The influence of crouch gait on sagittal trunk position and lower lumbar spinal loading in children with cerebral palsy.

Crouch gait is a common pattern in children with CP. Little investigation has been performed as to the role of the trunk during crouch gait. A compensatory movement of the trunk may alter the position of the ground reaction force with the effect of reducing the moment arm about the knee or hip. While this may benefit these joints in the context of reduced loading, there may be implications further up the kinematic chain at the level of the lumbar spine. Are compensatory movements of the trunk present during crouch gait in children with CP and are levels of loading at the lower lumbar spine affected? A full barefoot lower limb and trunk 3-dimensional kinematic and kinetic analysis, with kinetics estimated at the spinal position of L5/S1, was performed on 3 groups of children, namely CP Crouch, CP No-Crouch and TD. Differences in trunk position and L5/S1 loading were compared between groups. Mean trunk position in relation to the pelvis and laboratory was not statistically significant between groups. At the level of the spine, no differences were present in mean position between groups for L5/S1 sagittal moment or anterior/posterior force. Crouch gait does not elicit a compensatory response of the trunk in children with CP and, consequently, reactive forces and moments at the lower lumbar spine remain within normal limits. With this in mind, it is unlikely that a crouch gait pattern will affect the health of the spine over time in these children.

Kiernan D ，O'Sullivan R 《-》

Pathological Movements of the Pelvis and Trunk During Gait in Children With Cerebral Palsy: A Cross-Sectional Study With 3-Dimensional Kinematics and Lower Lumbar Spinal Loading.

Increased loading at the lumbar spine, particularly in the coronal plane, has been reported in children with cerebral palsy (CP). As pelvic and trunk movements associated with Trendelenburg and Duchenne type gait are most significant in the coronal plane, the potential exists for lower lumbar spinal loading to be negatively affected in children with CP and these types of movement patterns. The objective of this study was to assess trunk and pelvic kinematics and lower lumbar spinal loading patterns in children with CP and Trendelenburg and Duchenne type gait. This was a cross-sectional study. Three-dimensional kinematic (lower limb and thorax) and L5-S1 kinetic data were recorded. Children were divided according to clinical presentation of Trendelenburg or Duchenne type gait. Several discrete kinematic and kinetic parameters were assessed between groups. Three distinct pelvic and trunk movement patterns were identified for children with CP: Trendelenburg, Duchenne, and complex Trendelenburg-Duchenne. Peak L5-S1 lateral bending moments were increased by 62% in children with CP and Duchenne type gait. Children with CP and complex Trendelenburg-Duchenne gait demonstrated the largest deviations from normal, with increased peak ipsilateral and contralateral directed moments of 69% and 54%, respectively, compared with children with typical development. A test-retest reliability analysis or measure of minimal detectable change was not conducted as part of this study. Results suggest that measures of minimal detectable change may be high for some of the reported variables. In addition, the inverse dynamic approach determines only the net intersegmental reactive forces that reflect the effect of external loads. Previous studies have shown that spinal loads may be larger than the net intersegmental force. Trendelenburg and Duchenne type movements were not always distinct, and a third type of movement, a combination of the two, was the most common in this study. Clinicians should be aware that children with CP and the Duchenne type or the complex Trendelenburg-Duchenne type of gait pattern experience abnormal loading that may have significant implications for the lower spine in the long term.

Kiernan D ，O'Sullivan R ，Malone A ，O'Brien T ，Simms CK ... -  《-》

Three-dimensional lumbar segment movement characteristics during paediatric cerebral palsy gait.

Kinematic analysis of the trunk during cerebral palsy (CP) gait has been well described. In contrast, movement of the lumbar spine is generally ignored. This is most likely due to the complex nature of the spine. As an alternative to using complex sensor protocols, this study modelled the lumbar region as a single segment and investigated characteristic patterns of movement during CP gait. In addition, the impact of functional level of impairment and the relationship with lower lumbar spinal loading were examined. Fifty-two children with CP (26 GMFCS I and 26 GMFCS II) and 26 controls were recruited. A full barefoot 3-dimensional kinematic and kinetic analysis were conducted. Lumbar segment movement demonstrated increased forward flexion for CP children. This movement became more pronounced according to GMFCS level with GMFCS II children demonstrating increases of up to 8°. In addition, a moderate correlation was present between lumbar flexion/extension and L5/S1 sagittal moments (r=0.427 in the global frame and r=0.448 with respect to the pelvis, p<0.01). Children with CP demonstrated increased movement of the lumbar region compared to TD, with movement becoming more excessive as GMFCS level increased. Excessive forward flexion and loading at the lumbar spine were linked. However, the moderate correlation suggests other contributors to increased loading were present. In conclusion, this study is a first step at identifying how lumbar segment movement is altered during CP gait.

Kiernan D ，Malone A ，O'Brien T ，Simms CK ... -  《-》

The relationship of trunk kinematics and kinetics with lower limb pathology during gait in children with spastic cerebral palsy.

Trunk control during gait in children with cerebral palsy (CP) is known to be impaired. While differentiation of trunk movement between CP subtypes (unilateral/bilateral) has been examined, differentiation of lower lumbar spinal loading has not been considered. Furthermore, the relationship between lower lumbar loading and lower limb pathology has not been reported. How do lower lumbar spinal kinetics differ during unilateral and bilateral CP gait and what is the relationship between trunk kinematics and L5/S1 kinetics with lower limb pathology? Three-dimensional thorax kinematics and L5/S1 kinetics were measured during gait with children divided into 3 groups (unilateral CP (n = 21), bilateral CP (n = 31) and typical development (TD) (n = 26)). Differences in thorax kinematics and reactive forces and moments at L5/S1 between groups were analysed using Statistical Parametric Mapping. Correlation coefficients were calculated between Gait Profile Score (GPS) and kinematic measures of the thorax and kinetics at L5/S1. An increased ipsilateral bending moment was present for unilateral CP in the coronal plane (55-70% Gait Cycle (GC), p < 0.001), while children with bilateral CP demonstrated two distinct increased peaks during mid-stance (10-30 % GC, p < 0.001) and mid-swing (60-80% GC, p = 0.004) compared to TD. RMS and RoM thorax flexion, side flexion and L5/S1 lateral bend moment demonstrated significant moderate correlations with GPS. This study confirmed an increased involvement at the trunk and of lower lumbar spinal loading for children with bilateral CP compared to unilateral CP. It has been suggested that altered trunk movement in CP gait may be a combination of both a compensation for lower limb pathology and an underlying deficit. Our result of positive yet moderate correlations between GPS and trunk movement and lower spinal loading support this theory.

Kiernan D 《-》

"Children with cerebral palsy experience greater levels of loading at the low back during gait compared to healthy controls".

Excessive trunk motion has been shown to be characteristic of cerebral palsy (CP) gait. However, the associated demands on the lower spine are unknown. This study investigated 3-dimensional reactive forces and moments at the low back in CP children compared to healthy controls. In addition, the impact of functional level of impairment was investigated (GMFCS levels). Fifty-two children with CP (26 GMFCS I and 26 GMFCS II) and 26 controls were recruited to the study. Three-dimensional thorax kinematics and reactive forces and moments at the low back (L5/S1 spine) were examined. Discrete kinematic and kinetic parameters were assessed between groups. Thorax movement demonstrated increased range for CP children in all 3 planes while L5/S1 reactive forces and moments increased with increasing level of functional impairment. Peak reactive force data were increased by up to 57% for GMFCS I and 63% for GMFCS II children compared to controls. Peak moment data were increased by up to 21% for GMFCS II children compared to GMFCS I and up to 90% for GMFCS II compared to control. In addition, a strong correlation was demonstrated between thorax side flexion and L5/S1 lateral bend moment (r=0.519, p<0.01) and medial/lateral force (r=0.352, p<0.01). Children with CP demonstrated increased lower spinal loading compared to TD. Furthermore, GMFCS II children demonstrated significantly more involvement. Intervention should be aimed at reducing excessive thorax movement, especially in the coronal plane, in order to reduce abnormal loading on the spine in this population.

Kiernan D ，Malone A ，O'Brien T ，Simms CK ... -  《-》