Single-session reliability of discrete gait parameters in ambulatory children with cerebral palsy based on GMFCS level

Comparing Walking-Related Everyday Life Tasks of Children with Gait Disorders in a Virtual Reality Setup With a Physical Setup: Cross-Sectional Noninferiority Study

BACKGROUND

A frequent rehabilitation goal for children with gait disorders is to practice daily-life walking activities. Unfortunately, these are often difficult to practice in a conventional therapeutic setting. Virtual reality (VR) with head-mounted displays (HMDs) could be a promising approach in neurorehabilitation to train such activities in a safe environment. First, however, we must know whether obstacles in VR are indeed mastered as obstacles.

OBJECTIVE

This study aimed to provide information on whether VR is feasible and motivating to induce and practice movements needed to master real obstacles in children and adolescents with gait disorders. Furthermore, this project aims to evaluate which kinds of everyday walking activities are appropriate to be practiced in VR.

METHODS

In this cross-sectional study, participants stepped over a bar, crossed a gap, balanced over a beam, and circumvented stationary obstructions arranged in a course under real physical and virtual conditions wearing a VR HMD. We recorded the respective primary outcomes (step height, step length, step width, and minimal shoulder-obstacle distance) with motion capture. We then calculated the mean differences and 95% CI of the spatiotemporal parameters between the VR and physical setup and later compared them using noninferiority analysis with margins defined a priori by a clinical expert panel. Additionally, the participants responded to a standardized questionnaire while the therapists observed and evaluated their movement performance.

RESULTS

We recruited 20 participants (mean age 12.0, range 6.6-17.8 years) with various diagnoses affecting their walking ability. At 3.77 (95% CI 1.28 to 6.26) cm, the mean difference in step height of the leading foot in the overstepping task did not exceed the predefined margin of -2 cm, thus signifying noninferiority of the VR condition compared to mastering the physical obstacles. The same was true for step length (-1.75, 95% CI -4.91 to 1.41 cm; margin -10 cm), step width (1.05, 95% CI 0.20 to -1.90 cm; margin 3 cm), and the minimal shoulder-obstacle distance (0.25, 95% CI -0.85 to 0.35 cm; margin -2 cm) in the other tasks. Only the trailing foot in the overstepping task yielded inconclusive results.

CONCLUSIONS

Children with gait disorders perform everyday walking tasks like overstepping, crossing, balancing, or circumventing similarly in physical and VR environments, suggesting that VR could be a feasible therapeutic tool to practice everyday walking tasks.

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.

Foot and Ankle Somatosensory Deficits Affect Balance and Motor Function in Children With Cerebral Palsy

Sensory dysfunction is prevalent in cerebral palsy (CP). Evidence suggests that sensory deficits can contribute to manual ability impairments in children with CP, yet it is still unclear how they contribute to balance and motor performance. Therefore, the objective of this study was to investigate the relationship between lower extremity (LE) somatosensation and functional performance in children with CP. Ten participants with spastic diplegia (Gross Motor Function Classification Scale: I-III) and who were able to stand independently completed the study. Threshold of light touch pressure, two-point discriminatory ability of the plantar side of the foot, duration of cutaneous vibration sensation, and error in the joint position sense of the ankle were assessed to quantify somatosensory function. The balance was tested by the Balance Evaluation System Test (BESTest) and postural sway measures during a standing task. Motor performance was evaluated by using a battery of clinical assessments: (1) Gross Motor Function Measure (GMFM-66-IS) to test gross motor ability; (2) spatiotemporal gait characteristics (velocity, step length) to evaluate walking ability; (3) Timed Up and Go (TUG) and 6 Min Walk (6MWT) tests to assess functional mobility; and (4) an isokinetic dynamometer was used to test the Maximum Volitional Isometric Contraction (MVIC) of the plantar flexor muscles. The results showed that the light touch pressure measure was strongly associated only with the 6MWT. Vibration and two-point discrimination were strongly related to balance performance. Further, the vibration sensation of the first metatarsal head demonstrated a significantly strong relationship with motor performance as measured by GMFM-66-IS, spatiotemporal gait parameters, TUG, and ankle plantar flexors strength test. The joint position sense of the ankle was only related to one subdomain of the BESTest (Postural Responses). This study provides preliminary evidence that LE sensory deficits can possibly contribute to the pronounced balance and motor impairments in CP. The findings emphasize the importance of developing a thorough LE sensory test battery that can guide traditional treatment protocols toward a more holistic therapeutic approach by combining both motor and sensory rehabilitative strategies to improve motor function in CP.

Test-retest reliability and minimal detectable change of ankle kinematics and spatiotemporal parameters in MS population

BACKGROUND

Many people with multiple sclerosis (pwMS) experience walking impairments often including foot drop, evident as either reduced dorsiflexion at initial contact and/or at the swing phase of the gait cycle. To measure even subtle differences in ankle kinematics, 3D gait analysis is considered a 'gold' standard. However, the psychometric properties of ankle kinematics in the MS population have not yet been examined.

OBJECTIVE

The aim of the study was to examine test-retest relative and absolute reliability of sagittal ankle kinematics and spatiotemporal parameters in two groups of pwMS with different levels of walking impairment.

METHODS

Two groups of pwMS underwent 3D gait analysis on two occasions 7-14 days apart. Group A consisted of 21 (14 female) people with Expanded Disability Status Scale (EDSS) 1-3.5 and group B consisted of 28 participants (14 female) with EDSS 4-6. The Intraclass Correlation Coefficient (ICC_2,2), standard error of measurement (SEM) and minimal detectable change (MDC_95%) were calculated for peak dorsiflexion (DF) in swing, ankle angle at initial contact (IC), gait profile score (GPS), walking speed, cadence and step length.

RESULTS

Both groups presented 'excellent' ICC values (>0.75) for DF in swing, IC and step length of most and least affected limbs, walking speed and cadence, with GPS for both limbs exhibiting 'fair' to 'good' ICCs (0.489-0.698). The MDC_95% values for all ankle kinematic parameters in group A were lower (1.9°-4.2°) than those in group B (2.2°-7.7°).

CONCLUSION

The present results suggest that ankle kinematic and spatiotemporal parameters derived from 3D gait analysis are reliable outcome measures to be used in the MS population. Further, this study provides indices of reliability that can be applied to both clinical decision making and in the design of studies aimed at treating foot drop in people with MS.

Reliability of single-day walking performance and physical activity measures using inertial sensors in children with cerebral palsy

BACKGROUND

There is a lack of objective and reliable tools to measure walking performance in children with cerebral palsy (CP).

OBJECTIVE

To evaluate the reliability of inertial measurement units (IMUs) measuring daily life walking performance and physical activity (PA) in children with CP and healthy controls.

METHODS

Algorithms were developed to analyse data collected with IMUs during 2 standard school days of the same week and 1 weekend day in 15 children with CP and 14 controls. Additionally, within a clinical trial, 10 children with CP were measured twice, on the same weekday 2 to 4 weeks apart. Relative and absolute reliabilities of PA (% time walking, standing, sitting/lying) and gait parameters (e.g., velocity, cadence) were evaluated by using the intraclass correlation coefficient (ICC) and minimal detectable change (MDC₉₅), comparing 2 school days of the same week, a school day with a weekend day, and the same weekday 2 to 4 weeks apart.

RESULTS

For the 15 children with CP (mean [SD] age 13.5 [3.4] years), ICCs were very high (0.70-0.98) when comparing gait parameters for 2 school days. ICCs were lower when comparing 2 school days for 14 control children (mean [SD] age 13.9 [3.0] years) and lowest when comparing a school day with a weekend day for both CP and control children. ICCs for PA were 0.90-0.91 when measuring the same weekday 2 to 4 weeks apart but were very low when comparing 2 school days of the same week or a school day with a weekend day. MDC₉₅ values were high for both groups and all comparisons but comparable with findings of in-lab studies of similar parameters.

CONCLUSIONS

Our IMU and algorithm setup appears to be a reliable tool to measure daily life gait parameters in children with CP when repeatedly measured on 2 school days. PA was also reliably assessed but when measuring the same school day some weeks apart. However, the high MDC₉₅ values question whether the setup can be used as a responsive outcome measure of interventions.

Reproducibility of gait kinematics and kinetics in chronic stroke patients

BACKGROUND

The search for reliable techniques to assess gait in stroke patients is crucial for the design and follow-up of rehabilitation programs.

OBJECTIVE

To assess the reproducibility of kinematic and kinetic gait parameters in chronic stroke patients using a three-dimensional gait analysis system.

METHODS

Ten chronic stroke patients were assessed while walking along a 20 m walkway at their natural speed, using a gait analysis system of six infrared cameras and two force plates. Each patient performed 10 gait trials on 2 separate days. Inter-measurement agreement was assessed with the Coefficient of Multiple Correlation, while Root Mean Square Differences were used to quantify the variability of the trials.

RESULTS

The majority of kinetics and kinematics showed excellent reproducibility in all patients. Joints' power seemed to be more reliable compared with joints' angle and moment. Most parameters presented greater variability in non-paretic than the paretic leg, while they were less variable in the sagittal compared with the non-sagittal planes. Less than 10 trials were sufficient to obtain excellent reproducibility for most kinematic and kinetic parameters.

CONCLUSIONS

The reproducibility of movement assessment through three-dimensional gait analysis appears excellent in chronic stroke patients.

Postural insoles on gait in children with cerebral palsy: Randomized controlled double-blind clinical trial

The aim of the present study was to assess the effect of postural insoles on gait performance in children with Cerebral Palsy (CP). Twenty four children between four and 12 years of age were randomly allocated either the control group (n = 12) or experimental group (n = 12). The control group used placebo insoles and the experimental group used postural insoles. Three-dimensional gait analysis was performed under three conditions: barefoot, in shoes and in shoes with insoles. Three evaluations were carried out: 1)immediately following placement of the insoles; 2)after three months of insole use; and 3)one month after suspending insole use. Regarding the immediate effects and after three months use of insole, significant improvements in gait velocity and cadence were found in the experimental group, along with an increase in foot dorsiflexion, a reduction in knee flexion and a reduction in internal rotation. Conversely, these changes were not maintained in the third assessment, one month after withdrawal of the insoles. The use of postural insoles led to improvements in gait performance in children with CP.

Psychometric properties of measures of gait quality and walking performance in young people with Cerebral Palsy: A systematic review

Availability of outcome measures (OMs) with robust psychometric properties is an essential prerequisite for the evaluation of interventions designed to address gait deterioration in young people with Cerebral Palsy (CP). This review evaluates evidence for the reliability, validity and responsiveness of outcome measures of gait quality and walking performance in young people with CP. A systematic search was performed in MEDLINE, CINAHL, PubMed and Scopus. Articles that met the eligibility criteria were selected. Methodological quality of studies was independently rated by two raters using the modified COnsensus-based Standard for the selection of health status Measurement INstruments checklist. Strength of evidence was rated using standardised guidelines. Best evidence synthesis was scored according to Cochrane criteria. Fifty-one articles reporting on 18 distinct OMs were included for review. Best evidence synthesis indicated a moderate to strong evidence for the reliability for OMs of walking performance but conflicting evidence for the reliability of OMs of gait quality. The evidence for responsiveness for all OMs included in this review was rated as 'unknown'. The limitations of using the modified COSMIN scoring for small sample sizes are acknowledged. Future studies of high methodological quality are needed to explore the responsiveness of OMs assessing gait quality and walking performance in young people with CP.

Effectiveness of robot-assisted gait training in children with cerebral palsy: a bicenter, pragmatic, randomized, cross-over trial (PeLoGAIT)

BACKGROUND

Walking ability is a priority for many children with cerebral palsy (CP) and their parents when considering domains of importance regarding treatment interventions. Partial body-weight supported treadmill training has become an established therapeutic treatment approach to address this demand. Further, new robotic rehabilitation technologies have increasingly been implemented in the clinical setting to allow for longer training sessions with increased step repetitions while maintaining a consistent movement pattern. But the current evidence about its clinical effectiveness in pediatric rehabilitation is weak. The aim of this research project is therefore to investigate the effectiveness of robot-assisted gait training on improvements of functional gait parameters in children with cerebral palsy.

METHODS/DESIGN

Children aged 6 to 18 years with bilateral spastic cerebral palsy who are able to walk at least 14 m with or without walking aids will be recruited in two pediatric therapy centers in Switzerland. Within a pragmatic cross-over design with randomized treatment sequences, they perform 5 weeks of robot-assisted gait training (three times per week with a maximum of 45 min walking time each) or a 5-week period of standard treatment, which is individually customized to the needs of the child and usually consists of 1-2 sessions of physiotherapy per week and additional hippotherapy, circuit training as well as occupational therapy as necessary. Both interventions take place in an outpatient setting. The percentage score of the dimension E of the Gross Motor Function Measure-88 (GMFM-88) as primary outcome as well as the dimension D of the GMFM-88, 6-minute and 10-meter walking tests as secondary outcomes are assessed before and at the end of each intervention period. Additionally, a 5-week follow-up assessment is scheduled for the children who are assigned to the standard treatment first. Treatment effects, period effects as well as follow-up effects are analyzed with paired analyses and independent test statistics are used to assess carry-over effects.

DISCUSSION

Although robot-assisted gait training has become an established treatment option to address gait impairments, evidence for its effectiveness is vague. This pragmatic trial will provide important information on its effects under clinical outpatient conditions.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT00887848 . Registered 23 April 2009.

Corticoreticular tract lesion in children with developmental delay presenting with gait dysfunction and trunk instability

The corticoreticular tract (CRT) is known to be involved in walking and postural control. Using diffusion tensor tractography (DTT), we investigated the relationship between the CRT and gait dysfunction, including trunk instability, in pediatric patients. Thirty patients with delayed development and 15 age-matched, typically-developed (TD) children were recruited. Fifteen patients with gait dysfunction (bilateral trunk instability) were included in the group A, and the other 15 patients with gait dysfunction (unilateral trunk instability) were included in the group B. The Growth Motor Function Classification System, Functional Ambulation Category scale, and Functional Ambulation Category scale were used for measurement of functional state. Fractional anisotropy, apparent diffusion coefficient, fiber number, and tract integrity of the CRT and corticospinal tract were measured. Diffusion parameters or integrity of corticospinal tract were not significantly different in the three study groups. However, CRT results revealed that both CRTs were disrupted in the group A, whereas CRT disruption in the hemispheres contralateral to clinical manifestations was observed in the group B. Fractional anisotropy values and fiber numbers in both CRTs were decreased in the group A than in the group TD. The extents of decreases of fractional anisotropy values and fiber numbers on the ipsilateral side relative to those on the contralateral side were greater in the group B than in the group TD. Functional evaluation data and clinical manifestations were found to show strong correlations with CRT status, rather than with corticospinal tract status. These findings suggest that CRT status appears to be clinically important for gait function and trunk stability in pediatric patients and DTT can help assess CRT status in pediatric patients with gait dysfunction.

Immediate Effect of Postural Insoles on Gait Performance of Children with Cerebral Palsy: Preliminary Randomized Controlled Double-blind Clinical Trial

[Purpose] Improved gait efficiency is one of the goals of therapy for children with cerebral palsy (CP). Postural insoles can allow more efficient gait by improving biomechanical alignment. The aim of the present study was to assess the effect of postural insoles on gait performance of children with CP classified as levels I or II of the Gross Motor Function Classification System (GMFCS). [Subjects and Methods] the study was a randomized controlled double-blind clinical trial. After meeting the legal aspects and the eligibility criteria, 10 children between four and 12 years old were randomly divided into a two groups: a control group (n=5), and an experimental group (n=5). Children in the control group used a placebo insoles, and children in the experimental group used postural insoles. Evaluation consisted of three-dimensional gait analysis under three conditions: barefoot, shoes without insoles and shoes with postural insoles or shoes with placebo insoles. [Results] Regarding the immediate effects of insole use, significant improvements in gait velocity and cadence were observed in the experimental group in comparison to the control group. [Conclusion] The use of postural insoles led to improvements in gait velocity and cadence of the children with cerebral palsy classified as levels I or II of the GMFCS.

Spatio-temporal gait analysis in children with cerebral palsy using, foot-worn inertial sensors

A child's natural gait pattern may be affected by the gait laboratory environment. Wearable devices using body-worn sensors have been developed for gait analysis. The purpose of this study was to validate and explore the use of foot-worn inertial sensors for the measurement of selected spatio-temporal parameters, based on the 3D foot trajectory, in independently walking children with cerebral palsy (CP). We performed a case control study with 14 children with CP aged 6-15 years old and 15 age-matched controls. Accuracy and precision of the foot-worn device were measured using an optical motion capture system as the reference system. Mean accuracy ± precision for both groups was 3.4 ± 4.6 cm for stride length, 4.3 ± 4.2 cm/s for speed and 0.5 ± 2.9° for strike angle. Longer stance and shorter swing phases with an increase in double support were observed in children with CP (p=0.001). Stride length, speed and peak angular velocity during swing were decreased in paretic limbs, with significant differences in strike and lift-off angles. Children with cerebral palsy showed significantly higher inter-stride variability (measured by their coefficient of variation) for speed, stride length, swing and stance. During turning trajectories speed and stride length decreased significantly (p<0.01) for both groups, whereas stance increased significantly (p<0.01) in CP children only. Foot-worn inertial sensors allowed us to analyze gait spatiotemporal data outside a laboratory environment with good accuracy and precision and congruent results with what is known of gait variations during linear walking in children with CP.

Examination of Knee Joint Moments on the Function of Knee-Ankle-Foot Orthoses During Walking

The goal of this study was to investigate clinically relevant biomechanical conditions relating to the setup and alignment of knee-ankle-foot orthoses and the influence of these conditions on knee extension moments and orthotic stance control during gait. Knee moments were collected using an instrumented gait laboratory and concurrently a load transducer embedded at the knee-ankle-foot orthosis knee joint of four individuals with poliomyelitis. We found that knee extension moments were not typically produced in late stance-phase of gait. Adding a dorsiflexion stop at the orthotic ankle significantly decreased the knee flexion moments in late stance-phase, while slightly flexing the knee in stance-phase had a variable effect. The findings suggest that where users of orthoses have problems initiating swing-phase flexion with stance control orthoses, an ankle dorsiflexion stop may be used to enhance function. Furthermore, the use of stance control knee joints that lock while under flexion may contribute to more inconsistent unlocking of the stance control orthosis during gait.

Quantitative analysis of gait coordination based on gait events in children with cerebral palsy

OBJECTIVE

The objective of this study was to quantify gait coordination of the lower limbs in children with cerebral palsy (CP) based on gait events.

DESIGN

The kinematic data of 50 children with typical development and 26 children with CP prerehabilitation and postrehabilitation were recorded. The hip and knee joint angles in the sagittal plane on both sides were obtained at six gait events. Then a gait coordination index (GCI) model was established based on the gait features extracted from the joint angles of the children with typical development using kernel-based principal component analysis, which was then used to calculate the GCI of children with CP. One-way analysis of variance was used to compare GCI and joint angles at each gait event. Intraclass correlation coefficient was calculated to evaluate the reliability of GCI in two trials separated by a day.

RESULTS

GCI in children with CP postrehabilitation was significantly higher than that in the children with typical development (P < 0.05) but significantly lower than that in children with CP prerehabilitation (P < 0.05). There are significant differences in GCI for children with CP prerehabilitation between level I, level II, and level III (P < 0.05). The results of intraclass correlation coefficients (>0.8) indicated that the obtained GCIs were reliable.

CONCLUSIONS

GCI can reflect gait coordination of lower limbs in children with CP and may be a useful tool for rehabilitation assessment.

Reliability of surface electromyography timing parameters in gait in cervical spondylotic myelopathy

The aims of this study were to validate a computerised method to detect muscle activity from surface electromyography (SEMG) signals in gait in patients with cervical spondylotic myelopathy (CSM), and to evaluate the test-retest reliability of the activation times designated by this method. SEMG signals were recorded from rectus femoris (RF), biceps femoris (BF), tibialis anterior (TA), and medial gastrocnemius (MG), during gait in 12 participants with CSM on two separate test days. Four computerised activity detection methods, based on the Teager-Kaiser Energy Operator (TKEO), were applied to a subset of signals and compared to visual interpretation of muscle activation. The most accurate method was then applied to all signals for evaluation of test-retest reliability. A detection method based on a combined slope and amplitude threshold showed the highest agreement (87.5%) with visual interpretation. With respect to reliability, the standard error of measurement (SEM) of the timing of RF, TA and MG between test days was 5.5% stride duration or less, while the SEM of BF was 9.4%. The timing parameters of RF, TA and MG designated by this method were considered sufficiently reliable for use in clinical practice, however the reliability of BF was questionable.

Reliability of three-dimensional gait analysis in cervical spondylotic myelopathy

BACKGROUND

Gait impairment is one of the primary symptoms of cervical spondylotic myelopathy (CSM). Detailed assessment is possible using three-dimensional gait analysis (3DGA), however the reliability of 3DGA for this population has not been established. The aim of this study was to evaluate the test-retest reliability of temporal-spatial, kinematic and kinetic parameters in a CSM population.

METHODS

Twelve patients with CSM (mean age 54 years) were consecutively recruited from a neurosurgery clinic. 3DGA was conducted on 2 separate days, less than 1 week apart, using the VICON(®) 250 Motion Analysis. The average of 10 gait cycles was analysed. Reliability was assessed using the one-way random intraclass correlation coefficient (ICC), the standard error of measurement (SEM), and Bland-Altman limits of agreement (LOA).

RESULTS

Temporal-spatial parameters showed excellent reliability, with ICCs above 0.9 for speed, cadence, stride length, double support time, and step width. ICCs for kinematic parameters ranged from acceptable (0.62, peak knee flexion in stance) to excellent (0.95, total hip sagittal plane motion). The SEM for all kinematic parameters was below 4°, with the exception of peak hip internal rotation (5.8°). Peak values were less reliable than the total range of motion in a plane. The majority of kinetic parameters showed excellent reliability (ICCs>0.85), with the exception of peak medio-lateral ground reaction force (ICC 0.12).

CONCLUSIONS

This information will enhance the interpretation of gait scores for CSM patients, as an estimate of the change required to exceed measurement error is now available.