Gait in children with cerebral palsy: observer reliability of Physician Rating Scale and Edinburgh Visual Gait Analysis Interval Testing scale

Automated Implementation of the Edinburgh Visual Gait Score (EVGS) Using OpenPose and Handheld Smartphone Video

Recent advancements in computing and artificial intelligence (AI) make it possible to quantitatively evaluate human movement using digital video, thereby opening the possibility of more accessible gait analysis. The Edinburgh Visual Gait Score (EVGS) is an effective tool for observational gait analysis, but human scoring of videos can take over 20 min and requires experienced observers. This research developed an algorithmic implementation of the EVGS from handheld smartphone video to enable automatic scoring. Participant walking was video recorded at 60 Hz using a smartphone, and body keypoints were identified using the OpenPose BODY25 pose estimation model. An algorithm was developed to identify foot events and strides, and EVGS parameters were determined at relevant gait events. Stride detection was accurate within two to five frames. The level of agreement between the algorithmic and human reviewer EVGS results was strong for 14 of 17 parameters, and the algorithmic EVGS results were highly correlated (r > 0.80, "r" represents the Pearson correlation coefficient) to the ground truth values for 8 of the 17 parameters. This approach could make gait analysis more accessible and cost-effective, particularly in areas without gait assessment expertise. These findings pave the way for future studies to explore the use of smartphone video and AI algorithms in remote gait analysis.

Validity and reliability of the 3-meter backward walk test in children with cerebral palsy

OBJECTIVE

To examine the validity and reliability of 3-Meter Backwalk Test (3MBWT) in children with Cerebral Palsy (CP).

METHODS

Study included 55 children with CP with the mean age of 12.34 ± 3.78 years, at Expanded and Revised Gross Motor Functional Classification System (GMFCS-E&R) I and II levels. Intraclass Correlation Coefficient (ICC) was used for the intra-rater and inter-rater reliability of 3MBWT according to the GMFCS-E&R levels. MDC estimates were calculated using baseline data. Convergent validity of 3MBWT was evaluated with its correlation between the Timed Up and Down Stairs Test (TUDS), Pediatric Balance Scale (PBS), Timed Up and Go Test (TUG), Pediatric Reach Test (PRT), Four Square Step Test (FSST).

RESULTS

Intra-rater and inter-rater reliability of 3MBWT was determined excellent at GMFCS-E&R I (Intra-rater ICC = 0.981-0.987, inter-rater ICC = 0.982-0.993), and GMFCS-E&R II (ICC = 0.927-0.933, ICC = 0.954-0.968). Intra-rater MDC values for GMFCS-E&R I were 1.17-1.22 s (s); 1.40-1.42 s for GMFCS-E&R II. Inter-rater MDC values for GMFCS-E&R I were 1.00-1.28 s, and MDC values for GMFCS-E&R II were 1.08-1.22 s. There was strong correlation between 3MBWT and PBS, TUG, and FSST in GMFCS-E&R I, moderate correlation between 3MBWT and TUDS, strong correlation between BBS, moderate correlation between TUG, and strong correlation between FSST in GMFCS-E&R II (p < 0.05).

CONCLUSION

The 3MBWT was found to be valid and reliable in children with CP. According to the MDC results, small differences in CP children can be adequately detected with 3MBWT. The 3MBWT also may add some more information on to GMFCS (E&R) data for following the disease progression as well as rehabilitation responses.

TRIAL REGISTRATION NUMBER

NCT04653363.

Evaluation methods to assess the efficacy of equinovarus foot surgery on the gait of post-stroke hemiplegic patients: A literature review

Introduction

The aim of this study was to realize a systematic review of the different ways, both clinical and instrumental, used to evaluate the effects of the surgical correction of an equinovarus foot (EVF) deformity in post-stroke patients.

Methods

A systematic search of full-length articles published from 1965 to June 2021 was performed in PubMed, Embase, CINAHL, Cochrane, and CIRRIE. The identified studies were analyzed to determine and to evaluate the outcomes, the clinical criteria, and the ways used to analyze the impact of surgery on gait pattern, instrumental, or not.

Results

A total of 33 studies were included. The lack of methodological quality of the studies and their heterogeneity did not allow for a valid meta-analysis. In all, 17 of the 33 studies involved exclusively stroke patients. Ten of the 33 studies (30%) evaluated only neurotomies, one study (3%) evaluated only tendon lengthening procedures, 19 studies (58%) evaluated tendon transfer procedures, and only two studies (6%) evaluated the combination of tendon and neurological procedures. Instrumental gait analysis was performed in only 11 studies (33%), and only six studies (18%) combined it with clinical and functional analyses. Clinical results show that surgical procedures are safe and effective. A wide variety of different scales have been used, most of which have already been validated in other indications.

Discussion

Neuro-orthopedic surgery for post-stroke EVF is becoming better defined. However, the method of outcome assessment is not yet well established. The complexity in the evaluation of the gait of patients with EVF, and therefore the analysis of the effectiveness of the surgical management performed, requires the integration of a patient-centered functional dimension, and a reliable and reproducible quantified gait analysis, which is routinely usable clinically if possible.

Expert visual assessment strategies for equine lameness examinations in a straight line and circle: A mixed methods study using eye tracking

BACKGROUND

A large number of lameness indicators have been suggested for the visual equine lameness assessment. However, it remains unknown which of these are commonly used by experts.

METHODS

Twenty-four expert lameness assessors from 10 leading UK institutions viewed 28 video clips of sound and mildly lame horses (median score 2/10). Horses were shown at trot in a straight line (rear and front view) and circle (side view, left and right rein). Eye tracking data were collected at 60 Hz while participants evaluated each clip. A questionnaire captured contextual information.

RESULTS

During assessment on the straight line, participants consistently looked mostly at the head and pelvis. On the circle, many participants consistently looked at the head, yet the subsequent choice, weighting and order of examined body regions was unsystematic between and within participants, and there was a bias towards prolonged assessment of the horse's front region. Questionnaires revealed different descriptions of lameness indicators for the same body region and different approaches to decision making under uncertainty.

CONCLUSION

In contrast to reasonably high similarity on the straight line, expert veterinarians have not developed a consistent assessment approach when evaluating horses on the circle. The reliability of various lameness indicators on the circle requires a stronger evidence base for a more systematic, repeatable approach.

Three decades of gait index development: A comparative review of clinical and research gait indices

BACKGROUND

A wide variety of indices have been developed to quantify gait performance markers and associate them with their respective pathologies. Indices scores have enabled better decisions regarding patient treatments and allowed for optimized monitoring of the evolution of their condition. The extensive range of human gait indices presented over the last 30 years is evaluated and summarized in this narrative literature review exploring their application in clinical and research environments.

METHODS

The analysis will explore historical and modern gait indices, focusing on the clinical efficacy with respect to their proposed pathology, age range, and associated parameter limits. Features, methods, and clinically acceptable errors are discussed while simultaneously assessing indices advantages and disadvantages. This review analyses all indices published between 1994 and February 2021 identified using the Medline, PubMed, ScienceDirect, CINAHL, EMBASE, and Google Scholar databases.

FINDINGS

A total of 30 indices were identified as noteworthy for clinical and research purposes and another 137 works were included for discussion. The indices were divided in three major groups: observational (13), instrumented (16) and hybrid (1). The instrumented indices were further sub-divided in six groups, namely kinematic- (4), spatiotemporal- (5), kinetic- (2), kinematic- and kinetic- (2), electromyographic- (1) and Inertial Measurement Unit-based indices (2).

INTERPRETATION

This work is one of the first reviews to summarize observational and instrumented gait indices, exploring their applicability in research and clinical contexts. The aim of this review is to assist members of these communities with the selection of the proper index for the group in analysis.

What is the minimum torque required to obtain passive elbow end range of motion?

BACKGROUND

Passive range of motion is a common clinical assessment. The point at which passive end range of motion is measured is typically described by the 'end-feel'of the joint.

RESEARCH QUESTION

What is the minimum amount of torque required to obtain passive elbow flexion and extension in children?

METHODS

Twenty-five children (age, 7.5 ± 1.6 years-old), who had previously sustained unilateral distal humeral fractures, participated in this prospective study.Passive elbow flexion and extension was measured at least 8 weeks and up to one year out of cast. Motion capture cameras were used to track twenty-one reflective markers placed on subjects and two markers attached to the pad of a force transducer.Five trials of passive range of motion (flexion and extension) were performed on both arms. Elbow joint moments were calculated as products of the forces applied and lengths to the elbow centers. A one way ANOVA was used to determine differences in moments for flexion and extension for both involved and uninvolved limbs. Pairedsamples t-tests were used to determine differences between the involved and the uninvolved limbs for both maximum flexion and extension.

RESULTS

There was no difference in the minimum mean joint moment (2.7 ± 1.1 Nm) at end range of motion. However, differences in passive range of motion was found between involved and uninvolved elbows (flexion p < .001; extension p = .001).

SIGNIFICANCE

The results demonstrate therapists obtained end range of passive elbow flexion and extension applying the same amount of minimum torque. A small torque is sufficient to achieve end range of elbow motion for children. This torque can be used in guiding clinical practice for assessing passive range of elbow motion in pediatric population. Because of a paucity of data for any joint, future research developing force data for other joints should be conducted.

A-GAS: A Probabilistic Approach for Generating Automated Gait Assessment Score for Cerebral Palsy Children

Gait disorders in children with cerebral palsy (CP) affect their mental, physical, economic, and social lives. Gait assessment is one of the essential steps of gait management. It has been widely used for clinical decision making and evaluation of different treatment outcomes. However, most of the present methods of gait assessment are subjective, less sensitive to small pathological changes, time-taking and need a great effort of an expert. This work proposes an automated, comprehensive gait assessment score (A-GAS) for gait disorders in CP. Kinematic data of 356 CP and 41 typically developing subjects is used to validate the performance of A-GAS. For the computation of A-GAS, instance abnormality index (AII) and abnormality index (AI) are calculated. AII quantifies gait abnormality of a gait cycle instance, while AI quantifies gait abnormality of a joint angle profile during walking. AII is calculated for all gait cycle instances by performing probabilistic and statistical analyses. Abnormality index (AI) is a weighted sum of AII, computed for each joint angle profile. A-GAS is a weighted sum of AI, calculated for a lower limb. Moreover, a graphical representation of the gait assessment report, including AII, AI, and A-GAS is generated for providing a better depiction of the assessment score. Furthermore, the work compares A-GAS with a present rating-based gait assessment scores to understand fundamental differences. Finally, A-GAS's performance is verified for a high-cost multi-camera set-up using nine joint angle profiles and a low-cost single camera set-up using three joint angle profiles. Results show no significant differences in performance of A-GAS for both the set-ups. Therefore, A-GAS for both the set-ups can be used interchangeably.

The Telemedicine-Based Pediatric Examination of the Back and Lower Limbs: A Narrative Review

The COVID-19 pandemic has accelerated the transition to virtual healthcare while also prompting an abundance of new literature highlighting telemedicine's capabilities and limitations for various medical applications, notably musculoskeletal examinations. Telemedicine provides an opportunity to deliver timely patient- and family-centred care while maintaining physical distancing and improving access to remote communities. This review aims to narrate the current state of the literature on telemedicine applied in the context of a musculoskeletal examination for children aged 3 to 18 years. The PubMed and ScienceDirect databases were searched for relevant articles from January 2015 to August 2021 using a combination of keywords and nested searches. The general examination components relevant to the back and lumbosacral spine, hip, knee, ankle/foot, and gait are described. These components include inspection, palpation, range of motion, motor, and sensory examination as well as special testing. There is general feasibility, validity, and substantial reliability in performing most examination components, and primary diagnoses established virtually were found to be either the same or similar in the vast majority of cases. Despite the current literature focusing mainly on adult populations, we describe how each aspect of the exam can be reliably incorporated into a virtual appointment specific to the pediatric population. Currently available smartphone-based applications that measure joint range of motion were generally found to have high reliability and validity. Caregivers are needed for most of the consultation, especially in younger children, but select physical exam maneuvers can be self-performed by older children and adolescents alone. By providing an overview of the available smartphone tools as well as the reliability and validity of remote assessments, this review not only establishes a foundation for a structured pediatric musculoskeletal examination, but also aims to increase providers' confidence in incorporating telemedicine into their practice.

Usability and Reliability of the Edinburgh Visual Gait Score in Children with Spastic Cerebral Palsy Using Smartphone Slow-Motion Video Technology and a Motion Analysis Application: A Pilot Study

BACKGROUND

The Edinburgh Visual Gait Score (EVGS) is a comprehensive measure of gait abnormalities in children with cerebral palsy (CP) and has good psychometric properties. However, it is cumbersome to administer and requires multiple devices to record and measure its various components. We conducted this study to determine if a smartphone video protocol could be used to improve the usability and reliability of the EVGS for daily use in a clinic setting.

METHODS

We used a handheld smartphone camera with slow-motion video technology and a motion analysis application to record and measure the EVGS of 30 ambulatory children with spastic CP. We tested the inter- and intra-rater reliability of various components of the EVGS between two observers.

RESULTS

Average age was 7 years 3 months (range 4-14 years). The mean (range) EVGS scores for the trunk, pelvis, hip, knee, ankle, and foot were 1.18 (0-3), 0.68 (0-3), 1.1 (0-4), 3.95 (1.5-7.5), 1.87 (0-4) and 4.13 (2-6.5) respectively. Total score was 12.92 (7-21.5). The mean (SD) scores for Gross Motor Function Classification System (GMFCS) levels II and III were 10.73 (3.86) and 14.96 (4.2) (p < 0.001). The intra-observer and inter-observer reliability using percentage of complete agreement was 65-98.3% and 61.7-92.5% respectively, with kappa values ranging from 0.15 to 0.87. Reliability was more for distal limb segments as compared to proximal segments.

CONCLUSION

We have described a simple and reliable method for quantitative OGA of children with CP, using smartphone video technology and motion analysis application, which can be performed by every clinician in an office setting.

LEVEL OF EVIDENCE

Level III.

Calcaneal lengthening osteotomy in spastic planovalgus feet

PURPOSE OF STUDY

Planovalgus deformity in cerebral palsy is disabling for the child in terms of increased energy expenditure during the gait cycle. The lever arm function of the foot is lost due to midfoot break and the achilles tendon is at a disadvantage being unable to lift the body weight during push-off. We evaluated the results of calcaneal lengthening osteotomy in such patients with clinical, radiological and gait parameters.

METHODS

17 spastic feet in a sample of 10 children were included in our study. The children were classified according to the GMFCS classification system and clinical parameters such as heel valgus and heel rise tests, radiological angles such as Talo-calcaneal angle and Talo-navicular coverage angle on AP view and Calcaneal pitch angle, calcaneus-5th metatarsal angle and talus-1st metatarsal angle on lateral view were measured. Video gait analysis was performed to observe knee progression angle in mid stance and peak knee flexion angle in mid and terminal stance.

RESULTS

Improvement was noted clinically in the heel valgus angle (preop-12.06°, postop-5.12°) and radiological parameters showed an improved coverage of the talus by navicular with simultaneous lifting of the medial longitudinal arch. Gait analysis showed decreased knee flexion trend in mid and terminal stance phase with better restoration of the knee axis.

CONCLUSION

Calcaneal lengthening osteotomy with peroneus brevis lengthening corrects almost all aspects of planovalgus deformity with an improved gait pattern without disturbing joint range of motion. It is a safe procedure for GMFCS grade 1 and 2 patients without much complications.

Selective peripheral neurotomy (SPN) as a treatment strategy for spasticity

Spasticity can be caused by central nervous system dysfunction, such as cerebral palsy and stroke. The accepted pathogenesis of spasticity is that the muscles are in the state of uninhibited stretch reflex without enough control of central nervous system. So far, there is no ideal way about how to repair central nervous system. However, the uninhibited stretch reflex can be reduced, targeting the posterior root of the spinal cord and peripheral nerves innervating the limbs, which are called selective posterior rhizotomy (SPR) and selective peripheral neurotomy (SPN), respectively. SPN is indicated for focal or multifocal spasticity, which is well accepted due to its low invasiveness and ease of use. How does the operation work? What do we do before and during this operation? Is there any risk to the patients? Our review summarizes the mechanism, indications, preoperative assessments, techniques, and complications of SPN. We hope that the spastic patients, such as pediatric cerebral palsy patients and older stroke patients, will benefit from this surgery.

Validity of quantitative assessment of posterior pelvic tilt and contralateral vaulting in hemiplegia using 3D treadmill gait analysis

BACKGROUND

Assessing abnormal gait patterns could indicate compensatory movements, which could be an index for recovery and a process of motor learning. To quantify the degree of posterior pelvic tilt, contralateral vaulting is necessary.

OBJECTIVES

This study aimed to develop and evaluate the validity of quantitative indices for posterior pelvic tilt and contralateral vaulting in hemiplegic patients.

METHODS

Forty-six healthy control subjects and 112 hemiplegic patients participated in this study. Of the 112 patients, 50 were selected into each abnormal gait pattern group, with some overlap. Three experienced physical therapists observed their walking and graded the severity of the two abnormalities in five levels. An index to quantify each of the two abnormal gait patterns was calculated from the three-dimensional treadmill gait analysis. The index values of patients were compared with those of healthy subjects and with the results of observational gait assessment done by three physical therapists with expertise in gait analysis.

RESULTS

The index values were significantly higher in hemiplegic patients than in healthy subjects (28.0% and 44.7% for the posterior pelvic tilt in healthy subjects and patients, respectively and 0.9 and 4.7 for the contralateral vaulting, respectively). A strong correlation was observed between the index value and the median observational rating for two abnormal gait patterns (r = -0.68 and -0.72).

CONCLUSIONS

The proposed indices for posterior pelvic tilt and contralateral vaulting are useful for clinical gait analysis, and thus encouraging a more detailed analysis of hemiplegic gait using a motion analysis system.

Pediatric telerehabilitation medicine: Making your virtual visits efficient, effective and fun

The COVID-19 pandemic has accelerated many changes in medicine including the transition from providing care in person to providing care via technology enabled telemedicine. The benefits of telemedicine visits with a Pediatric Rehabilitation Medicine (PRM) provider, also known as telerehabilitation medicine visits, are numerous. Telerehabilitation medicine provides an opportunity to deliver timely, patient and family-centric rehabilitation care while maintaining physical distance and reducing potential COVID-19 exposure for our patients, their caregivers and medical providers. Telerehabilitation medicine also allows for access to PRM care in rural areas or areas without medical specialty, virtual in-home equipment evaluation, and reduced travel burden. Because of these and many other benefits, telerehabilitation medicine will likely become part of our ongoing model of care if barriers to telemedicine continue to be lowered or removed. This paper is intended to establish a foundation for pediatric telerehabilitation medicine visit efficiency and effectiveness in our current environment and into the future.

The nature and extent of upper limb associated reactions during walking in people with acquired brain injury

BACKGROUND

Upper limb associated reactions (ARs) are common in people with acquired brain injury (ABI). Despite this, there is no gold-standard outcome measure and no kinematic description of this movement disorder. The aim of this study was to determine the upper limb kinematic variables most frequently affected by ARs in people with ABI compared with a healthy cohort at matched walking speed intention.

METHODS

A convenience sample of 36 healthy control adults (HCs) and 42 people with ABI who had upper limb ARs during walking were recruited and underwent assessment of their self-selected walking speed using the criterion-reference three dimensional motion analysis (3DMA) at Epworth Hospital, Melbourne. Shoulder flexion, abduction and rotation, elbow flexion, forearm rotation and wrist flexion were assessed. The mean angle, standard deviation (SD), peak joint angles and total joint angle range of motion (ROM) were calculated for each axis across the gait cycle. On a group level, ANCOVA was used to assess the between-group differences for each upper limb kinematic outcome variable. To quantify abnormality prevalence on an individual participant level, the percentage of ABI participants that were outside of the 95% confidence interval of the HC sample for each variable were calculated.

RESULTS

There were significant between-group differences for all elbow and shoulder abduction outcome variables (p < 0.01), most shoulder flexion variables (except for shoulder extension peak), forearm rotation SD and ROM and for wrist flexion ROM. Elbow flexion and shoulder abduction were the axes most frequently affected by ARs. Despite the elbow being the most prevalently affected (38/42, 90%), a large proportion of participants had abnormality, defined as ±1.96 SD of the HC mean, present at the shoulder (32/42, 76%), forearm (20/42, 48%) and wrist joints (10/42, 24%).

CONCLUSION

This study provides valuable information on ARs, and highlights the need for clinical assessment of ARs to include all of the major joints of the upper limb. This may inform the development of a criterion-reference outcome measure or classification system specific to ARs.

The Pediatric Temporal-spatial Deviation Index: quantifying gait impairment for children with cerebral palsy

AIM

To develop an easily-administered metric to quantify gait impairment in children and to assess its use in children with cerebral palsy (CP).

METHOD

The Pediatric Temporal-spatial Deviation Index (TDI) was developed from gait data collected from 75 typically developing children (37 males, 38 females; mean age 9y 4mo; interquartile range [IQR] 8-10y) and 17 children diagnosed with spastic CP (nine males, eight females; mean age 9y 9mo; IQR 9-11y), in Gross Motor Function Classification System (GMFCS) levels I to III, aged 7 to 11 years. Children walked on a pressure-sensitive mat. Children with CP also completed 3D gait analysis. The Kaiser-Meyer-Olkin test of sampling adequacy was used for temporal-spatial feature selection. Principal components obtained from temporal-spatial gait parameters quantified deviation from typically developing gait. Deviation was normalized to a Pediatric TDI score mean (standard deviation [SD]) of 100 (10). The Pediatric TDI for children with CP was compared to 3D motion capture-based Gait Deviation Index (GDI).

RESULTS

The Pediatric TDI was significantly lower for children with CP compared to typically developing children (p<0.001), correlated with average GDI (r=0.610, p=0.009), and demonstrated sensitivity (0.78) and specificity (0.88) to gait function, assessed with GDI.

INTERPRETATION

The Pediatric TDI is an easily administered, revealing gait metric that can be used in children with CP in pediatric clinics and for research. Detection of gait abnormalities in the clinic can expedite diagnosis and treatment. What this paper adds The Pediatric Temporal-spatial Deviation Index (TDI) is a single-score index of gait deviation, based on nine parameters. The Pediatric TDI was more revealing than single temporal-spatial gait parameters. The Pediatric TDI is quick and simple to administer in the clinic.

Knee joint sagittal plane movement in cerebral palsy: a comparative study of 2-dimensional markerless video and 3-dimensional gait analysis

Background and purpose - Gait analysis is indicated in children with cerebral palsy (CP) to identify and quantify gait deviations. One particularly difficult-to-treat deviation, crouch gait, can progress in adolescence and ultimately limit the ability to ambulate. An objective quantitative assessment is essential to early identify progressive gait impairments in children with CP. 3-dimensional gait analysis (3D GA) is considered the gold standard, although it is expensive, seldom available, and unnecessarily detailed for screening and follow-up. Simple video assessments are time-consuming when processed manually, but more convenient if used in conjunction with video processing algorithms; this has yet been validated in CP. We validate a 2-dimensional markerless (2D ML) assessment of knee joint flexion/extension angles of the gait cycle in children and young adults with CP. Patients and methods - 18 individuals, mean age 15 years (6.5-28), participated. 11 had bilateral, 3 unilateral, 3 dyskinetic, and 1 ataxic CP. In the Gross Motor Function Classification System, 6 were at level I, 11 at level II, and 1 at level III. We compared 2D ML, using a single video camera with computer processing, and 3D GA. Results - The 2D ML method overestimated the knee flexion/extension angle values by 3.3 to 7.0 degrees compared with 3D GA. The reliability within 2D ML and 3D GA was mostly good to excellent. Interpretation - Despite overestimating, 2D ML is a reliable and convenient tool to assess knee angles and, more importantly, to detect changes over time within a follow-up program in ambulatory 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.

Impairments, activity limitations, and participation restrictions of the international classification of functioning, disability, and health model in children with ambulatory cerebral palsy

Objectives:

To examine the impairments, activity limitations, and participation restrictions in children with spastic unilateral and bilateral cerebral palsy (CP). We investigated the relationship between these factors according to the international classification of functioning, disability, and health (ICF) model.

Methods:

This prospective cross sectional study included 60 children aged between 4-18 years with spastic CP (30 unilateral, 30 bilateral involvement) classified as Levels I and II on the gross motor function classification system. Children had been referred to the Pediatric Rehabilitation Unit in the Department of Physiotherapy and Rehabilitation, Hacettepe University, Ankara, Turkey between March 2014 and March 2015. The Physician Rating scale was used to assess body functions and structures. The Gillette Functional Assessment Questionnaire 22-item skill set, Pediatric Functional Independence Measure, and Pediatric Outcomes Data Collection Instrument were used to assess activity and participation levels.

Results:

There was a significant positive correlation between impairments and activity limitations (r=0.558; p=0.000), as well as between activity limitations and participation restrictions (r=0.354, p=0.005).

Conclusion:

These results show that activity limitations in children with unilateral and bilateral ambulatory CP may be related to their impairments and participation restrictions, although the sample size of our study is not large enough for generalizations. Overall, our study highlights the need for up-to-date, practical evaluation methods according to the ICF model.

Orthopedic surgery in cerebral palsy: Instructional course lecture

Orthopedic surgery (OS) plays an important role in the management of cerebral palsy (CP). The objectives of OS are to optimize functions and prevent deformity. Newer developments in OS for CP include emphasis on hip surveillance, minimally invasive procedures, use of external fixators instead of plates and screws, better understanding of lever arm dysfunctions (that can only be corrected by bony OS), orthopedic selective spasticity-control surgery, and single-event multilevel lever arm restoration and anti spasticity surgery, which have led to significant improvements in gross motor function and ambulation, especially in spastic quadriplegia, athetosis, and dystonia. The results of OS can be dramatic and life altering for the person with CP and their caregivers if it is performed meticulously by a specialized surgical team, at the appropriate age, for the correct indications, employing sound biomechanical principles and is followed by physician-led, protocol based, intensive, multidisciplinary, institutional rehabilitation, and long term followup. However, OS can be a double-edged sword, and if performed less than optimally, and without the supporting multidisciplinary medical and rehabilitation team, expertise and infrastructure, it often leads to significant functional worsening of the person with CP, including irretrievable loss of previous ambulatory capacity. OS must be integrated into the long term management of the person with CP and should be anticipated and planned at the optimal time and not viewed as a "last resort" intervention or failure of rehabilitation. This instructional course lecture reviews the relevant contemporary principles and techniques of OS in CP.

Effectiveness of a low-cost body weight support training device in the rehabilitation of cerebral palsy

Background

Body weight supported treadmill training (BWSTT) has been proven to be effective in rehabilitation of persons with cerebral palsy (CP). However, it has still not found widespread usage, especially in industrially developing countries, due to its high cost. Treadmill training promotes a rhythmical movement of the lower extremities through motor learning, which can be enhanced by BWSTT for persons with CP. Hence, the research and development team of a tertiary level neuromusculoskeletal rehabilitation center designed a low-cost body weight support training (BWST) device. The aim of this study was to evaluate the effectiveness of the BWST device on gait and ambulation in persons with CP post single-event multilevel surgery (SEMLS) of the lower extremities.

Method

A randomized controlled trial was conducted in 50 persons with CP aged between 5 and 20 years, who underwent a type of SEMLS called single-event multilevel lever arm restoration and anti-spasticity surgery (SEMLARASS). They were randomly assigned to two groups: group A (n = 25) received gait training and treadmill training with the BWST device, and group B (n = 25) received gait training and treadmill training without the BWST device. The designed BWST device was manually operated and based on an un-weighing principle in which a vest of different sizes un-weighed 10-30% of the individual's weight transmitted to the ground by means of adjustable counterweights fixed on a movable metallic frame which had an adjustable top lever (holding the vest) and a handle bar for the patient to hold. The entire cost for the finished BWST device was estimated around 700 USD. The study duration was 5 weeks with 1 h of intervention per day for 6 days per week. Physician Rating Scale (PRS), Dynamic Gait Index (DGI) and Functional Mobility Scale (FMS) were the primary outcome measures.

Results

Group A showed significant positive differences in the scores of PRS (p < 0.001), DGI (p < 0.001) and FMS (p < 0.01) when compared with group B, 5 weeks after the intervention, and the results were maintained at a follow-up of 12 months.

Conclusion

The low-cost BWST device was found to be clinically effective in improving gait and ambulation in persons with CP following SEMLARASS.

Efficacy of an activity monitor as a biofeedback device in cerebral palsy

Background

Assessment of physical outcomes in patients with cerebral palsy (CP) is considered an effective way to monitor their progress, evaluate interventions and guide health care policy. However, no study using an activity monitor (AM) as a biofeedback device in treatment of people with CP has been published. Hence, the objective of this study was to evaluate the use of the AM as a biofeedback device in individuals with CP after a type of single-event multilevel surgery (SEMLS) called Single-Event Multilevel Lever Arm Restoration and Anti-Spasticity Surgery (SEMLARASS).

Method

A randomized, controlled trial was conducted among 40 individuals with CP in the age group between 10 to 20 years who underwent SEMLARASS. They were randomly assigned to two groups: Group A (n = 20) and Group B (n = 20). Both groups received intensive rehabilitation including different types of activity-based training for around three hours per day. Both groups were assessed with standard subjective outcomes (Physician Rating Scale (PRS), Dynamic Gait Index (DGI) and Functional Mobility Scale (FMS)) and objective outcomes with the use of an AM (IntenzLife, Model No. 56084-1) for measuring step count, distance walked and calories used. During the intervention, for Group A, they were also given an AM after presetting individualized stride length and body weight, to monitor their daily activity levels. The AM was worn around the neck of the person throughout the day and provided a daily report of the measurements and acted as a biofeedback device for individuals with CP who were given specific targets to achieve on a weekly basis. Both groups were evaluated before and after eight weeks of intensive rehabilitation.

Results

Group A showed significant differences in the scores of step count (p < 0.001), distance walked (p < 0.001), PRS (p < 0.001), DGI (p < 0.010) and FMS (p < 0.001) when compared to Group B after intensive rehabilitation. However, the calories used (p < 0.086) was not significantly different.

Conclusion

The AM, which is considered to be a valid and reliable tool for assessing the level of physical activity in CP, can also be used as a biofeedback device for improving specific walking parameters in persons with CP post-SEMLARASS.

CORRELATION BETWEEN VISUAL GAIT ANALYSIS AND FUNCTIONAL ASPECTS IN CEREBRAL PALSY

Objective:

To verify the correlation between visual gait analysis (VGA) by the Edinburgh visual gait score (EVGS) and functional aspects using the Timed Up and Go Test (TUG) and Gross Motor Function Classification System (GMFCS) in individuals with cerebral palsy (CP).

Methods:

Retrospective cross sectional study of 35 patients with CP. The mean age 12.61 years old, 94.3% were spastic; 34.4% hemiplegic, 54.3% diplegic, 11.4% triplegic; 45.7% were level II GMFCS, 42.9% level I, 5.7% level III and 5.7% level IV. VGA was analyzed by the Edinburgh visual gait score (EVGS), functional mobility was assessed by TUG and functionality through GMFCS. The Spearman correlation was used for statistical analysis.

Results:

The mean EVGS score was 18.97. The mean TUG was 13.71sec. EVGS showed moderate correlation with TUG (r=0.46, p=0.03) and GMFCS (r=0.45, p=0.00).

Conclusion:

Worse VGA scores correlate to worse functionality and mobility performance. Due to the observed correlation, it is possible to assert that VGA is a useful tool on evaluation of CP patients. Level of Evidence III, Retrospective Comparative Study.

Reliability and validity of Edinburgh visual gait score as an evaluation tool for children with cerebral palsy

Assessment of gait abnormalities in cerebral palsy (CP) is challenging, and access to instrumented gait analysis is not always feasible. Therefore, many observational gait analysis scales have been devised. This study aimed to evaluate the interobserver reliability, intraobserver reliability, and validity of Edinburgh visual gait score (EVGS). Video of 30 children with spastic CP were reviewed by 7 raters (10 children each in GMFCS levels I, II, and III, age 6-12 years). Three observers had high level of experience in gait analysis (10+ years), two had medium level (2-5 years) and two had no previous experience (orthopedic fellows). Interobserver reliability was evaluated using percentage of complete agreement and kappa values. Criterion validity was evaluated by comparing EVGS scores with 3DGA data taken from the same video visit. Interobserver agreement was 60-90% and Kappa values were 0.18-0.85 for the 17 items in EVGS. Reliability was higher for distal segments (foot/ankle/knee 63-90%; trunk/pelvis/hip 60-76%), with greater experience (high 66-91%, medium 62-90%, no-experience 41-87%), with more EVGS practice (1st 10 videos 52-88%, last 10 videos 64-97%) and when used with higher functioning children (GMFCS I 65-96%, II 58-90%, III 35-65%). Intraobserver agreement was 64-92%. Agreement between EVGS and 3DGA was 52-73%. We believe that having EVGS as part of the standardized gait evaluation is helpful in optimizing the visual scoring. EVGS can be a supportive tool that adds quantitative data instead of only qualitative assessment to a video only gait evaluation.

Examination of the use of a dual-channel functional electrical stimulation system on gait, balance and balance confidence of an adult with spastic diplegic cerebral palsy

The purpose of this case report is to determine the effects of a dual-channel functional electrical stimulation (FES) system on gait and balance of a 57-year-old male diagnosed with spastic diplegic cerebral palsy (CP). Outcome measures included the: Activities-specific Balance Confidence Scale (ABC); Dynamic Gait Index (DGI); Observational Gait Scale (OGS) and Tinetti Performance Oriented Mobility Assessment (POMA). Assessments were completed with and without use of FES during the initial examination and after two, four and six weeks of intervention with FES. ABC Scale scores improved from 32.8 to 48.1% during the 6-week intervention. Scores on the DGI improved from 6/24 to 9/24 without FES and from 9/24 to 14/24 with FES. OGS scores improved on both legs with and without FES. Tinetti POMA scores improved from 12/28 to 15/28 without FES and decreased from 16/28 to 15/28 with FES. The patient demonstrated improvement in both objective and subjective measures. The use of FES facilitated improved gait and balance; however, the patient was still at increased risk for falls after the 6-week intervention despite improved scores on the ABC Scale, DGI, OGS and Tinetti POMA.

Observational gait assessment tools in paediatrics--a systematic review

Instrumented gait analysis (IGA) is an expensive technique used to objectively detect gait abnormalities in children. Observational gait assessment is considered as a cost effective alternate for IGA in regular clinical practice. This article is aimed at systematically reviewing the available paediatric gait analysis tools and examines their reliability and validity compared to IGA. This review also examines the structure of these tools, their clinical use and limitations. Articles were searched from PubMed, CINHL, AMED, BNI, EMBASE, PEDro and Cochrane library from the earliest record on the database to December 2012. Hand searches were carried out in a few journals. Studies that examined children's gait using a structured assessment tool were included and analysed for their quality, reliability and validity. Pre-established criteria were used to judge the quality of methodology and reliability and validity. Five observational gait tools for children with Cerebral Palsy (CP) and one for children with Downs Syndrome were identified. Nine studies related to children with CP were enrolled for this review. None of the tools have accomplished the level of IGA's consistency. Edinburgh Visual Gait Score (EVGS) was found to have better reliability and validity than the other tools. Very limited studies were available for most of the gait assessment tools therefore their clinical use cannot be judged based on the existing evidence. EVGS was found to have better concurrent validity and reliability and it should be considered to assess CP gait in regular practice. Future work to investigate the use of low cost technology to improve observers' accuracy of EVGS is suggested.

GRIN: "GRoup versus INdividual physiotherapy following lower limb intra-muscular Botulinum Toxin-A injections for ambulant children with cerebral palsy: an assessor-masked randomised comparison trial": study protocol

BACKGROUND

Cerebral palsy is the most common cause of physical disability in childhood. Spasticity is a significant contributor to the secondary impairments impacting functional performance and participation. The most common lower limb spasticity management is focal intramuscular injections of Botulinum Toxin-Type A accompanied by individually-delivered (one on one) physiotherapy rehabilitation. With increasing emphasis on improving goal-directed functional activity and participation within a family-centred framework, it is timely to explore whether physiotherapy provided in a group could achieve comparable outcomes, encouraging providers to offer flexible models of physiotherapy delivery. This study aims to compare individual to group-based physiotherapy following intramuscular Botulinum Toxin-A injections to the lower limbs for ambulant children with cerebral palsy aged four to fourteen years.

METHODS/DESIGN

An assessor-masked, block randomised comparison trial will be conducted with random allocation to either group-based or individual physiotherapy. A sample size of 30 (15 in each study arm) will be recruited. Both groups will receive six hours of direct therapy following Botulinum Toxin-A injections in either an individual or group format with additional home programme activities (three exercises to be performed three times a week). Study groups will be compared at baseline (T1), then at 10 weeks (T2, efficacy) and 26 weeks (T3, retention) post Botulinum Toxin-A injections. Primary outcomes will be caregiver/s perception of and satisfaction with their child's occupational performance goals (Canadian Occupational Performance Measure) and quality of gait (Edinburgh Visual Gait Score) with a range of secondary outcomes across domains of the International Classification of Disability, Functioning and Health.

DISCUSSION

This paper outlines the study protocol including theoretical basis, study hypotheses and outcome measures for this assessor-masked, randomised comparison trial comparing group versus individual models of physiotherapy following intramuscular injections of Botulinum Toxin-A to the lower limbs for ambulant children with cerebral palsy.

TRIAL REGISTRATION

ACTRN12611000454976.

Neuromechanical assessment of lidocaine test block in spastic lower limbs

The objective of this study was to quantify in spastic lower limbs the changes in reflex EMGs and in ankle stiffness after a lidocaine block of the soleus nerve to better understand physiological effects of lidocaine. Twenty patients were prospectively included and assessed before and after lidocaine block of the soleus nerve. We studied clinical and neuromechanical parameters of the triceps surae, including quantification of the maximum Hoffmann’s reflex (Hmax) and tendinous reflex (T) normalized to the maximum direct motor response (Mmax), and passive ankle stiffness assessed by sinusoidal length perturbations. All patients whatever the aetiology of spasticity were improved in clinical parameters of spasticity after the block (62% reduction of the Ashworth score, 85% reduction of stretch reflex scores, increased score on the Physicians’ Rating Scale). All patients presented a reduction of the Hmax–Mmax ratio (mean reduction of 67%) and the T–Mmax ratio (82%). Ankle stiffness was decreased by an average of 23%. Measured stiffness was correlated with the Ashworth score and the T–Mmax ratio. Relatively greater change in the T reflex than in the H reflex suggests that lidocaine block reduces hyperreflexia not only by interfering with generation of afferent volleys in the injected nerve, but also probably by altering generation of the volleys at the level of muscle spindles in the affected spastic muscles, presumably by blocking the transmission along gamma-efferent fibers.

Long-term neuromechanical results of selective tibial neurotomy in patients with spastic equinus foot

BACKGROUND

The neuromechanical consequences of tibial neurotomy have not been extensively studied.

METHODS

Fifteen patients were evaluated before and after selective tibial neurotomy (after 2 months and after 15 months) by means of clinical, neurophysiological [tendon (T) reflexes, Hoffmann (H) reflexes and maximum motor response, Mmax] and mechanical parameters (passive stiffness of plantar flexors at the ankle). The neurotomy concerned the soleus (100 % of cases), gastrocnemius (20 % of cases), posterior tibial (60 % of cases) and flexor digitorum longus (47 % of cases) nerves.

RESULTS

Neurotomy provided more than 90 % improvement of clinical spasticity scores, 20 % improvement of walking scores and the angle of passive dorsiflexion (APDF) of the ankle (mean angle: 7°), temporary reduction of the soleus Mmax (18 % at 2 months with return to the preoperative value at 15 months), and lasting reduction of the soleus Hmax/Mmax (68 % at 2 months, 78 % at 15 months) and T/Mmax (84 % at 2 months, 80 % at 15 months). M and H responses of the gastrocnemius (whether or not they were included in the neurotomy) were not modified, while T/Mmax decreased to the same degree as for soleus. Passive stiffness was lastingly decreased from 64.0 Nm/rad to 49.0 Nm/rad (2 months) and 49.5 Nm/rad (15 months).

CONCLUSION

Selective tibial neurotomy of the soleus nerve induces long-term reduction of reflex hyperexcitability and passive stiffness of plantar flexors in spastic patients, with no lasting impairment of motor efferents. In parallel, it modifies the tendon reflexes of synergistic muscles (gastrocnemius) not concerned by the neurotomy.

Motor measures: a moving target?

Outcome measures may be used for a variety of reasons by clinicians and researchers. This paper provides an overview on motor measures that can be used in research or practice and are classified within the International Classification of Functioning, Disability and Health or ICF. Specifically, body function measures of neuromusculoskeletal and movement-related functions are presented, as are mobility measures within the activity and participation domain of the ICF. Descriptions of measures within these categories and their psychometric properties are provided. Current challenges and future directions for motor measurement are delineated.

Real-time intersession and interrater reliability of the functional movement screen

The purpose of this study was to examine the real-time intersession and interrater reliability of the functional movement screen (FMS). The overall study consisted of 19 volunteer civilians (12 male, 7 female). The intersession reliability consisted of 12 men and 7 women, whereas 10 men and 6 women participated in the interrater reliability test session. Two raters (A and B) were involved in the interrater reliability aspect of this study. The FMS includes 7 tests: deep squat (DS), hurdle step (HS), in-line lunge (IL), shoulder mobility (SM), active straight leg raise (ASLR), trunk stability push-up (TSPU), and rotary stability (RS). Researchers analyzed the data via intraclass correlation (ICC). To determine the reliability of the intersession scoring of the FMS and the intrasession interrater scoring of the FMS a 2-way mixed effects model intraclass correlation coefficient (ICC(3,1)) was used for the continuous data, whereas a weighted Cohen's kappa (κ) was used for the categorical data. The dependent variables were FMS total score (0-21 scale) and associated tests were DS, HS, IL, SM, ASLR, TSPU, and RS. Intersession reliability (ICC, SEM) and κ were as follows: FMS total score (0.92, 0.51), DS (κ = 0.69), HS (κ = 0.16), IL (κ = 0.69), SM (κ = 0.84), ASLR (κ = 0.69), TSPU (κ = 0.77), and RS (no covariance). Interrater reliability (ICC, SEM) and κ were as follows: FMS total score (0.98, 0.25), DS (κ = 1.0), HS (κ = 0.33), IL (κ = 0.88), SM (κ = 0.90), ASLR (κ = 0.88), TSPU (κ = 0.75), and RS (no covariance). The FMS total scores displayed high intersession and interrater reliabilities. Finally, with the exception of HS, all tasks displayed moderate to high intersession reliability and good to high interrater reliability.

A French observational study of botulinum toxin use in the management of children with cerebral palsy: BOTULOSCOPE

BACKGROUND

Dystonia and spasticity are common symptoms in children with Cerebral Palsy (CP), whose management is a challenge to overcome in order to enable the harmonized development of motor function during growth.

AIM

To describe botulinum toxin A (BTX-A) use and efficacy as a treatment of focal spasticity in CP children in France.

METHODS

This prospective observational study included 282 CP children mostly administered according to French standards with BTX-A in lower limbs. Realistic therapeutic objectives were set with parents and children together before treatment initiation and assessed using the Visual Analogue Scale (VAS). Child management was recorded and the efficacy of injections was assessed during a 12-month follow-up period by physicians (Modified Ashworth Scale, joint range of motion, Physician Rating Scale, Gillette Functional Assessment Questionnaire and Gross Motor Function Measure-66) and by patients/parents (Visual Analogue Scale).

RESULTS

BTX-A treatment was administered in different muscle localizations at once and at doses higher than those recommended by the French Health Authorities. Children were treated in parallel by physiotherapy, casts and ortheses. Injections reduced spasticity and improved joint range of motion, gait pattern and movement capacity. Pain was reduced after injections. BTX-A administration was safe: no botulism-like case was reported. The log of injected children who were not included in the study suggested that a large population could benefit from BTX-A management.

CONCLUSIONS

We showed here the major input of BTX-A injections in the management of spasticity in CP children. The results are in favor of the use of BTX-A as conservative safe and efficient treatment of spasticity in children, which enables functional improvement as well as pain relief.

Video analysis software increases the interrater reliability of video gait assessments in children with cerebral palsy

The aim of this study was to determine the effect of using video analysis software on the interrater reliability of visual assessments of gait videos in children with cerebral palsy. Two clinicians viewed the same random selection of 20 sagittal and frontal video recordings of 12 children with cerebral palsy routinely acquired during outpatient rehabilitation clinics. Both observers rated these videos in a random sequence for each lower limb using the Observational Gait Scale, once with standard video software and another with video analysis software (Dartfish(®)) which can perform angle and timing measurements. The video analysis software improved interrater agreement, measured by weighted Cohen's kappas, for the total score (κ 0.778→0.809) and all of the items that required angle and/or timing measurements (knee position mid-stance κ 0.344→0.591; hindfoot position mid-stance κ 0.160→0.346; foot contact mid-stance κ 0.700→0.854; timing of heel rise κ 0.769→0.835). The use of video analysis software is an efficient approach to improve the reliability of visual video assessments.

Botulinum toxin assessment, intervention and after-care for lower limb spasticity in children with cerebral palsy: international consensus statement

Botulinum neurotoxin type-A (BoNT-A) has been used in association with other interventions in the management of spasticity in children with cerebral palsy (CP) for almost two decades. This consensus statement is based on an extensive review of the literature by an invited international committee. The use of BoNT-A in the lower limbs of children with spasticity caused by CP is reported using the American Academy of Neurology Classification of Evidence for therapeutic intervention. Randomized clinical trials have been grouped into five areas of management, and the outcomes are presented as treatment recommendations. The assessment of children with CP and evaluation of outcomes following injection of BoNT-A are complex, and therefore, a range of measures and the involvement of a multidisciplinary team is recommended. The committee concludes that injection of BoNT-A in children with CP is generally safe although systemic adverse events may occur, especially in children with more physical limitations (GMFCS V). The recommended dose levels are intermediate between previous consensus statements. The committee further concludes that injection of BoNT-A is effective in the management of lower limb spasticity in children with CP, and when combined with physiotherapy and the use of orthoses, these interventions may improve gait and goal attainment.

Video gait analysis for ambulatory children with cerebral palsy: Why, when, where and how!

PURPOSE

This paper outlines the application of video gait analysis (VGA) for children with cerebral palsy (CP) when full instrumented three dimensional gait analysis (3DGA) is either not indicated or not available.

SCOPE

Gait analysis is an important part of the assessment of ambulant children with CP for diagnosing gait deviations and for evaluating change. Many regard 3DGA as the most informative method of assessing gait, however, it is not always accessible, practical, or feasible and the detail obtained is not always indicated. VGA in conjunction with other carefully selected outcome measures can provide a comprehensive gait assessment in situations where 3DGA is not available or not indicated. Indications for VGA use include: documenting change in gait pattern over time, frequent monitoring in the rehabilitation phase following treatments and interventions (including surgery, spasticity management, serial casting and intensive therapy), monitoring orthotic changes, and for very young children and those with behavioural/cognitive issues that preclude them from cooperating with a 3DGA. Simple and inexpensive VGA systems can be set up in most settings. In an effort to make the process more objective and reliable a number of observational gait scales have been developed. Of these the Edinburgh Gait Score (EGS) has the strongest psychometric properties and is the most comprehensive by including both the coronal and the sagittal planes.

CONCLUSION

While 3DGA remains an important part of complex clinical decision-making, there is also an increasingly important role for VGA. Guidelines need to be developed for its use within the field of gait analysis.

Reproducibility and validity of video screen measurements of gait in children with spastic cerebral palsy

PURPOSE

To determine the reproducibility and validity of video screen measurement (VSM) of sagittal plane joint angles during gait.

METHODS

17 children with spastic cerebral palsy walked on a 10m walkway. Videos were recorded and 3d-instrumented gait analysis was performed. Two investigators measured six sagittal joint/segment angles (shank, ankle, knee, hip, pelvis, and trunk) using a custom-made software package. The intra- and interrater reproducibility were expressed by the intraclass correlation coefficient (ICC), standard error of measurements (SEM) and smallest detectable difference (SDD). The agreement between VSM and 3d joint angles was illustrated by Bland-Altman plots and limits of agreement (LoA).

RESULTS

Regarding the intrarater reproducibility of VSM, the ICC ranged from 0.99 (shank) to 0.58 (trunk), the SEM from 0.81 degrees (shank) to 5.97 degrees (trunk) and the SDD from 1.80 degrees (shank) to 16.55 degrees (trunk). Regarding the interrater reproducibility, the ICC ranged from 0.99 (shank) to 0.48 (trunk), the SEM from 0.70 degrees (shank) to 6.78 degrees (trunk) and the SDD from 1.95 degrees (shank) to 18.8 degrees (trunk). The LoA between VSM and 3d data ranged from 0.4+/-13.4 degrees (knee extension stance) to 12.0+/-14.6 degrees (ankle dorsiflexion swing).

CONCLUSION

When performed by the same observer, VSM mostly allows the detection of relevant changes after an intervention. However, VSM angles differ from 3d-IGA and do not reflect the real sagittal joint position, probably due to the additional movements in the other planes.

The updated European Consensus 2009 on the use of Botulinum toxin for children with cerebral palsy

An interdisciplinary European group of clinical experts in the field of movement disorders and experienced Botulinum toxin users has updated the consensus for the use of Botulinum toxin in the treatment of children with cerebral palsy (CP). A problem-orientated approach was used focussing on both published and practice-based evidence. In part I of the consensus the authors have tabulated the supporting evidence to produce a concise but comprehensive information base, pooling data and experience from 36 institutions in 9 European countries which involves more than 10,000 patients and over 45,000 treatment sessions during a period of more than 280 treatment years. In part II of the consensus the Gross Motor Function Measure (GMFM) and Gross Motor Function Classification System (GMFCS) based Motor Development Curves have been expanded to provide a graphical framework on how to treat the motor disorders in children with CP. This graph is named "CP(Graph) Treatment Modalities - Gross Motor Function" and is intended to facilitate communication between parents, therapists and medical doctors concerning (1) achievable motor function, (2) realistic goal-setting and (3) treatment perspectives for children with CP. The updated European consensus 2009 summarises the current understanding regarding an integrated, multidisciplinary treatment approach using Botulinum toxin for the treatment of children with CP.

Development and reliability of an observational gait analysis tool for children with Down syndrome

PURPOSE

To develop an observational gait analysis tool for children with Down syndrome and to examine its reliability.

METHODS

Two physical therapists and 5 physical therapy students participated in this study. Sixty videos were examined to determine interrater reliability. Four months later, 15 of those 60 videos were reexamined twice (2 weeks apart) by the students for intrarater reliability. Intraclass correlation coefficients for interrater and intrarater reliability, percentage of agreement, and standard error of measurement were calculated.

RESULTS

Interrater reliability was 0.663, intrarater reliability was 0.616-0.877, standard error of measurement was 1.89, and absolute agreement was found for 35.56% of the trials.

CONCLUSION

Good reliability was found, but further study is needed to determine validity and clinical relevance.

Reliability and validity of the Visual Gait Assessment Scale for children with hemiplegic cerebral palsy when used by experienced and inexperienced observers

This study investigated the reliability and validity of the Visual Gait Assessment Scale when used by experienced and inexperienced observers. Four experienced and six inexperienced observers viewed videotaped footage of four children with hemiplegic cerebral palsy on two separate occasions. Validity of the Scale was obtained by comparison with three-dimensional gait analysis (3DGA). The experienced observers generally had higher inter-observer and intra-observer reliability than the inexperienced observers. Both groups showed higher agreement for assessments made at the ankle and foot than at the knee and hip. The experienced observers had slightly higher agreement with 3DGA than the inexperienced observers. The inexperienced observers showed a learning effect and had higher inter-observer agreement and higher agreement with 3DGA in the second assessment of the videotapes. This scale can be used by inexperienced observers but is limited to observations in the sagittal plane and by poor reliability at the knee and hip for experienced and inexperienced observers.

Gillette Gait Index as a gait analysis summary measure: comparison with qualitative visual assessments of overall gait

BACKGROUND

The Gillette Gait Index (GGI) is a summary measure incorporating 16 clinically important kinematic and temporal parameters. The purpose of this study was to compare GGI scores from computerized gait analysis versus qualitative visual assessments of overall gait to assess the validity of the GGI as a summary score for gait analysis.

METHODS

The GGI was calculated for 25 children with cerebral palsy who underwent computerized gait analysis before and 1 year after lower extremity surgery to correct gait problems. Twelve observers reviewed video recordings from the gait analysis to assess the severity of each patient's gait impairment preoperatively and postoperatively and the amount of preoperative to postoperative change. Variability of the video ratings was assessed, and GGI scores were compared with the mean video ratings.

RESULTS

The individual ratings showed some variability, with moderate intrarater agreement (weighted kappa = 0.49-0.56) and slight to fair interrater agreement (kappa = 0.11-0.25). However, the mean scores from all raters were much more consistent, as demonstrated by a highly significant relationship in preoperative to postoperative change viewing the videos separately versus together (r2 = 0.62; P = 0.0001). GGI scores were correlated with these mean scores preoperatively (r2 = 0.34; P = 0.003), postoperatively (r2 = 0.30; P= 0.005), and in preoperative to postoperative change (r2 = 0.30, P = 0.006 for absolute change; r2 = 0.22, P = 0.02 for percentage change).

CONCLUSIONS

These results support the validity of GGI as a gait analysis summary score and suggest that GGI may be a useful outcome measure in patients undergoing gait analysis.

CLINICAL RELEVANCE

Clinicians and researchers should consider using the GGI as a quantitative outcome measure for assessing overall gait.

Test-retest reliability of spatial and temporal gait parameters in children with cerebral palsy as measured by an electronic walkway

PURPOSE

The purpose of this study was to examine test-retest reliability of seven selected temporal and spatial gait parameters and asymmetry measures in children with cerebral palsy.

METHOD

Seventeen children with CP between 3 and 13 years of age walked at three different speeds across an electronic walkway of 5.2m. The tests were repeated after approximately 25 min. The scores were normalized to a walking speed of 1.1m/s to avoid the confounding effect of gait speed on speed dependent gait parameters. Intraclass correlation coefficients (ICC(1,1) and ICC(3,1)) with 95% confidence intervals, within-subject standard deviation (S(w)) and smallest detectable difference (SDD) were calculated.

RESULTS

The relative reliability of cadence, step length, stride length and single stance time was high to excellent (ICC(1,1) between 0.73 and 0.95), while it was poor for step width (ICC(1,1)=0.27 and 0.35). The relative reliability for two calculated asymmetry measures were high for the step length index (ICC(1,1)=0.82) and moderate for the single stance time index (ICC(1,1)=0.49). The absolute reliability values for all gait parameters are reported.

CONCLUSIONS

Five of seven gait parameters measured by an electronic walkway and normalized to a common walking speed, appear to be highly repeatable in a short-term time span in children with CP who were able to walk without assistive walking devices, provided sufficient cognitive function.

Effects of Botulinum Toxin A Therapy with Electrical Stimulation on Spastic Calf Muscles in Children with Cerebral Palsy

OBJECTIVE

To assess the additive effect of adjuvant electrical stimulation on botulinum toxin A injection in children with spastic diplegic cerebral palsy.

DESIGN

Eighteen children with dynamic foot equinus deformity were treated with botulinum toxin A injection into the calf muscles. Seven children were assigned to a treatment group who received botulinum toxin A and adjuvant electrical stimulation, and 11 children were assigned to a control group with botulinum toxin injection only. Before botulinum injection, and at 2 wks and 3 mos after injection, the Physician Rating Scale, passive ranges of ankle and knee motion, and the modified Ashworth scale were measured.

RESULTS

A significant increase in passive range of ankle motion was observed at 2 wks after injection in the treatment group and at 3 mos after injection in both groups. Both groups showed significant improvements by the modified Ashworth scale at 2 wks after injection. Subscales of the Physician Rating Scale (equinus foot, crouched gait) and total Physician Rating Scale scores were significantly improved in the treatment group at 3 mos after injection, but this was not observed in the control group.

CONCLUSIONS

Adjuvant electrical stimulation for a short period after botulinum toxin A injection was found to benefit early improvement of range of motion and maintenance of gait improvement in children with spastic diplegia cerebral palsy showing dynamic equinus.

Effect of multilevel botulinum toxin a and comprehensive rehabilitation on gait in cerebral palsy

To evaluate the effect of multilevel botulinum toxin A and comprehensive rehabilitation on gait pattern, muscle length, and spasticity, a multicenter randomized trial was performed in 46 children with spastic cerebral palsy who walk with flexed knees. Their mean age was 8.0 years (range 4 to 11 years). They were randomly allocated to the intervention group (multilevel botulinum toxin A and comprehensive rehabilitation) or the control group (usual care). After 6 weeks, a significant treatment effect in the intervention group was observed on: improved knee extension during midstance and terminal swing (7 degrees and 5 degrees , P < 0.01, respectively); hip rotation during terminal swing (4 degrees , P = 0.02); gait score (1.7, P < 0.01); decreased spasticity in hamstrings (11 degrees , P < 0.01), gastrocnemius (6 degrees , P = 0.01), and soleus (5 degrees , P = 0.02); and increased muscle length in hamstrings (9 degrees , P < 0.01) and gastrocnemius (5 degrees , P < 0.01). The improved muscle length was maintained up to 24 weeks. This study demonstrated that multilevel botulinum toxin A and comprehensive rehabilitation improves knee extension during gait, increases muscle length, and decreases spasticity in injected muscles after 6 weeks in children who walk with flexed knees. Although the effect on muscle length was maintained after 24 weeks, the effect on gait and spasticity had disappeared.

European consensus table 2006 on botulinum toxin for children with cerebral palsy

An interdisciplinary group of experienced botulinum toxin users and experts in the field of movement disorders was assembled, to develop a consensus on best practice for the treatment of cerebral palsy using a problem-orientated approach to integrate theories and methods. The authors tabulated the supporting evidence to produce a condensed but comprehensive information base, pooling data and experience from nine European countries, 13 institutions and more than 5500 patients. The consensus table summarises the current understanding regarding botulinum toxin treatment options in children with CP.