCHILD) in a sample of Turkish non-ambulatory children with cerebral palsy

AIM

The aim of this study was to translate and transculturally adapt the Caregiver Priorities and Child Health Index of Life with Disabilities questionnaire into the Turkish language and test the reliability and validity.

MATERIAL AND METHODS

Eighty-two children with cerebral palsy and their parents were included in the study. The majority of children had spastic cerebral palsy. According to the Gross Motor Function Classification System, 26 children were level III, 30 children were level IV, and 26 children were level V. International accepted guidelines were used in the transcultural adaptation and validation process. Reliability was assessed through statistical analysis of the test results for test-retest and internal consistency. To assess construct validity, Caregiver Priorities and Child Health Index of Life with Disabilities was compared with the Child Health Questionnaire Parent Form. Concurrent validity was assessed by examining how Caregiver Priorities and Child Health Index of Life with Disabilities scores changed according to Gross Motor Function Classification System levels.

RESULTS

The mean total score of Caregiver Priorities and Child Health Index of Life with Disabilities was 58.34±26.39. The intraclass correlation coefficient for the total questionnaire score was 0.75, ranging from 0.43 to 0.89 for six domains. Cronbach's alpha was above 0.80 in all domains of Caregiver Priorities and Child Health Index of Life with Disabilities, except the health domain. The construct validity was good because there was a positive correlation between total Child Health Questionnaire Parent Form and Caregiver Priorities and Child Health Index of Life with Disabilities scores (r=0.58, p<0.01) according to the Pearson correlation analysis. Caregiver Priorities and Child Health Index of Life with Disabilities scores were found to be different between Gross Motor Function Classification System levels (p<0.05).

CONCLUSION

This study showed that the Caregiver Priorities and Child Health Index of Life with Disabilities appears to be easy to administer, seems to have significant validity and reliability, and may be useful in the evaluation of health-related quality of life of children with cerebral palsy.

External Match Loads of Footballers With Cerebral Palsy: A Comparison Among Sport Classes

Purpose: To determine and compare the external match load, according to sport class (FT), of footballers with cerebral palsy (CP) during the International Federation of CP Football World Championships Qualification Tournament. Methods: Forty-two international male footballers with CP participated in the data collection. The footballers with CP were classified according to their FT into 3 groups (ie, FT5/6, FT7, and FT8). External match load (ie, total distance covered, distance covered at different speeds, accelerations, decelerations, player load, peak metabolic power, and changes of directions) was collected for both halves during official matches with global positioning system devices. Results: Players with lower impairment (FT8) covered more distance (effect size = 0.30–0.60) at high-intensity running (13.0–18.0 km·h−1) and sprinting (>18.0 km·h−1) and performed more (effect size = 0.29–1.08) accelerations, decelerations, and changes of direction at high intensity in matches than did other players (ie, FT5/6 and FT7 groups). Conclusion: Because high-intensity actions are relevant to football performance and there are differences caused by players’ impairments, the International Federation of CP Football classification protocols should include high-intensity actions during the technical assessment as part of the procedures for determining the sport class of football players with CP.

Incidence of knee height asymmetry in a paediatric population of corrected leg length discrepancy: a retrospective chart review study

PURPOSE

The purpose of the study is to provide a methodology to quantify knee height asymmetry (KHA) and to establish the incidence of knee height asymmetry in a patient population visiting the limb length discrepancy clinic in a paediatric-orthopaedic hospital centre.

METHOD

A retrospective chart review was performed on all patients who attended the limb length discrepancy clinic and underwent corrective surgery at the Shriners Hospital for Children-Canada from December 2009 to December 2015. Full-standing anteroposterior radiographs were used to measure pre- and post-surgery limb length discrepancy and knee height asymmetry for 52 individuals included in the study.

RESULTS

Sixty-seven percent of the studied population had a KHA of 20 mm or less, 25% had a KHA between 20 and 40 mm, and 8% had a KHA of over 40 mm. The average KHA preoperatively for all 52 individuals was 17 ± 14 mm (range 0-59 mm), which represents roughly 2.5% of total limb length. There was a 3-mm non-significant reduction in KHA size between pre-and post-operative states (p = 0.22).

CONCLUSION

The current study provides a method to quantify knee height asymmetry. Using this method, it was shown that knee height asymmetry is frequent in youth with limb length discrepancy in both pre- and post-corrective surgery states. The relatively high incidence of knee height asymmetry highlights the importance to investigate the impact of knee height asymmetry in youth living with a limb length discrepancy.

A randomized, single-blind cross-over design evaluating the effectiveness of an individually defined, targeted physical therapy approach in treatment of children with cerebral palsy

Objective:

A pilot study to compare the effectiveness of an individual therapy program with the effects of a general physical therapy program.

Design:

A randomized, single-blind cross-over design.

Participants:

Ten ambulant children with bilateral spastic cerebral palsy, age four to nine years.

Intervention:

Participants were randomly assigned into a ten-week individually defined, targeted or a general program, followed by a cross-over.

Main outcome measures:

Evaluation was performed using the Gross Motor Function Measure-88 and three-dimensional gait analysis. General outcome parameters were Gross Motor Function Measure-88 scores, time and distance parameters, gait profile score and movement analysis profiles. Individual goal achievement was evaluated using z-scores for gait parameters and Goal Attainment Scale for gross motor function.

Results:

No significant changes were observed regarding gross motor function. Only after individualized therapy, step- and stride-length increased significantly ( p = 0.022; p = 0.017). Change in step-length was higher after the individualized program ( p = 0.045). Within-group effects were found for the pelvis in transversal plane after the individualized program ( p = 0.047) and in coronal plane after the general program ( p = 0.047). Between-program differences were found for changes in the knee in sagittal plane, in the advantage of the individual program ( p = 0.047). A median difference in z-score of 0.279 and 0.419 was measured after the general and individualized program, respectively. Functional goal attainment was higher after the individual therapy program compared with the general program (48 to 43.5).

Conclusion:

The results indicate slightly favorable effects towards the individualized program. To detect clinically significant changes, future studies require a minimal sample size of 72 to 90 participants.