The change in sagittal plane gait patterns from childhood to maturity in bilateral cerebral palsy

Three-Dimensional Instrumented Gait Analysis for Children With Cerebral Palsy: An Evidence-Based Clinical Practice Guideline

BACKGROUND

Children with cerebral palsy (CP) who walk have complex gait patterns and deviations often requiring physical therapy (PT)/medical/surgical interventions. Walking in children with CP can be assessed with 3-dimensional instrumented gait analysis (3D-IGA) providing kinematics (joint angles), kinetics (joint moments/powers), and muscle activity.

PURPOSE

This clinical practice guideline provides PTs, physicians, and associated clinicians involved in the care of children with CP, with 7 action statements on when and how 3D-IGA can inform clinical assessments and potential interventions. It links the action statement grades with specific levels of evidence based on a critical appraisal of the literature.

CONCLUSIONS

This clinical practice guideline addresses 3D-IGA's utility to inform surgical and non-surgical interventions, to identify gait deviations among segments/joints and planes and to evaluate the effectiveness of interventions. Best practice statements provide guidance for clinicians about the preferred characteristics of 3D-IGA laboratories including instrumentation, staffing, and reporting practices.Video Abstract: Supplemental digital content available at http://links.lww.com/PPT/A524.

The impact of hamstring lengthening on stance knee flexion at skeletal maturity in ambulatory cerebral palsy

This study reports the long-term outcomes of hamstring lengthening to treat flexed knee gait in children with ambulatory cerebral palsy (CP) after skeletal maturity. This retrospective longitudinal observational study used instrumented gait analysis (GA) <8 and >15 years old in children with bilateral CP. The primary variable was knee flexion in stance phase. Eighty children (160 limbs) were included; 49% were male, 51% female. Mean age at first GA was 6.0 (SD: 1.2) years and 19.6 (SD: 4.5) years at final GA. Mean follow-up was 13.7 (SD: 4.7) years. Children were classified as Gross Motor Function Classification System I-8, II-46 and III-26. Average Gross Motor Function Measure Dimension D was 72% (SD: 20%). Hamstring lengthenings occurred once in 82, twice in 54 and three times in 10 limbs. From initial to final GA, average knee flexion in stance was unchanged, 27.8° (SD: 14.8°) to final 27.0° (SD: 11.2°; P = 0.54). Knee flexion at foot contact was 39.6° (SD: 13.0°), improving to final GA of 30.7° (SD: 10.6°; P < 0.001). Initial gait deviation index was 65.8 (SD: 31.9), improving to final 78.9 (SD: 28.2; P < 0.001). Older age, males and concomitant plantar flexor lengthening predicted change toward more flexed knee gait. Hamstring lengthening did not lead to back-kneeing gait at maturity while maintaining childhood stance phase knee flexion. A subgroup still developed significant flexed knee gait posture and may have benefited from more aggressive treatment options. This outcome may also be impacted by diverse functional levels, etiologies and treatments of flexed knee gait.

Crouch Gait in Cerebral Palsy: Current Concepts Review

Background and Objective

Crouch gait is the most common pathological gait pattern in cerebral palsy and is commonly seen in patients with spastic diplegia. It is characterized by excessive knee flexion throughout the stance phase of gait cycle. The aim of this review is to discuss the current literature about CG for a more comprehensive understanding.

Methods

A literature review about various aspects of crouch gait in cerebral palsy was undertaken. This included its etiology and pathophysiology, biomechanics in crouch gait, natural history of untreated crouch gait, clinical and radiological evaluation and different modalities of available treatment.

Results

The etiology is multifactorial and the pathophysiology is poorly understood. This makes its management challenging, thereby leading to a variety of available treatment modalities. Inadvertent lengthening of muscle-tendon units is an important cause and can be avoided. A meticulous clinical and radiological evaluation of patients, supplemented by observational and instrumented gait analysis is mandatory in choosing correct treatment modality and improving the treatment outcome. Younger children can be managed satisfactorily by various non-operative methods and spasticity reduction measures. However, crouch gait in cerebral palsy has a progressive natural history and surgical interventions are needed frequently. The current literature supports combination of various soft tissue and bony procedures as a part of single event multilevel surgery. Growth modulation in the form of anterior distal femur hemiepiphysiodesis for correction of fixed flexion deformity of knee has shown encouraging results and can be an alternative in younger children with sufficient growth remaining.

Conclusions

In spite of extensive research in this field, the current understanding about crouch gait has many knowledge gaps. Further studies about the etiopathogenesis and biomechanics of crouch using instrumented gait analysis are suggested. Similarly, future research should focus on the long term outcomes of different treatment modalities through comparative trials.

A prospective assessment of gait kinematics and related clinical examination measures in cerebral palsy crouch gait

Background While prospectively assessed crouch gait in cerebral palsy (CP) does not necessarily progress, prospective changes in clinical examination measures have not been reported. This study prospectively examined the association between selected clinical examination variables and change in crouch gait in a cohort with bilateral CP. Methods Inclusion criteria were a diagnosis of ambulant bilateral CP, knee flexion at mid-stance >19 0 and a minimum of two-years between gait analyses. The change in kinematic variables was assessed using Statistical Parameter Mapping (SPM) and changes in clinical measures using appropriate paired tests. Linear regression examined the association between progression of crouch and clinical examination variables. Results There was no mean change in crouch in 27 participants over 3.29 years. However, there was significant variability within this group. Clinical hamstring tightness (60.00 0 to 70.48 0, p<0.01) and external knee rotation during stance (SPM analysis, p<0.001) increased but there was no association between changes in clinical examination variables and changes in crouch (p-values 0.06 - 0.89).    Conclusions This prospective study found no association between the changes in clinical examination variables and changes in crouch highlighting the likely multi-factorial aetiology of this gait pattern and the need for larger prospective studies. The variability crouch gait progression among the 27 participants highlights the pitfall of group mean values in such a heterogeneous population.

A longitudinal analysis of selective motor control during gait in individuals with cerebral palsy and the relation to gait deviations

OBJECTIVE

To investigate longitudinal changes in selective motor control during gait (SMCg) in individuals with cerebral palsy (CP), and to assess if they are related to changes in gait deviations.

METHOD

Twenty-three children/adolescents with spastic CP (mean ± SD age = 9.0±2.5 years) and two 3D gait assessments (separated by 590±202 days) with no interim surgical intervention, were included. SMCg was assessed using muscle synergy analysis to determine the dynamic motor control index (walk-DMC). Gait deviation was assessed using the Gait profile score (GPS) and Gait variable scores (GVS).

RESULTS

There were no mean changes in walk-DMC score, GPS or GVS between assessments. However, changes in walk-DMC scores in the more involved leg related to changes in hip flexion-extension and hip internal-external GVS (rp = -0.56; p = 0.017 and rp = 0.65; p = 0.004, respectively).

CONCLUSIONS

On average, there were no significant longitudinal changes in SMCg. However, there was considerable variability between individuals, which may relate to changes in hip joint kinematics. This suggests that a combination of neural capacity and biomechanical factors influence lower limb muscle co-activation in individuals with CP, with a potential important role for the hip muscles. These findings highlight the importance of taking an individualized approach when evaluating SMCg in individuals with CP.

A 10.5-year follow-up of walking with unilateral spastic cerebral palsy

Purpose

The purpose of this study was to describe gait evolution in patients with unilateral spastic cerebral palsy (USCP) using modified Gait Profile Score (mGPS without hip rotation), Gait Variable Score (GVS), walking speed, and the observed effects of single-level surgery (SLS) after 10 years.

Methods

Fifty-two patients with USCP (Gross Motor Function Classification System I) and data from two Clinical Gait Analyses (CGAs) were included. The evolution of patients' mGPS, GVS, and walking speed were calculated. Two "no surgery" and "single-level surgery" patient categories were analyzed. Paired t-tests were used to compare the data between CGAs and as a function of treatment category. Pearson's correlations were used to examine relationships between baseline values and evolutions in mGPS and walking speed.

Results

Mean ages (SD) at first and last CGAs were 9.3 (3.2) and 19.7 (6.0) years old, respectively, with an average follow-up of 10.5 (5.6) years. Mean mGPS for the patients' affected side was significantly lower at the last CGA for the full cohort: baseline = 8.5° (2.1) versus follow-up = 7.2° (1.6), effect size = 0.73, p < 0.001. Significant improvements in mGPS and GVS for ankle and foot progression were found for the SLS group. The mGPS change and mGPS at baseline (r = -0.79, p < 0.001) were negatively correlated.

Conclusions

SLS patients demonstrated a positive long-term change in gait pattern over time. The group that had undergone surgery had worse gait scores at baseline than the group that had not, but the SLS group's last CGA scores were relatively closer to those of the "no surgery" group.

Level of evidence

This was a retrospective comparative therapeutic study (level III).

Analysis of cerebral palsy gait based on movement primitives

BACKGROUND

Cerebral palsy is the most prevalent motor disorder among children. Despite extensive studies on motor modularity of gait of children with cerebral palsy, kinematic modularity of their gait has not been addressed which is the main goal of this study.

METHODS

The kinematics of the gait of 13 typical development children and 188 children with cerebral palsy was captured and analyzed, where the cerebral palsy children were grouped into True, Jump, Apparent, and Crouch. Non-negative matrix factorization method was used to extract the kinematic modulus of each group, which were then clustered to find their characteristic movement primitives. The movement primitives of groups were then matched based on the similarity of their activation profiles.

FINDINGS

The number of movement primitives was three for the Crouch group, four for the other cerebral palsy groups, and five for the typical development group. Compared to the typical development children, the kinematic modules and activations of the cerebral palsy groups involved higher variability and co-activation, respectively (P < 0.05). Three temporally matched movement primitives were shared by all groups, but with altered structures.

INTERPRETATION

The gait of children with cerebral palsy involved lower complexity and higher variability due to the reduced and inconsistent kinematic modularity. Three basic movement primitives were sufficient to prodcue the overall gait kinematics, as observed in the Crouch group. Other movement primitives, were responsible for providing smooth transitions between basic movement primitives, as seen in more complex gait patterns.