Kinematic adaptation and changes in gait classification in running compared to walking in children with unilateral spastic cerebral palsy.

Classification of sagittal gait patterns in unilateral spastic cerebral palsy (CP) provides direct implication for treatment. Five types are described: type 0 has minor gait deviation; type 1 has inadequate ankle dorsiflexion in swing; type 2 has inadequate ankle dorsiflexion throughout the gait cycle; types 3 and 4 have abnormal function of the knee and hip joint respectively. During gait analysis of children with unilateral spastic CP we observed frequently that a knee flexion deficit disappeared during running. That may have an impact on classification and treatment. Does the classification type change while running and how do patients' kinematics adapt to running? 64 children with unilateral spastic CP were classified using instrumented gait analysis for walking and running. The deviation of four parameters from typically developing children (TD) were used to distinguish between types: peak ankle dorsiflexion in swing for type 1, peak ankle dorsiflexion in stance for type 2, knee range of motion for type 3, and hip range of motion for type 4. A three-factor ANOVA for factors group (CP/TD), locomotion (walk/run) and limb side (in-/uninvolved) was conducted. The number of patients with type 1, 3 and 4 decreased considerably from walking to running, whereas, the number of type 0 and 2 patients increased. The ANOVA showed that three of four parameters of patients' pathologic limb adapt similarly to TD to running, except for the ankle dorsiflexion in stance. Running shows that there is a natural way to resolve abnormalities. Therefore, recommended treatments of hip and knee joint abnormalities based on the walking classification can be questioned and additional running analysis may be important for surgical decision making.

Krätschmer R ，Böhm H ，Döderlein L 《-》

Effects of backward-downhill treadmill training versus manual static plantarflexor stretching on muscle-joint pathology and function in children with spastic Cerebral Palsy.

Patients with spastic Cerebral Palsy are prone to equinus deformities, likely affected by short and inextensible plantarflexor muscles. Manual stretching is a popular treatment but its effectiveness concerning joint mobility, muscle-tendon morphometrics and walking function is debated. Eccentric exercise by backward-downhill treadmill training could be a therapeutic alternative for ambulatory patients improving gait and muscle function. What are the effects of eccentric training by backward-downhill treadmill training and plantarflexor stretching concerning gait and muscle function in patients with spastic Cerebral Palsy? 10 independent ambulators with spastic Cerebral Palsy (12 [SD 4] years old, 2 uni- and 8 bilaterally affected) participated in a randomized crossover-study. One group started with manual static stretching, the other one with backward-downhill treadmill training. Each treatment period lasted 9 weeks (3 sessions per week). Pre and post treatments, 3D gait was assessed during comfortable and during fastest possible walking. Ultrasonography and dynamometry were used to test plantarflexor strength, passive joint flexibility, as well as gastrocnemius morphometrics, stiffness and strain on muscle-tendon and joint level. When comparing both treatments, backward-downhill treadmill training lead to larger single stance dorsiflexion at comfortable walking speed (+2.9°, P = 0.041) and faster maximally achievable walking velocities ( + 0.10 m/s, P = 0.017). Stretching reduced knee flexion in swing, particularly at faster walking velocities (-5.4°, P = 0.003). Strength, ankle joint flexibility, as well as stiffness on muscle-tendon and joint level were not altered, despite similar increases in passive muscle and fascicle strain with both treatments (P ≤ 0.023). Backward-downhill treadmill training can be an effective gait treatment, probably improving coordination or reducing dynamic stretch sensitivity. More intense BDTT might be necessary to further alter muscle-tendon properties. Manual static plantarflexor stretching may not be optimal in Cerebral Palsy patients with high ambulatory status.

Hösl M ，Böhm H ，Eck J ，Döderlein L ，Arampatzis A ... -  《-》

Multi-joint gait clustering for children and youth with diplegic cerebral palsy.

Kuntze G ，Nettel-Aguirre A ，Ursulak G ，Robu I ，Bowal N ，Goldstein S ，Emery CA ... -  《PLoS One》

Does muscle coactivation influence joint excursions during gait in children with and without hemiplegic cerebral palsy? Relationship between muscle coactivation and joint kinematics.

The theoretical role of muscle coactivation is to stiffen joints. The aim of this study was to assess the relationship between muscle coactivation and joint excursions during gait in children with and without hemiplegic cerebral palsy. Twelve children with hemiplegic cerebral palsy and twelve typically developing children underwent gait analysis at three different gait speeds. Sagittal hip, knee, and ankle kinematics were divided into their main components corresponding to joint excursions. A coactivation index was calculated for each excursion from the electromyographic envelopes of the rectus femoris/semitendinosus, vastus medialis/semitendinosus, or tibialis anterior/soleus muscles. Mixed linear analyses of covariance modeled joint excursions as a function of the coactivation index and limb. In typically developing children, increased coactivation was associated with reduced joint excursion for 8 of the 14 linear models (hip flexion, knee loading, knee extension in stance, knee flexion in swing, ankle plantarflexion from initial contact to foot-flat, ankle dorsiflexion in stance and in swing). Conversely, ankle plantarflexion excursion at push-off increased with increasing tibialis anterior/soleus coactivation. In the involved limbs of the children with cerebral palsy, knee loading, ankle plantarflexion at push off, and ankle dorsiflexion in swing decreased, while hip extension increased, with increasing muscle coactivation. The relationships between muscle coactivation and joint excursion were not equally distributed in both groups, and predominant in typically developing children. The results suggest that excessive muscle coactivation is not a cause of stiff-knee gait in children with hemiplegic cerebral palsy, but appears to be related to spastic drop foot.

Gross R ，Leboeuf F ，Hardouin JB ，Perrouin-Verbe B ，Brochard S ，Rémy-Néris O ... -  《-》

Do children with cerebral palsy change their gait when walking over uneven ground?

Independently ambulant children with Cerebral Palsy (CP) often report balance difficulties when walking in challenging settings. The aim of this study was to compare gait in children with CP to typically developing (TD) children walking over level ground and uneven ground, as an evaluation of dynamic balance. Thirty-four children participated, 17 with CP (10 hemiplegia and 7 diplegia, mean age 10 years) and 17 TD (mean age 10 years 1 month). Three-dimensional kinematic and kinetic data of the lower limbs and trunk were captured during walking over level and uneven ground using Codamotion®. Statistical analysis was performed using a mixed-effects model two-factor Analysis of Variance (Group×Surface). Over both surfaces, children with CP showed increased trunk movement in the sagittal (Group effect, p<0.001) and transverse planes (p<0.001), and increased pelvic movement in the coronal plane (p=0.008), indicating impaired trunk control. Peak separation between the centre of mass and centre of pressure was reduced in CP, indicating impaired dynamic balance (p=0.027). TD children made a number of significant adaptations to uneven ground, including reduced hip extension (mean difference 3.4°, 95% CI [-5.3, -1.0] p=0.006), and reduced ankle movement in the sagittal (5.2°, 95% CI [0.01, 10] p=0.049) and coronal planes (2.4°, 95% CI [0.3, 4.5], p=0.029), but these adaptations were not measured in CP. A significant Group×Surface interaction was detected for knee sagittal range (p=0.009). The findings indicate that children with CP walk show impaired control of trunk movement and are less able to adapt their gait to uneven ground, particularly at the ankle.

Malone A ，Kiernan D ，French H ，Saunders V ，O'Brien T ... -  《-》