Reliability of popliteal angle measurement: a study in cerebral palsy patients and healthy controls

Reliability of the Clinical Measurement of Joint Motion and Muscle Length in the Upper and Lower Extremities of Children with Cerebral Palsy: A Systematic Review

Reliability of joint motion and muscle length measurement in children with cerebral palsy was examined. Twenty-one studies of intraobserver and/or interobserver reliability were reviewed: joint motion of upper extremities in four and lower extremities in 13; muscle length of upper extremities in one and lower extremities in 15. Intraclass correlation coefficients for goniometric interobserver reliability varied widely for joint motion (range 0.38-0.92) and muscle length (range 0.20-0.95). Inclusion of an error measurement to provide clinicians with a value indicating true change was limited. Further research is required to determine intraobserver and interobserver reliability for these important pediatric clinical measurements.

Interrater reliability for unilateral and bilateral tests to measure the popliteal angle in children and youth with cerebral palsy

Background

Short hamstring muscles can cause several problems for children with cerebral palsy. The results of the clinical measurement of hamstring length are often used in decision-making about treatment of children with cerebral palsy. There are different ways of performing this measurement. The aim of this study was to evaluate the interrater reliability of the unilateral and bilateral measurement of the popliteal angle in children and youth with cerebral palsy.

Methods

Two methods for estimating hamstring length using unilateral and bilateral measurements of the popliteal angle were applied in children with cerebral palsy. Both tests were applied bilaterally by two independent examiners on the same day for each child. The intraclass correlation coefficient (ICC) was calculated to evaluate the interrater reliability of both measurements. Seventy young people with cerebral palsy (32 females, 38 males, mean age 10 years 8 months, range 5–22 years) at Gross Motor Function Classification System levels I (n = 17), II (n = 31), III (n = 12) and IV (n = 10) were included.

Results

The interrater reliability was good for both measurements. The ICC values were 0.80 on the right and 0.86 on the left for the unilateral popliteal angle, and 0.82 on the right and 0.83 on the left for the bilateral popliteal angle.

Conclusions

Both unilateral and bilateral measurement of the popliteal angle is a reliable method for estimating hamstring length in children and youth with cerebral palsy.

Photo-Based Range-of-Motion Measurement: Reliability and Concurrent Validity in Children With Cerebral Palsy

PURPOSE

To investigate intrarater and interrater reliability, agreement, and concurrent validity of a smartphone photography-based application compared with a universal goniometer in children with cerebral palsy.

METHODS

Range of motion of hip abduction, popliteal angle, and ankle dorsiflexion was measured with a universal goniometer and a photography-based application in children with cerebral palsy, Gross Motor Function Classification System levels I to V.A 2-way random-effects intraclass correlation coefficients and Bland-Altman plots, standard error of measurement, and smallest detectable change were used for analyses.

RESULTS

The application had good to excellent reliability and concurrent validity compared with a universal goniometer, while the large measurement error of both methods suggests that changes of 10° to 23° are needed to be certain that changes over time are not results of measurement error.

CONCLUSIONS

A photography-based goniometer can be a reliable and valid tool when measuring range of motion in children with cerebral palsy.

Change in popliteal angle and hamstrings spasticity during childhood in ambulant children with spastic bilateral cerebral palsy. A register-based cohort study

BACKGROUND

Muscle contractures are developing during childhood and may cause extensive problems in gait and every day functioning in children with cerebral palsy (CP). The aim of the present study was to evaluate how the popliteal angle (PA) and hamstrings spasticity change during childhood in walking children with spastic bilateral CP.

METHODS

The present study was a longitudinal register-based cohort study including 419 children (1-15 years of age) with spastic bilateral CP, gross motor function classification system (GMFCS) level I, II and III included in the Norwegian CP Follow-up Program (CPOP). From 2006 to 2018 a total of 2193 tests were performed. The children were tested by trained physiotherapists yearly or every second year, depending on GMFCS level and age. The PA and the hamstrings spasticity (Modified Ashworth scale (MAS)) were measured at every time point. Both legs were included in the analysis.

RESULTS

There was an increase in PA with age for all three GMFCS levels with significant differences between the levels from 1 up to 8 years of age. At the age of 10 years there was no significant difference between GMFCS level II and III. At the age of 14 years all three GMFCS levels had a mean PA above 40° and there were no significant differences between the groups. The hamstrings spasticity scores for all the three GMFCS levels were at the lower end of the MAS (mean < 1+), however they were significantly different from each other until 8 years of age. The spasticity increased the first four years in all three GMFCS levels, thereafter the level I and II slightly increased, and level III slightly decreased, until the age of 15 years.

CONCLUSION

The present study showed an increasing PA during childhood. There were significantly different PAs between GMFCS level I, II and III up to 8 years of age. At the age of 14 years all levels showed a PA above 40°. The spasticity increased up to 4 years of age, but all the spasticity scores were at the lower end of the MAS during childhood.

Postanesthesia alternation of lower limb contractures in children with spastic cerebral palsy

The aim of this study was to clarify the effects of general anesthesia (GA) on joint range of motion (ROM) in children with spastic cerebral palsy (SCP). Eighty-four SCP cases (mean age 8.4 years) admitted for first corrective surgery were retrospectively reviewed. Lower limb ROM were measured 1 day before operation and immediately after GA. Contracture of hip, knee, and ankle joints decreased significantly after GA, with + 11.1° (39.5%) for the hip abduction angle, -3.7° (18.0%) for the Thomas test, -15.0° (19.1%) for the popliteal angle, + 6.6° (39.8%) and 7.0° (109%) for ankle dorsiflexion with knee flexion and extension, respectively (all P < 0.001). These changes were correlated positively to pre-GA contracture and body weight, negatively to age, but independent of preoperative functional level, geographic classification of SCP, or modified Ashworth scale. On the basis of these findings, routine post-GA reassessments of joint ROM before corrective surgeries were recommended for pediatric SCP cases.

Outcome Assessment and Function in Cerebral Palsy

Care and research in childhood cerebral palsy (CP) continue to evolve. As our understanding of CP grows more nuanced, so grows our need to describe function, activities, challenges, adaptations of children with CP. In CP, robust means of measuring outcomes are vital to understanding utility of treatments. Research must accurately measure meaningful constructs of children with CP as a reliable ruler to establish if interventions produce useful effects. This article addresses the challenges of outcome measurement in CP, current status of outcome measurement in CP, and issues of understanding change in childhood CP.

The popliteal angle tests in patients with cerebral palsy

The aims were to determine during the popliteal angle (PA) tests whether particular knee muscles are activated and whether the position of pelvis affects the level of muscles activation. Twenty-two patients with cerebral palsy were recruited (age: 14±4.94 years). Knee muscle activities and range of motion were measured during PA. Knee flexors were active during tests, with fivefold increase of activation of ipsilateral hamstring. Higher and more frequent activation of muscles only in the contralateral limb was seen. Muscles activation should be considered as a confounding factor during tests. PA should not be relied upon as a major criterion for the treatment selection in cerebral palsy.

Stretching and Progressive Resistance Exercise in Children With Cerebral Palsy: A Randomized Controlled Trial

PURPOSE

To evaluate the effect of stretching and progressive resistance exercise on range of motion and muscle strength in children with cerebral palsy.

METHODS

Thirty-seven children with spastic bilateral cerebral palsy and Gross Motor Function Classification System levels I to III were randomized to an intervention and a comparison group. The intervention included stretching of hamstrings and progressive resistance exercise, targeting the lower extremities for 16 weeks, followed by a 16-week maintenance program. Passive and active popliteal angle and muscle strength were evaluated at 0, 16, and 32 weeks.

RESULTS

After 16 weeks nonsignificant improvements were found in passive, active popliteal angle and quadriceps and hamstrings strength.

CONCLUSION

A 16-week stretching and progressive resistance exercise program followed by a 16-week maintenance program showed nonsignificant improvements in passive, active popliteal angle and muscle strength for the intervention group.

Reliability of Inclinometer-Derived Passive Range of Motion Measures in Youth with Cerebral Palsy

Aims: This study evaluated, for youth with cerebral palsy (CP), the reliability of passive range of motion (PROM) measures taken with an inclinometer, a device that may be simpler to use than a goniometer. Methods: The PROM for elbow and wrist extension, ankle dorsal flexion (knee flexed 90° and fully extended), and the knee popliteal angle of 30 youth with CP (18 boys, 12 girls, 7.0 ± 3.8 years old, classified in Gross Motor Function Classification levels I-V) was measured using an inclinometer. Two physical therapists took the measures during two different sessions, a maximum of 1 week apart. Results: Good mean intra-rater inter-session, inter-rater intra-session, and inter-rater inter-session reliability (ICC = 0.75-0.89), was found for the elbow, ankle, and knee sites. Absolute reliability for these sites and conditions was 7-14° (90% confident) and 10-16° (95% confident). Reliability values for wrist extension were comparable, albeit slight lower. Conclusions: Similar to published values for goniometry, inclinometery yields reliable upper and lower limb PROM measures from ambulatory and non-ambulatory youth with CP whether measures are carried out by different evaluators within or across sessions or whether measures are performed by the same evaluator across sessions.

Normative Values of Physical Examinations Commonly Used for Cerebral Palsy

PURPOSE

The aim of this study was to establish normative values and to identify age-related change in physical examinations that are commonly used while evaluating patients with cerebral palsy (CP).

MATERIALS AND METHODS

One hundred four healthy volunteers (mean age 36 years, standard deviation 15 years) were enrolled and divided into four age groups: 13-20, 21-35, 36-50, and 51 years and older. The eighteen physical examination tests for CP were selected by five orthopedic surgeons in consensus-building session. The measurements were taken by three orthopedic surgeons.

RESULTS

There was no significant difference in the measures of physical examination among all the age groups, except for the Staheli test (p=0.002). The post hoc test revealed that the mean hip extension was 2.7° higher in the 13-20-year-old group than in the other age groups. The bilateral popliteal angle had a tendency to increase in those over 36-years-old. There were 31 participants (30%) with a unilateral popliteal angle greater than 40°.

CONCLUSION

We documented normative values that can be widely used for evaluating CP in patients 13 years and older.

Simulated Ankle Equinus Affects Knee Kinematics During Gait

BACKGROUND

It is critical to distinguish gait compensations from true abnormalities when planning interventions to improve gait in individuals with neuromuscular disorders.

QUESTIONS/PURPOSES

The aim of this study was to determine the effect of isolated ankle equinus on knee kinematics during the initial contact phase of gait.

METHODS

Ten healthy subjects (29 + 4.3 years) participated, and testing occurred in a motion analysis laboratory. This cross-sectional study investigated five gait conditions in each subject: shoe alone, shoe with unilateral ankle foot orthosis locked at neutral, 10°, 20°, and 30° of fixed ankle plantar flexion. Gait kinematics were recorded and calculated with 3D motion analysis. The difference between the shoe and each brace condition was analyzed by repeated-measures ANOVA. The primary outcome was knee flexion at initial contact.

RESULTS

With greater than 10° simulated ankle equinus, the primary gait compensation pattern was increased knee flexion at initial contact. A significant degree of knee flexion occurred ranging from 7° to 22°.

CONCLUSION

Our data suggests that observed knee flexion at initial contact may be a compensation pattern in individuals with >10° ankle equinus. However, in individuals with ≤10° ankle equinus, observed knee flexion may represent a true gait deviation. This has clinical significance in the realm of cerebral palsy for treatment planning to improve gait.

Assessment of net knee moment-angle characteristics by instrumented hand-held dynamometry in children with spastic cerebral palsy and typically developing children

Background

The limited range of motion during walking in children with spastic cerebral palsy (SCP) may be the result of altered mechanical characteristics of muscles and connective tissues around the knee joint. Measurement of static net knee moment-angle relation will provide insights into these alterations, for which instrumented hand-held dynamometry may be applied.

The aims of this study were: (1) to test the measurement error of the estimated net knee moment-angle characteristics, (2) to determine the correlation between knee extension angle measurement at a standardized knee moment and popliteal angle from common physical examination and (3) to compare net knee moment–angle characteristics in SCP versus typically developing children.

Methods

With the child lying in sideward position, the knee was extended by moving the lower leg by a hand-held force transducer on a low friction cart. Force data were collected for a range of knee angles. Data were excluded when activity (EMG) levels of knee extensor and flexor muscles exceeded the EMG level during rest by more than two standard deviations. The net knee flexion moments were calculated from recorded force data and measured moment arm. Reliability for knee angles corresponding with 0.5, 1, 2, 3, and 4 Nm knee net flexion moments was assessed by standard error of measurements (SEM) and smallest detectable difference (SDD).

Results

For between day comparison, SEMs were about 5° and SDDs were below 14° for knee angles at 1-4 Nm net knee flexion moments. In SCP children, the knee angle measured at 4 Nm knee flexion moment was not related to the popliteal angle (r = 0.52). The slope at 4 Nm of the knee moment-angle curve in SCP children was significantly higher than that in typically developing children.

Conclusions

The presented knee hand-held dynamometry allows assessment of net knee flexion moment-knee angle characteristics in typically developing and SCP children and can be used to identify clinically relevant changes as a result of treatment. Overall stiffness of structures that contribute to the net knee flexion moment at the knee (i.e. muscles, tendons, ligaments) is elevated in SCP children.

Electronic supplementary material

The online version of this article (doi:10.1186/s12984-015-0056-y) contains supplementary material, which is available to authorized users.

Assessment and comparison of the effects of two techniques on hamstring flexibility

Introduction There are several stretching techniques that help increase flexibility, however, there are still questions regarding which method leads to the most effective gains. Objectives To assess and compare the effects of two stretching techniques, namely proprioceptive neuromuscular facilitation (PNF) and static stretching on the flexibility of hamstring muscles of young women. Methods The study sample consisted of 45 young women, mean age 20.45 (± 1.66),assigned to one of three groups: static stretching group (SSG, n = 15), proprioceptive neuromuscular facilitation group (PNFG, n = 15) and control group (CG, n = 15). Both SSG and PNFG carried out three weekly stretching sessions over a four-week period. The sit and reach and popliteal angle tests were used at the beginning and end of the intervention. Normally distributed data were analyzed using Student’s t-test, whereas data with non-normal distribution were analyzed using the Wilcoxon test, to compare initial and end measurements for each technique. Finally, we used the Mann-Whitney U test to compare both techniques with each other. A significance level of 5% (p < 0.05) was adopted. Results There was a significant increase in hamstring flexibility when analyzing the assessments and reassessments of both stretching protocols. Conclusions Both techniques were effective in increasing hamstring flexibility and there were no significant differences to indicate which one is better in increasing the flexibility of this muscle group.

Stability of serial range-of-motion measurements of the lower extremities in children with cerebral palsy: can we do better?

BACKGROUND

Serial joint range-of-motion (ROM) measurements are an important component of assessments for children with cerebral palsy. Most research has studied ROM stability using group data. Examination of longitudinal intraindividual measures may provide more clinically relevant information about measurement variability.

OBJECTIVE

The aim of this study was to examine the stability of intraindividual longitudinal measurements of hip abduction (ABD), popliteal angle (POP), and ankle dorsiflexion (ADF) ROM measures of children with cerebral palsy.

DESIGN

Secondary data analyses were performed.

METHODS

The stability patterns of individual serial measurements of ABD, POP, and ADF from 85 children (mean age=3.8 years, SD=1.4) collected at baseline (T1), 3 months (T2), 6 months (T3), and 9 months (T4) were examined using T1 as the anchor and bandwidths of ±15 degrees (ABD and POP) and ±10 degrees (ADF) as acceptable variability. Frequencies of stability categories (0°-5°, 5.1°-10°, 10.1°-15°, and >15°) were calculated. Patterns of stability across the 4 time periods also were examined. Group means (T1-T4) were compared using repeated-measures analysis of variance.

RESULTS

No significant differences in group means were found except for ABD. Stability patterns revealed that 43.3% to 69.5% of joint measurements were stable with T1 measurements across all 3 subsequent measurements. Stability category frequencies showed that many measurements (ABD=17%, POP=29.9%, and ADF=37.1%) went outside the variability bandwidths even though 39% or more of joint measurements had a change of 5 degrees or less over time.

LIMITATIONS

Measurement error and true measurement variability cannot be disentangled. The results cannot be extrapolated to other joint ROMs.

CONCLUSIONS

Individual ROM serial measurement exhibits more variability than group data. Range-of-motion data must be interpreted with caution clinically and efforts made to ensure standardization of data collection methods.

Agreement between visual and goniometric assessments of adductor and popliteal angles in infants

CONTEXT

Amiel-Tison method is a commonly used technique for assessing tone and neurological status of infants. There is a paucity of data on the reliability of visual assessment of angles, a component of this method.

SUBJECTS AND METHODS

We compared the visual and the goniometric assessment of adductor and popliteal angles in infants with hypertonia and neurologically normal controls. A total of 16 infants with hypertonia and 15 normal infants underwent blinded assessment of the adductor and popliteal angles.

STATISTICAL ANALYSIS

The mean and standard deviation for the difference between visual and goniometric measurements were calculated for popliteal and adductor angles.

RESULTS

The mean differences between visual and goniometric measurements for the popliteal angle were 4.94 (SD3.40) and 8.73 (SD6.10) degrees for the cases and controls respectively. Similarly, the values for adductor angle measurements were 8.94 (SD8.23) and 14.47 (SD8.47) degrees respectively.

CONCLUSION

The deviation of visual assessment from goniometric measurement was found to be less for popliteal angle measurement as compared to adductor angle measurements. It was note-worthy that the difference was less for the measurements of children with spasticity.

Comparação do alongamento estático, balístico e contrair-relaxar nos músculos isquiotibiais

Objetivou-se, por meio deste estudo, comparar o efeito de três técnicas de alongamento muscular (balístico, estático e contrai-relaxa) no ganho imediato de flexibilidade dos músculos isquiotibiais. Foram avaliados 23 sujeitos, de ambos os gêneros [média (DP) idade 21,17 (1,4)]. Todos os voluntários realizaram o alongamento estático, o balístico e o contrai-relaxa. Cada técnica foi realizada em sessão única com intervalo de sete dias entre as sessões. Para avaliar os efeitos imediatos das diferentes técnicas, realizaram-se, antes e após a série de alongamentos, os testes de flexibilidade Sentar e Alcançar e o Teste do Ângulo Poplíteo. Em comparação à linha de base, houve aumento significativo de flexibilidade para o teste do Ângulo Poplíteo após aplicação do alongamento balístico (6,26%) e contrai-relaxa (6,5%), respectivamente (p<0,05). Ao contrair-relaxar as três técnicas em relação ao escore de mudança, encontrou-se diferença considerável no teste do Ângulo Poplíteo para os alongamentos balístico e contrair-relaxar, porém, o Teste Sentar e Alcançar não apresentou relevância. De acordo com esses dados, as técnicas balísticas e -contrair-relaxar foram melhores que a técnica de alongamento estático, e ambas as técnicas mostraram-se igualmente efetivas. As técnicas de alongamento balístico e contrair-relaxar melhoraram a flexibilidade dos músculos isquiotibiais.

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.

The Toe Walking Tool: a novel method for assessing idiopathic toe walking children

BACKGROUND

The diagnosis of idiopathic toe walking (ITW) is achieved by the exclusion of all medical causes associated with toe walking. In order to identify children with this gait type, an online Toe Walking Tool questionnaire was developed that utilized questions to identify healthy idiopathic toe walkers and excluded those who toe walk as a result of a medical condition.

METHOD

A Delphi panel process was conducted to establish the relevance and validity of the questions. A group of 10 allied health professionals assessed 12 children utilizing the Toe Walking Tool. A kappa was calculated to determine reliability.

RESULTS

Clinicians agreed the questionnaire was an appropriate and effective assessment tool. The tool proved valid in that no child tested who toe walked as a result of a medical condition was able to progress through the testing process. Testing group of practitioners had a Fleiss Kappa agreement of 0.928.

CONCLUSION

The Toe Walking Tool is a valid and reliable method of assessing children who present to the general allied health clinician with toe walking. This tool can assist with the decision of when to refer a child for further specialist investigation of their toe walking.

Walking ability and predictors of performance on the 6-minute walk test in adults with spastic cerebral palsy

AIM

To describe walking ability and identify factors predicting walking capacity in adults with spastic cerebral palsy (CP) assessed with the 6-minute walk test (6MWT).

METHOD

A cross-sectional clinical study as part of the recruitment process for a randomized controlled trial on the effects of botulinum toxin A. Data analysed were the 6MWT, Timed Up and Go (TUG) test, Borg Scale, spasticity, muscle strength, popliteal angle, pain, fatigue, type of CP, foot deformity, Gross Motor Function Classification System (GMFCS) levels, Functional Mobility Scale (FMS) scores, a gait questionnaire, interview, and demographic data.

RESULTS

In total, 126 persons were included (53 males, 73 females; mean age 39 y [SD 12 y]; 59 with unilateral and 67 with bilateral spastic CP; GMFCS level I, n=12; level II, n=94; level III, n=20). Mean distance on the 6MWT was 485 m (SD 95 m) with FMS scores reflecting independent walking performance in daily life. Multiple regression analysis identified sex, type of CP, popliteal angle, pain, and TUG values as significant predictors, with TUG values as the strongest predictor (standardized regression coefficient=-0.57, p<0.001).

INTERPRETATION

Our results demonstrate that 39% of the participants had declined one GMFCS level from adolescence to their present age, and that the TUG was the strongest predictor for the 6MWT. This implicates the importance of focusing specifically on the different elements of functional mobility in further studies.

Natural history of flexed knee gait in diplegic cerebral palsy evaluated by gait analysis in children who have not had surgery

Eighteen children with diplegic cerebral palsy and no history of orthopaedic surgery had two gait analyses a mean of 6.3 years apart to analyse the effects of time on their gait. The mean age of the children at first analysis was 7.7 years (range 4.4-13.3 years). The data was analysed as a whole group (18 children) and as two sub-groups of nine children: those with a shorter follow-up (mean 5.0 years) and those with a longer follow-up (mean 7.5 years) between analyses. The following significant bilateral changes were seen in the whole group and longer follow-up sub-group: deterioration in the range of knee flexion, mid-stance knee flexion, peak knee extension in stance and hamstring length and an improvement in mean and maximum hip rotation. Temporal data showed no significant changes once normalised. There were no bilateral significant changes in data from children evaluated at a mean of 5 years follow-up. GMFCS scores generally improved over time despite the significant increase in flexed knee gait. There was no significant change in gait deviation index in any group over time. There was an increase in body mass index in 16 children but there was no correlation between this and the degree of mid-stance knee flexion. These findings may have implications for longer term follow-up of children with cerebral palsy into adulthood.

Is visual estimation of passive range of motion in the pediatric lower limb valid and reliable?

Background

Visual estimation (VE) is an essential tool for evaluation of range of motion. Few papers discussed its validity in children orthopedics' practice. The purpose of our study was to assess validity and reliability of VE for passive range of motions (PROMs) of children's lower limbs.

Methods

Fifty typically developing children (100 lower limbs) were examined. Visual estimations for PROMs of hip (flexion, adduction, abduction, internal and external rotations), knee (flexion and popliteal angle) and ankle (dorsiflexion and plantarflexion) were made by a pediatric orthopaedic surgeon (POS) and a 5^th year resident in orthopaedics. A last year medical student did goniometric measurements. Three weeks later, same measurements were performed to assess reliability of visual estimation for each examiner.

Results

Visual estimations of the POS were highly reliable for hip flexion, hip rotations and popliteal angle (ρ_c ≥ 0.8). Reliability was good for hip abduction, knee flexion, ankle dorsiflexion and plantarflexion (ρ_c ≥ 0.7) but poor for hip adduction (ρ_c = 0.5). Reproducibility for all PROMs was verified. Resident's VE showed high reliability (ρ_c ≥ 0.8) for hip flexion and popliteal angle. Good correlation was found for hip rotations and knee flexion (ρ_c ≥ 0.7). Poor results were obtained for ankle PROMs (ρ_c < 0.6) as well as hip adduction and abduction, the results of which not being reproducible. Influence of experience was clearly demonstrated for PROMs of hip rotations, adduction and abduction as well as ankle plantarflexion.

Conclusion

Accuracy of VE of passive hip flexion and knee PROMs is high regardless of the examiner's experience. Same accuracy can be found for hip rotations and abduction whenever VE is performed by an experienced examiner. Goniometric evaluation is recommended for passive hip adduction and for ankle PROMs.

Evaluation of clinical spasticity assessment in cerebral palsy using inertial sensors

Spasticity is clinically assessed using goniometry to measure the joint angle of the catch (AOC) during fast passive muscle stretch. The precision and accuracy of the goniometric AOC measurements are questionable, because of the inevitable joint repositioning after occurrence of the catch. This study aims to evaluate the use of goniometry in estimating the AOC in spasticity assessment of the medial hamstrings, soleus and gastrocnemius in twenty children with Cerebral palsy (CP), using inertial sensors (IS) as reference system. The IS were initially validated with an optoelectronic system to measure 3d-orientation and proved to be accurate within 1 degree. To evaluate the precision and accuracy of the goniometry, the joint angle measured with the goniometer after repositioning was compared to the joint angle measured simultaneously with the IS, and to the true AOC, detected and measured with the IS during the fast muscle stretch. Results showed that goniometry is an imprecise method to measure the true AOC in spasticity assessment. The error is mainly due to joint repositioning after the fast muscle stretch. For spasticity assessment, it is advised to apply inertial sensors when a precise measurement of the angle of catch is required.

Understanding function and other outcomes in cerebral palsy

Describing the status of children with cerebral palsy (CP) and quantifying change in their status are 2 central challenges to research and clinical management of CP. The science of assessing and reporting status is outcome measurement, and it is rapidly developing in the arena of CP. Because of the large number of domains to measure, the variability of CP manifestations, and a limited number of "gold standard" evaluations, creating an accurate, comprehensive, responsive, and broadly applicable measurement strategy is a serious endeavor. A range of outcome measures are available to address CP issues across the spectrum of disability. The use of these measures, and others yet to be developed, provides researchers and clinicians the best means of understanding CP and the effects of treatments.

Nerve palsy after hamstring lengthening in patients with cerebral palsy

BACKGROUND

The purpose of this study was to assess the incidence of, risk factors for, and treatment of nerve palsy after hamstring lengthening in children with cerebral palsy.

METHODS

A medical record review of patients with cerebral palsy who had hamstring lengthening between 1994 and 2005 was performed. Data included the preoperative popliteal angle, the presence of a knee flexion contracture, postoperative pain management, and type of immobilization. The presence of postoperative nerve palsy was established based on the recording of numbness, loss of motor function in the foot, or hypersensitivity of the foot in the inpatient record or the postoperative clinic notes. The need for medical management and time to resolution of symptoms were noted.

RESULTS

A total of 292 children underwent 329 hamstring lengthening surgeries. The mean age at surgery was 9.5 years (range, 2.5-18 years). Twenty-eight patients (9.6%) experienced postoperative nerve palsy. Time to recognition of the palsy ranged from 4 hours to 72 days. Patients diagnosed within 24 hours had loss of motor function and/or lack of sensation of the toes. Patients diagnosed from 8 to 72 days postoperatively had dysesthesias of the feet. Treatment of early palsies consisted of the removal of immobilization, bivalving of casts, or wedging casts into flexion. Fourteen of 28 patients were treated with Neurontin. Twenty-two of 25 patients with adequate follow-up recovered nerve function. Older children, noncommunicative patients, nonambulatory patients, and those who had epidural pain management were at statistically significant higher risk for postoperative palsy. The trend for palsies in spastic quadriplegic patients and after repeat lengthening procedures did not reach significance. There was no significant relationship between popliteal angle or the presence of a knee flexion contracture and development of nerve palsy.

CONCLUSIONS

Nerve palsy occurred in 9.6% of patients undergoing hamstring lengthening. Although the greatest risk was in noncommunicative adolescents who were nonambulatory, a small number of younger ambulatory patients developed palsies as well, so that all patients must be considered at risk. Vigilance in patients with epidural pain control to avoid excessive hip flexion and/or knee extension is warranted. Treatment is immediate knee flexion. Resolution of symptoms occurred in 82.1% of patients.

Efeito de diferentes tempos de alongamento na flexibilidade da musculatura posterior da coxa

O alongamento é uma das técnicas mais utilizadas para se obter aumento da amplitude de movimento (ADM), porém não há consenso sobre o tempo necessário de alongamento para aumentar a flexibilidade. O objetivo do estudo foi verificar qual tempo de duração de alongamento é mais eficaz, avaliando-se a flexibilidade pela mensuração do ângulo poplíteo (AP). Foram recrutadas 30 voluntárias com idade média de 21,1±2,9 anos, divididas aleatoriamente em cinco grupos (controle, 15, 60, 90 e 120 segundos), e submetidas a quatro semanas de alongamento passivo durante diferentes tempos, sendo avaliadas por três examinadores clínicos pelo teste do AP associado à ADM. Os dados foram submetidos a análise estatística, com nível de significância p<0,05; para verificar a confiabilidade inter-examinadores foi utilizado o coeficiente de correlação intraclasse (ICC); a confiabilidade foi excelente (ICC=0,985). Houve diferença significativa quando se compararam 15 segundos de alongamento com 120 segundos (p<0,01) e também na comparação entre os grupos de 90 e 120 segundos (p<0,05). O ganho de ADM foi maior nos grupos 90 e 120 segundos. O grupo de 120 segundos apresentou a maior média e o de 90 segundos, a maior variação no quesito confiabilidade entre examinadores. Conclui-se que quanto maior o tempo de sustentação do alongamento, maior será o ganho de flexibilidade.