- Cerebral Palsy Among Children FACT: An estimated 3 to 4 in every 1,000 school-age children in metropolitan Atlanta have cerebral palsy
- Diagnosis of cerebral palsy a research status report - 2002
- Gait analysis in children with cerebral palsy Armand S, Decoulon G, Bonnefoy-Mazure A EFORT Open Rev 2016;1:448-460. DOI: 10.1302/2058-5241.1.000052.
- Gait parameters in children with bilateral spastic cerebral palsy Gait parameters in children with bilateral spastic cerebral palsy: a systematic review of randomized controlled trials Gómez-Pérez C, Font-Llagunes JM, Martori JC, Vidal Samsó J Dev Med Child Neurol. 2018 Nov 28. doi: 10.1111/dmcn.14108. [Epub ahead of print]
- Length and force of the gastrocnemius and soleus Length and force of the gastrocnemius and soleus during gait following tendo Achilles lengthenings in children with equinus
- Lower limb extensor moments in chindren with spastic diplegic cerebral palsy McNee AE, Shortland AP, Eve LC, Robinson RO, Gough M
- The Effects of Quantitative gait Assessment and Botulinum Toxin A on Musculoskeletal Surgery The Effects of Quantitative gait Assessment and Botulinum Toxin A on Musculoskeletal Surgery in Children with Cerebral Palsy
- Transverse plane rotation of the foot and transverse hip and pelvic kinematics Gaston MS, Rutz E, Dreher T, Brunner R.
- abstract 1 Crouch gait in spastic diplegia after hell cord lengthening
- abstract 2 Crouch gait in cerebral palsy - The effects of Psoas lengthening
- abstract 3 Limits to passive range of joint motion and the effect on crouch gait in children with cerebral palsy
- abstract 4 Improved knee extension capacity following derotation of the tibia in a subject with crouch gait
- Hip locomotion mechanisms in cerebral palsy crouch gait Steinwender G, Saraph V, Zwick EB, Steinwender C, Linhart W
- The role of estimating muscle-tendon lengths and velocities of the Hamstrings The role of estimating muscle-tendon lengths and velocities of the Hamstrings in the evaluation and treatment of crouch gait
- A Systematic Review of the Effects of Single-Event Multilevel Surgery A Systematic Review of the Effects of Single-Event Multilevel Surgery on Gait Parameters in Children with Spastic Cerebral Palsy Lamberts RP, Burger M, du Toit J, Langerak NG
- Estimating the effect size of surgery to improve walking in children with cerebral palsy Estimating the effect size of surgery to improve walking in children with cerebral palsy from retrospective observational clinical data Rajagopal A, Kidziński Ł, McGlaughlin AS, Hicks JL, Delp SL, Schwartz MH
- Long-term development of gait after multilevel surgery in children with cerebral palsy Long-term development of gait after multilevel surgery in children with cerebral palsy: a multicentre cohort study Dreher T, Thomason P, Švehlík M, Döderlein L, Wolf SI, Putz C, Uehlein O, Chia K, Steinwender G, Sangeux M, Graham HK Dev Med Child Neurol. 2018 Jan;60(1):88-93. doi: 10.1111/dmcn.13618. Epub 2017 Nov 24.
- SimCP: A Simulation Platform to Predict Gait Performance Following Orthopedic Intervention SimCP: A Simulation Platform to Predict Gait Performance Following Orthopedic Intervention in Children With Cerebral Palsy Pitto L, Kainz H, Falisse A, Wesseling M, Van Rossom S, Hoang H, Papageorgiou E, Hallemans A, Desloovere K, Molenaers G, Van Campenhout A, De Groote F and Jonkers I
- Single-Event Multilevel Surgery for Crouching Cerebral Palsy Children Single-Event Multilevel Surgery for Crouching Cerebral Palsy Children: Correlations with Quality of Life and Functional Mobility Amen J, ElGebeily M, El-Mikkawy DM, Yousry AH, El-Sobky TA
CDC-USA
UCP Research and Educational Foundation
Papers
"Cerebral palsy (CP) children present complex and heterogeneous motor disorders that cause gait deviations. Clinical gait analysis (CGA) is needed to identify, understand and support the management of gait deviations in CP. CGA assesses a large amount of quantitative data concerning patients’ gait characteristics, such as video, kinematics, kinetics, electromyography and plantar pressure data. Common gait deviations in CP can be grouped into the gait patterns of spastic hemiplegia (drop foot, equinus with different knee positions) and spastic diplegia (true equinus, jump, apparent equinus and crouch) to facilitate communication. However, gait deviations in CP tend to be a continuum of deviations rather than well delineated groups. To interpret CGA, it is necessary to link gait deviations to clinical impairments and to distinguish primary gait deviations from compensatory strategies. CGA does not tell us how to treat a CP patient, but can provide objective identification of gait deviations and further the understanding of gait deviations. Numerous treatment options are available to manage gait deviations in CP. Generally, treatments strive to limit secondary deformations, re-establish the lever arm function and preserve muscle strength. Additional roles of CGA are to better understand the effects of treatments on gait deviations.Cerebral palsy (CP) children present complex and heterogeneous motor disorders that cause gait deviations. Clinical gait analysis (CGA) is needed to identify, understand and support the management of gait deviations in CP. CGA assesses a large amount of quantitative data concerning patients’ gait characteristics, such as video, kinematics, kinetics, electromyography and plantar pressure data. Common gait deviations in CP can be grouped into the gait patterns of spastic hemiplegia (drop foot, equinus with different knee positions) and spastic diplegia (true equinus, jump, apparent equinus and crouch) to facilitate communication. However, gait deviations in CP tend to be a continuum of deviations rather than well delineated groups. To interpret CGA, it is necessary to link gait deviations to clinical impairments and to distinguish primary gait deviations from compensatory strategies. CGA does not tell us how to treat a CP patient, but can provide objective identification of gait deviations and further the understanding of gait deviations. Numerous treatment options are available to manage gait deviations in CP. Generally, treatments strive to limit secondary deformations, re-establish the lever arm function and preserve muscle strength. Additional roles of CGA are to better understand the effects of treatments on gait deviations."
"AIM: To identify the gait parameters used to assess gait disorders in children with bilateral spastic cerebral palsy (CP) and evaluate their responsiveness to treatments. METHOD: A systematic search within PubMed, Web of Science, and Scopus (in English, 2000-2016) for randomized controlled trials of children with bilateral spastic CP who were assessed by instrumented gait analysis (IGA) was performed. Data related to participants and study characteristics, risk of bias, and outcome measures were collected. A list of gait parameters responsive to clinical interventions was obtained. RESULTS: Twenty-one articles met the inclusion criteria. Eighty-nine gait parameters were identified, 56 of which showed responsiveness to treatments. Spatiotemporal and kinematic parameters were widely used compared to kinetic and surface electromyography data. The majority of responsive gait parameters were joint angles at the sagittal plane (flexion-extension). INTERPRETATION: The IGA yields responsive outcome measures for the gait assessment of children with bilateral spastic CP. Spatiotemporal and kinematic (at sagittal plane) parameters are the gait parameters used most frequently. Further research is needed to establish the relevant gait parameters for each clinical problem. WHAT THIS PAPER ADDS: Fifty-six responsive gait parameters for children with bilateral spastic cerebral palsy were identified. Most responsive gait parameters belong to joint angles time-series at sagittal plane. Spatiotemporal and kinematic parameters are widely used compared to kinetic and surface electromyography parameters."
Orendurff MS, Aiona MD, Dorociak RD, Pierce RA
"Nine subjects (12 sides) with cerebral palsy who walked in equnius were evaluated prior to and 1 year after surgical tendo Achilles lengthening. Gastrocnemius and soleus length [Gait Posture, 6 (1997) 9] and plantarflexor force [Gait Posture, 6 (1997) 9; J Biomech, 23 (1990) 495] were calculated. The length of the gastrocnemius and soleus increased significantly (P<0.01) following the intervention. Force output of the triceps surae during push-off increased significantly (13.95 N/kg body weight (BW) preop to 30.31 N/kg BW postop; P<0.01). Assessment of the force-length capacity of the triceps surae in candidates for tendo Achilles lengthenings may identify individuals at risk of residual weakness and iatrogenic crouch."
"In this retrospective study, we quantified the mean extensor moment at the ankle, knee and hip over the stance period in a group of independently ambulant children with spastic diplegia (n = 90; 167 limbs) and in a group of normally-developing (ND) children (n = 22; 22 limbs). The mean knee extensor moment and the mean support moment demonstrated greater variance in children with diplegia than in normally-developing children (P < 0.0001 and P < 0.001). This was explained by a strong relationship between the mean knee extensor moment and minimum knee flexion in stance (r2 = 0.615; P < 0.0001) in the affected group with a positive mean knee extensor moment for all those children who walked in greater than 20 degrees of knee flexion. We also found a linear relationship between the support moment and knee flexion (r2 = 0.805; P < 0.0001). Our data supported the biomechanical analysis of Hof [Gait Posture, 12 (2000) 196] who suggested that his modified support moment should be a linear function with eccentricity at the knee. Extensor moments at the ankle (r2 = 0.001376; P = 0.641) and hip (r2 = 0.0860; P = 0.000168) bore weak relationships with increasing knee flexion even though there was a strong positive relationship between minimum knee flexion and minimum hip flexion (r2 = 0.316; P < 0.0001). We conclude that children with spastic diplegic cerebral palsy (SDCP) who walk with a crouch gait rely on their knee extensors to prevent collapse of the lower limbs. Intervention directed at redistributing extensor moments between the joints of the lower limbs may slow the increase in knee flexion and prolong reasonable walking function in this group."
Molenaers G, Desloovere K, Fabry G, De Cock P
"Results:
The progression to orthopaedic surgery was significantly different among the three groups (p < 0.0001). The proportion of patients who had undergone at least one surgical procedure by the age of seven years was 52% (sixty-four of 122) for Group 1, 27% (forty-six of 170) for Group 2, and 10% (thirteen of 132) for Group 3. There was a delay in surgery in Group 2 as compared with Group 1 (p < 0.00001 at seven, eight, and nine years of age) and a significant decrease in the prevalence of orthopaedic surgical procedures for Group 3 as compared with Group 1 (p < 0.00001 at four to eight years of age) and Group 2 (p < 0.0025 at four to nine years of age).
Conclusions:
In the treatment of children who have cerebral palsy, the introduction of gait analysis increases the age of the first orthopaedic surgical procedure and botulinum toxin type-A treatment delays and reduces the frequency of surgical procedures."
"External rotation of the foot associated with mid-foot break is a commonly observed gait abnormality in diplegic CP patients. Previous studies have shown a correlation between equinus and internal hip rotation in hemiplegic patients. This study aimed to determine if there was a correlation between the amount of transverse plane rotation in diplegic CP patients using kinematic data from standardised gait analysis. Lower limb data of 134 ambulant children with diplegic CP was analysed retrospectively determining the maximum change in foot, hip and pelvis rotation during loading response. Highly significant negative correlations (P=<0.001) were found between foot and hip movements and foot and pelvic movements. Equinus at initial contact diminished the foot:hip correlation while it enhanced the foot:pelvic correlation. There was less external rotation of the foot in equinus patients (P=0.012) and more external rotation of the pelvis in the equinus group (P=<0.001). This data reveal a correlation between transverse plane rotation at foot level to that at the hip and pelvis. The likely biomechanical explanation is relatively excessive transverse external rotation of the foot due to abnormalities such as mid-foot break. When under load, where the foot is fixed to the floor, internal rotation of the entire leg occurs. This is due to lever arm disease as a result of the relatively shortened foot and inefficiency of the plantar-flexion knee-extension couple. Equinus modulates the effect. When treating such patients, lever arm deformities at all levels must be considered to result in the best outcome and prevent recurrences."
Crouch Gait
Lenght of Hamstrings and Psoas muscles during crouch gait
"The purpose of this study was to evaluate three defined locomotion patterns in cerebral palsy gait using computerised gait analysis. Ambulant diplegic children who had no previous surgery were included in the study and were divided into two groups: one group consisted of children having a crouch gait, and the other group did not have the crouch pattern of gait. An age-matched group of normal children served as the control group. Locomotion patterns studied were the hip hike, propulsive function of the hip extensors, and pseudo-adduction. A statistical analysis was performed between the groups, using defined parameters. The mechanism of hip hike was not utilised by any of the groups. Both groups of diplegic children showed power generation at the hip beginning in the first double support phase of the gait cycle and continuing in the first half of single limb support, while in the normals this was only in the first half of single limb support. Both the groups of diplegic children showed significantly more internal rotation in the first half of stance as compared to the group of normal children; the degree of hip adduction was the same in all the groups. Thus diplegic children had pseudo-adduction."
Arnold AS, Liu MQ, Schwartz MH, Ounpuu S, Delp SL
"Persons with cerebral palsy frequently walk with excessive knee flexion during terminal swing and stance. This gait abnormality is often attributed to "short" or "spastic" hamstrings that restrict knee extension, and is often treated by hamstrings lengthening surgery. At present, the outcomes of these procedures are inconsistent. This study examined whether analyses of the muscle-tendon lengths and lengthening velocities of patients' hamstrings during walking may be helpful when deciding whether a candidate is likely to benefit from hamstrings surgery. One hundred and fifty-two subjects were cross-classified in a series of multi-way contingency tables based on their pre- and postoperative gait kinematics, muscle-tendon lengths, muscle-tendon velocities, and hamstrings surgeries. The lengths and velocities of the subjects' semimembranosus muscles were estimated by combining kinematic data from gait analysis with a three-dimensional computer model of the lower extremity. Log-linear analysis revealed that the subjects who walked with abnormally "short" or "slow" hamstrings preoperatively, and whose hamstrings did not operate at longer lengths or faster velocities postoperatively, were unlikely to walk with improved knee extension after treatment (p < 0.05). Subjects who did not walk with abnormally short or slow hamstrings preoperatively, and whose hamstrings did operate at longer lengths or faster velocities postoperatively, tended to exhibit unimproved or worsened anterior pelvic tilt after treatment (p < 0.05). Examination of the muscle-tendon lengths and velocities allows individuals who walk with abnormally short or slow hamstrings to be distinguished from those who do not, and thus may help to identify patients who are at risk for unsatisfactory postsurgical changes in knee extension or anterior pelvic tilt."
Single-event multilevel surgery (SEMLS)
"PURPOSE: The purpose of this systematic review is to provide an overview of different orthopedic SEMLS interventions and their effects on 3DGA parameters in children with spastic CP. METHODS: A comprehensive literature search within six databases revealed 648 records, from which 89 articles were selected for the full-text review and 24 articles (50 studies) included for systematic review. The Oxford Centre for Evidence-Based Medicine Scale and the Methodological Index for Non-Randomized Studies (MINORS) were used to appraise and determine the quality of the studies. RESULTS: Except for one level II study, all studies were graded as level III according to the Oxford Centre for Evidence-Based Medicine Scale. The MINORS score for comparative studies (n = 6) was on average 15.7/24, while non-comparative studies (n = 18) scored on average 9.8/16. Nineteen kinematic and temporal-distance gait parameters were selected, and a majority of studies reported improvements after SEMLS interventions. The largest improvements were seen in knee range of motion, knee flexion at initial contact and minimal knee flexion in stance phase, ankle dorsiflexion at initial contact, maximum dorsiflexion in stance and in swing phase, hip rotation and foot progression angles. However, changes in 3DGA parameters varied based on the focus of the SEMLS intervention. DISCUSSION: The current article provides a novel overview of a variety of SEMLS interventions within different SEMLS focus areas and the post-operative changes in 3DGA parameters. This overview will assist clinicians and researchers as a potential theoretical framework to further improve SEMLS techniques within different SEMLS focus groups. In addition, it can also be used as a tool to enhance communication with parents, although the results of the studies can't be generalised and a holistic approach is needed when considering SEMLS in a child with spastic CP."
"Single-event multilevel surgery (SEMLS) is a standard treatment approach aimed at improving gait for patients with cerebral palsy, but the effect of this approach compared to natural progression without surgical intervention is unclear. In this study, we used retrospective patient history, physical exam, and three-dimensional gait analysis data from 2,333 limbs to build regression models estimating the effect of SEMLS on gait, while controlling for expected natural progression. Post-hoc classifications using the regression model results identified which limbs would exhibit gait within two standard deviations of typical gait at the follow-up visit with or without a SEMLS with 73% and 77% accuracy, respectively. Using these models, we found that, while surgery was expected to have a positive effect on 93% of limbs compared to natural progression, in only 37% of limbs was this expected effect a clinically meaningful improvement. We identified 26% of the non-surgically treated limbs that may have shown a clinically meaningful improvement in gait had they received surgery. Our models suggest that pre-operative physical therapy focused on improving biomechanical characteristics, such as walking speed and strength, may improve likelihood of positive surgical outcomes. These models are shared with the community to use as an evaluation tool when considering whether or not a patient should undergo a SEMLS."
"AIM: We investigated the long-term efficacy and safety of multilevel surgery (MLS) in ambulatory children with bilateral spastic cerebral palsy (CP). METHOD: Two hundred and thirty-one children were evaluated at short term (1.1y, SD 0.4) and long term (9.1y, SD 3.0) follow-up using clinical examination and gait analysis. MLS was investigated by studying changes in the Gait Profile Score (GPS) referenced to the minimally important clinical difference. RESULTS: Ambulatory children aged 10 years and 7 months (SD 2y 11mo) at MLS in Gross Motor Function Classification System levels I (19), II (144), and III (68) showed a decrease (improvement) in preoperative GPS from 16.3° (SD 4.8) to 11.3° (SD 3.2) at short-term follow-up, an improvement of 5°. At long-term follow-up, GPS was maintained at 11.4° (SD 3.1). Overall, 177 (76.6%) children maintained their improvement in GPS after 9 years. INTERPRETATION: Multilevel surgery is a safe and effective surgical intervention, which leads to a significant improvement in gait kinematics in children with bilateral spastic CP. This study improves our understanding of MLS in the long term and will help to inform families and children when planning for MLS. WHAT THIS PAPER ADDS: Largest study of multilevel surgery (MLS) for children with bilateral spastic cerebral palsy, with longest follow-up. MLS resulted in significant long-term improvements in gait function. Minor adverse events were common, while events requiring intervention were uncommon (4% of children). Thirty-nine per cent of children required additional surgery during follow-up. 'Single-event multilevel surgery' was changed to the more realistic term 'multilevel surgery'."
"Gait deficits in cerebral palsy (CP) are often treated with a single-event multi-level surgery (SEMLS). Selecting the treatment options (combination of bony and soft tissue corrections) for a specific patient is a complex endeavor and very often treatment outcome is not satisfying. A deterioration in 22.8% of the parameters describing gait performance has been reported and there is need for additional surgery in 11% of the patients. Computational simulations based on musculoskeletal models that allow clinicians to test the effects of different treatment options before surgery have the potential to drastically improve treatment outcome. However, to date, no such simulation and modeling method is available. Two important challenges are the development of methods to include patient-specific neuromechanical impairments into the models and to simulate the effect of different surgical procedures on post-operative gait performance. Therefore, we developed the SimCP framework that allows the evaluation of the effect of different simulated surgeries on gait performance of a specific patient and includes a graphical user interface (GUI) that enables performing virtual surgery on the models. We demonstrated the potential of our framework for two case studies."
"OBJECTIVES: Crouch gait in cerebral palsy (CP) is characterized by excessive knee flexion throughout stance. Single-event multilevel orthopedic surgery is the standard of care to improve gait and function through correcting lever arm deformities in children with CP. A limited number of prospective studies on single-event multilevel orthopedic surgery for crouching CP children are available. We intended to evaluate the effectiveness of single‑event multilevel surgery (SEMLS) regarding functional mobility, energy consumption during gait, and the mental, attitudinal, and lifestyle status of CP children with crouch gait on the short term. METHODS: Thirty‑four limbs in 18 children with bilateral spastic and crouching CP were enrolled prospectively and subjected to SEMLS. The mean age was 12 years (range, 5.5–18). Outcome measures included clinical couch examination parameters, walking speed, physiological cost index (PCI), functional mobility scale (FMS), and the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0). In addition, we used instrumented three‑dimensional gait analysis as an outcome measure for some participants. RESULTS: At a mean follow‑up of 16 months (range, 12–22), the couch examination parameters, FMS at 5, 50, and 500 m, walking speed, PCI, and WHODAS 2.0 score showed a highly statistically significant improvement (P < 0.01). CONCLUSIONS: SEMLS for CP children and adolescents with crouch gait is effective for improving function, independence, energy consumption, and quality of life on the short term."