Relationship Between Functional Level and Muscle Thickness in Young Children With Cerebral Palsy

Association of activities of daily living and cognitive function with thickness of the upper extremity muscles in children and adults with cerebral palsy

PURPOSE

We examined the association of activities of daily living (ADL) and cognitive function with the upper extremity muscle thickness and upper extremity range of motion (ROM) and spasticity in children and adults with cerebral palsy (CP).

METHODS

The subjects were 20 children and adults with CP. The ADL performed using the upper extremities and cognitive function were assessed using the self-care domain of the Pediatric Evaluation of Disability Inventory (PEDI) and the full-scale intelligence quotient (FSIQ) of the Wechsler Intelligence Scale for Children, fourth edition (WISC-IV), respectively. The WISC-IV was assessed in only seven of 20 subjects able to undergo evaluation. The thickness of the upper extremity muscles was measured using an ultrasound imaging device. Moreover, ROM and spasticity of the upper extremities were assessed using the Modified Ashworth Scale (MAS). Manual manipulation ability was also assessed using the Manual Ability Classification System (MACS).

RESULTS

Stepwise regression analysis revealed that the extensor digitorum muscle thickness and MACS level were significant and independent factors of self-care in the PEDI. Partial correlation analysis with MACS level and age as control variables showed that the FSIQ of the WISC-IV was significantly associated with the thickness of the anterior fibers of the deltoid and flexor digitorum superficialis muscles.

CONCLUSION

Reduced ADL performed using the upper extremities is associated with decreased extensor digitorum muscle thickness rather than ROM and spasticity of the upper extremities in children and adults with CP.

Association of gross motor function and activities of daily living with muscle mass of the trunk and lower extremity muscles, range of motion, and spasticity in children and adults with cerebral palsy

PURPOSE

We examined the association of gross motor function and activities of daily living (ADL) with muscle mass of the trunk and lower extremity muscles in children and adults with cerebral palsy (CP).

METHODS

The subjects were 32 children and adults with CP. Muscle thickness of the trunk and lower extremity muscles was measured using an ultrasound imaging device.

RESULTS

Stepwise regression analysis revealed that the thoracic erector spinae muscle thickness was a significant and independent factor of gross motor function. Stepwise regression analysis also showed that the thickness of the rectus abdominis and vastus lateralis muscles were significant and independent factors of ADL.

CONCLUSIONS

Our findings suggest that declined gross motor function is associated with decreased thoracic erector spinae muscle mass in children and adults with CP. The results also indicate that declined ADL is associated with decreased muscle mass of the rectus abdominis and vastus lateralis muscles.

Relationship between ankle function and walking ability for children and young adults with cerebral palsy: A systematic review of deficits and targeted interventions

BACKGROUND

A primary goal of treatment for children with cerebral palsy is improved walking ability to allow for a more active and independent lifestyle. With the importance of ankle function to walking ability, and the deficits in ankle function associated with cerebral palsy, there is good rationale for targeting this joint in an effort to improve walking ability for this population.

RESEARCH QUESTION

How do deficits and targeted interventions of the ankle joint influence walking ability in children with cerebral palsy?

METHODS

A specific search criteria was used to identify articles that either (1) provided information on the relationship between ankle function and walking ability or (2) investigated the effect of a targeted ankle intervention on walking ability in cerebral palsy. PubMed, Embase, CINAHL, and Web of Science databases were searched from 1980-April, 2020. Resulting citations were compared against a prospective set of inclusion and exclusion criteria. Data relevant to the original research question was extracted, and the level of evidence for each intervention study was scored. Interpretation was focused on specific, pre-determined mobility measures.

RESULTS

Sixty-one citations met all criteria for data extraction, six of which were observational, and fifty-five of which were interventional. Level of evidence ranged from 2 to 4. Self-selected walking speed was the most common measure of walking ability, while physical activity level was the least common.

SIGNIFICANCE

Ankle function is an important contributor to the walking ability of children with cerebral palsy, and most interventions targeting the ankle seem to demonstrate a benefit on walking ability, but future higher-powered and/or controlled studies are necessary to confirm these findings.

Association of sagittal spinal alignment in the sitting position with the trunk and lower extremity muscle masses in children and adults with cerebral palsy: A pilot study

BACKGROUND

We examined the association of sagittal spinal alignment in the sitting position with the trunk and lower extremity muscle masses in children and adults with cerebral palsy (CP). We also compared muscle masses between children and adults with CP who could and could not sit without the support of their upper extremities.

METHODS

The subjects were 34 children and adults with CP. Sagittal spinal alignment in the sitting position, such as thoracic kyphosis, lumbar lordosis, and sacral anterior inclination angles were measured using a Spinal Mouse. The thicknesses of the trunk and lower extremity muscles were measured using an ultrasound imaging device. Furthermore, the subjects were classified into the sitting-possible group (n = 18), who could sit without the support of the upper extremities, or a sitting-impossible group (n = 16), who could not sit without the support of the upper extremities.

FINDINGS

Stepwise regression analysis revealed that the lumbar multifidus muscle thickness and body weight were significant and independent factors of the lumbar lordosis angle in the sitting position. The thicknesses of the thoracic erector spinae, gluteus maximus and minimus, long head of the biceps femoris, semitendinosus, and rectus femoris muscles were significantly lower in the sitting-impossible group than those in the sitting-possible group.

INTERPRETATION

Decreased lumbar lordosis angle in the sitting position was associated with decreased lumbar multifidus muscle mass in children and adults with CP. Furthermore, not only trunk extensor but also hip joint muscles may contribute to sitting without upper extremity support.

The Contribution of Decreased Muscle Size to Muscle Weakness in Children With Spastic Cerebral Palsy

Muscle weakness is a common clinical symptom in children with spastic cerebral palsy (SCP). It is caused by impaired neural ability and altered intrinsic capacity of the muscles. To define the contribution of decreased muscle size to muscle weakness, two cohorts were recruited in this cross-sectional investigation: 53 children with SCP [median age, 8.2 (IQR, 4.1) years, 19/34 uni/bilateral] and 31 children with a typical development (TD) [median age, 9.7 (IQR, 2.9) years]. Muscle volume (MV) and muscle belly length for m. rectus femoris, semitendinosus, gastrocnemius medialis, and tibialis anterior were defined from three-dimensional freehand ultrasound acquisitions. A fixed dynamometer was used to assess maximal voluntary isometric contractions for knee extension, knee flexion, plantar flexion, and dorsiflexion from which maximal joint torque (MJT) was calculated. Selective motor control (SMC) was assessed on a 5-point scale for the children with SCP. First, the anthropometrics, strength, and muscle size parameters were compared between the cohorts. Significant differences for all muscle size and strength parameters were found (p ≤ 0.003), except for joint torque per MV for the plantar flexors. Secondly, the associations of anthropometrics, muscle size, gross motor function classification system (GMFCS) level, and SMC with MJT were investigated using univariate and stepwise multiple linear regressions. The associations of MJT with growth-related parameters like age, weight, and height appeared strongest in the TD cohort, whereas for the SCP cohort, these associations were accompanied by associations with SMC and GMFCS. The stepwise regression models resulted in ranges of explained variance in MJT from 29.3 to 66.3% in the TD cohort and from 16.8 to 60.1% in the SCP cohort. Finally, the MJT deficit observed in the SCP cohort was further investigated using the TD regression equations to estimate norm MJT based on height and potential MJT based on MV. From the total MJT deficit, 22.6–57.3% could be explained by deficits in MV. This investigation confirmed the disproportional decrease in muscle size and muscle strength around the knee and ankle joint in children with SCP, but also highlighted the large variability in the contribution of muscle size to muscle weakness.

Meridian acupuncture plus massage for children with spastic cerebral palsy

OBJECTIVE

To evaluate the effect of combination therapy of meridian acupuncture and massage on motor development in children with spastic cerebral palsy (SCP).

METHODS

A total of 113 children with SCP in our hospital were allocated into research group (63 cases, treated with meridian acupuncture plus massage) and control group (50 cases, treated with routine rehabilitation measures). Clinical efficacy and alterations of inflammatory factors were observed. Peabody Developmental Motor Scale (PDMS) and gross motor function measure (GMFM-88; sitting, standing, walking) were employed for the assessment of motor ability. Changes in muscle tension were monitored with the Ashworth scale (AS), and modified Barthel index (MBI) and Gesell's Developmental Schedule (GDS) were used to evaluate children's daily activities, language, fine motor skills, and adaptability. Finally, the development of children in the two groups was monitored.

RESULTS

The research group had higher total effective rate than the control group (P=0.018). After treatment, the levels of interleukin 6 (IL-6) and tumor necrosis factor-α (TNF-α) in the research group were lower than those in the control group (P<0.05); the PDMS and AS scores were reduced in both groups, and the reduction was greater in research group (P<0.05); GFMF-88, Barthel and GDS scores increased in both groups, especially in the research group; children in research group were better developed than those in control group (P<0.05).

CONCLUSION

Meridian acupuncture plus massage contributes to a significant improvement of motor development in children with SCP.

Effect of performing daily activities while standing on the quantity and quality of the thigh muscles in adults with severe cerebral palsy: a cross-sectional study

[Purpose] To observe the effect of daily standing, as indicated by gross motor function, on the quantity and quality of the thigh muscles in adults with severe cerebral palsy and to obtain data to determine an appropriate intervention that will improve their quality of life. [Participants and Methods] Thirty-three adults with severe cerebral palsy participated in the study. We assessed the gross motor function using the GMFM-66-IS. We then evaluated the quadriceps muscle thickness and the rectus femoris muscle echo intensity using ultrasonography. We divided the participants into the standing and non-standing groups and then examined the correlations of the GMFM-66-IS score to muscle thickness and echo intensity. We calculated the difference in mean muscle thickness and echo intensity between the two groups using an independent t-test. [Results] Significant positive correlations were found between the GMFM-66-IS score and muscle thickness and echo intensity. In the group-specific analysis, no significant correlation was found between echo intensity and the GMFM-66-IS score in either group. Muscle thickness and echo intensity were greater in the participants of the standing group. [Conclusion] Daily standing, as indicated by gross motor function, affected muscle thickness and echo intensity. Quantitative and qualitative data might need to be evaluated when assessing the muscles of adults with severe cerebral palsy using ultrasonography.

Is there a relationship between muscle-tendon properties and a variety of functional tasks in children with spastic cerebral palsy?

BACKGROUND

Cerebral palsy (CP) is the most common motor and movement disability in childhood. The mechano-morphological alterations of the spastic muscle itself as well as the functional limitations in CP are well documented. However, the relationship between muscle tendon properties and functional tests in CP remains unknown.

RESEARCH QUESTION

The aim of this study was to explore the relationship between spastic muscle mechano-morphological properties and functional performance in children with CP.

METHODS

This study included retrospective data from 22 children with spastic cerebral palsy with a mean age of 12.8 years (19 GMFCS I/3 GMFC II, 15 male/7 female, 8 unilateral involved/14 bilateral). Mechano-morphological properties of gastrocnemius (GM) and Achilles tendon (AT) were correlated with a variety of functional measures, maximal isometric strength, the Muscle Power Sprint test (MPST), 6-minute walk test (6MWT) and 3D-gait analysis using the Pearson Coefficient.

RESULTS

Muscle-tendon properties were normalized to remove anthropometric dimensions because of strong associations with anthropometric data. Higher isometric muscle strength was related to longer normalized GM fascicle lengths (r = 0.67, p < 0.01). The distance reached in the 6MWT positively correlated with normalized GM fascicle lengths (r = 0.61, p < 0.01). Higher AT stiffness was associated with faster performance in the MPST (r = 0.77, p < 0.01). Finally, there was an association between ankle power and both longer normalized AT length and shorter muscle belly (r = 0.60 and r = 0.54, p < 0.01).

SIGNIFICANCE

The findings of this study give more insight into the function specific adaptations of a spastic muscle-tendon unit. While walking, assessed through the 6MWT, was related to normalized gastrocnemius fascicle length, sprint performance was associated with an increased AT stiffness. These results provide a better understanding of the relationship between functional tasks and spastic muscle-tendon properties, which offers potential for improved and targeted interventions in CP.

Measuring skeletal muscle morphology and architecture with imaging modalities in children with cerebral palsy: a scoping review

AIM

To investigate the use of ultrasound and magnetic resonance imaging (MRI) methodologies to assess muscle morphology and architecture in children with cerebral palsy (CP).

METHOD

A scoping review was conducted with systematic searches of Medline, Embase, Scopus, Web of Science, PubMed, and PsycInfo for all original articles published up to January 2019 utilizing ultrasound and/or MRI to determine morphological and architectural properties of lower limb skeletal muscle in children with CP.

RESULTS

Eighty papers used ultrasound (n=44), three-dimensional ultrasound (n=16), or MRI (n=20) to measure at least one muscle parameter in children and adolescents with CP. Most research investigated single muscles, predominantly the medial gastrocnemius muscle, included children classified in Gross Motor Function Classification System levels I (n=62) and II (n=65), and assessed fascicle length (n=35) and/or muscle volume (n=35). Only 21 papers reported reliability of imaging techniques. Forty-six papers assessed measures of Impairment (n=39), Activity (n=24), and Participation (n=3).

INTERPRETATION

Current research study design, variation in methodology, and preferences towards investigation of isolated muscles may oversimplify the complexities of CP muscle but provide a foundation for the understanding of the changes in muscle parameters in children with CP.

WHAT THIS PAPER ADDS

Current evidence is biased towards the medial gastrocnemius muscle and more functionally able children with cerebral palsy (CP). Variations in imaging techniques and joint positioning limit comparisons between studies. Clinimetric testing of parameters of CP muscle is not always considered. Assessment of parameter(s) of muscle with measures of participation is sparse.

Impact of Altered Gastrocnemius Morphometrics and Fascicle Behavior on Walking Patterns in Children With Spastic Cerebral Palsy

Spastic cerebral palsy (SCP) affects neural control, deteriorates muscle morphometrics, and may progressively impair functional walking ability. Upon passive testing, gastrocnemius medialis (GM) muscle bellies or fascicles are typically shorter, thinner, and less extensible. Relationships between muscle and gait parameters might help to understand gait pathology and pathogenesis of spastic muscles. The current aim was to link resting and dynamic GM morphometrics and contractile fascicle behavior (both excursion and velocity) during walking to determinants of gait. We explored the associations between gait variables and ultrasonography of the GM muscle belly captured during rest and during gait in children with SCP [n = 15, gross motor function classification system (GMFCS) levels I and II, age: 7–16 years] and age-matched healthy peers (n = 17). The SCP children’s plantar flexors were 27% weaker. They walked 12% slower with more knee flexion produced 42% less peak ankle push-off power (all p < 0.05) and 7/15 landed on their forefoot. During the stance phase, fascicles in SCP on average operated on 9% shorter length (normalized to rest length) and displayed less and slower fascicle shortening (37 and 30.6%, respectively) during push-off (all p ≤ 0.024). Correlation analyses in SCP patients revealed that (1) longer-resting fascicles and thicker muscle bellies are positively correlated with walking speed and negatively to knee flexion (r = 0.60–0.69, p < 0.0127) but not to better ankle kinematics; (2) reduced muscle strength was associated with the extent of eccentric fascicle excursion (r = −0.57, p = 0.015); and (3) a shorter operating length of the fascicles was correlated with push-off power (r = −0.58, p = 0.013). Only in controls, a correlation (r = 0.61, p = 0.0054) between slower fascicle shortening velocity and push-off power was found. Our results indicate that a thicker gastrocnemius muscle belly and longer gastrocnemius muscle fascicles may be reasonable morphometric properties that should be targeted in interventions for individuals with SCP, since GM muscle atrophy may be related to decreases in walking speed and undesired knee flexion during gait. Furthermore, children with SCP and weaker gastrocnemius muscle may be more susceptible to chronic eccentric muscle overloading. The relationship between shorter operating length of the fascicles and push-off power may further support the idea of a compensation mechanism for the longer sarcomeres found in children with SCP. Nevertheless, more studies are needed to support our explorative findings.

Ultrasound Imaging and Rehabilitation of Muscle Disorders: Part 2: Nontraumatic Conditions

Because of its several advantages, ultrasound imaging has started to take place in the diagnostic and therapeutic algorithms of a wide range of musculoskeletal disorders. After the first part on traumatic conditions, in this review, the authors aim to discuss the applicability of ultrasound imaging for nontraumatic muscle disorders in the daily clinical/academic practice. While trying to summarize the whole spectrum (e.g., myofascial pain syndrome, inflammatory diseases, neuromuscular disorders), special emphasis will be given to sarcopenia, which is, by far, the most challenging clinical condition in the era of "aging world." Of note, rehabilitation with regard to the exemplified problems will also be briefed throughout.

The Interzonal Distribution of the Load on the Plantar Surface of the Foot During Walking in the Patients with Cerebral Palsy as an Objective Criterion of Functional Impairment Severity

Relevance. The main direction of rehabilitation of children with cerebral palsy is the preservation and enhancement of the existing level of support and locomotion, as well as compensation of its impairment through various methods of rehabilitation. For an adequate prescription and reliable assessment of these measures effectiveness, it is necessary to use objective indicators of functional impairment characteristic of cerebral palsy. The purpose of this study was to substantiate objective biomechanical indicators of functional impairment in children with cerebral palsy based on the analysis of the interzonal distribution of the load on the foot during walking, taking into account the level of global motor functions impairment. Materials and Methods. 47 children with cerebral palsy at the GMFCS levels of impairment 1 to 3 were examined. The control group consisted of 14 children without anatomical and functional signs of support and locomotion system impairment. Biomechanical examination was performed on the complex «DiaSled-M-Scan» with matrix plantar pressure meters in the form of insoles. The statistical analysis of the data was carried out by nonparametric methods using the SPSS for Widows software. Results. The analysis of the anatomical and functional impairment of 94 feet of the children with cerebral palsy and 28 feet of the control group revealed differences in the interzonal distribution of the load under the feet in six variables (p from 0.001 to 0.003). The most typical were: an increase in the toe-to-heel load ratio (on average by 80%), an increase in the load on the arch (by 49%), and a decrease in the medio-lateral load ratio on the toe (by 37%). For GMFCS 1 patients, a significant indicator of impairment was an increase in the partial load on the arch, for GMFCS 2 and 3 patients — a decrease in the load on the heel and an increase it under the toe. This leads to an increase in the toe-to-heel load ratio. Conclusion. It is advisable to use the revealed indicators of roll-over-the-foot impairment in the functional diagnosis of the condition and in assessing the effectiveness of rehabilitation of children with cerebral palsy.

The Appendicular Lean Mass Index Is a Suitable Surrogate for Muscle Mass in Children with Cerebral Palsy

BACKGROUND

Densitometrically measured lean body mass (LBM) is often used to quantify skeletal muscle mass in children with cerebral palsy (CP). Since LBM depends on the individual's height, the evaluation of $\frac{{{\rm{LBM}}}}{{heigh{t^2}}}\ $ (lean BMI) is often recommended. However, LBM includes not only skeletal muscle mass but also the mass of skin, internal organs, tendons, and other components. This limitation applies to a far lesser extent to the appendicular lean mass index (LMIapp).

OBJECTIVES

The aim of the study was to evaluate skeletal muscle mass in children with CP using total lean BMI (LMItot) and LMIapp.

METHODS

The present study was a monocentric retrospective analysis of prospectively collected data among children and adolescents with CP participating in a rehabilitation program. In total, 329 children with CP [148 females; Gross Motor Function Classification Scale (GMFCS) I, 32 children; GMFCS II, 73 children; GMFCS III, 133 children; GMFCS IV, 78 children; and GMFCS V, 13 children] were eligible for analysis. The mean age was 12.3 ± 2.75 y. Pediatric reference centiles for age-adjusted LMIapp were generated using data from NHANES 1999-2004. Low skeletal muscle mass was defined as a z score for DXA determined LMItot and LMIapp less than or equal to -2.0.

RESULTS

The z scores for LMIapp were significantly lower than LMItot in children with CP, GMFCS levels II-V (P < 0.001), with the exception of GMFCS level I (P = 0.121), where no significant difference was found. The prevalence of low LMItot (16.1%; 95% CI: 16.1, 20.1%) was significantly lower (P < 0.001) than the prevalence of LMIapp (42.2%; 95% CI: 36.9, 47.9%) in the study population.

CONCLUSIONS

The prevalence of low skeletal muscle mass in children with CP might be underestimated by LMItot. LMIapp is more suitable for the evaluation of skeletal muscle mass in children with CP.