Factors associated with pelvic retraction during gait in cerebral palsy

Clinical and dynamic (gait-related) measures thought to be associated with pelvic retraction were investigated in patients with cerebral palsy. Gait laboratory data of 233 patients with cerebral palsy were studied retrospectively. Two groups were selected; those who demonstrated pelvic retraction during gait <-6.85 degrees (mean - 2 standard deviations from normal (n=88) and those with >-4.83 degrees (mean - 1 standard deviation from normal) (n=101). About 37.8% of the total population reviewed showed pelvic retraction of <-6.85 degrees . There was a higher prevalence of retraction among hemiplegics (46.3%) compared to diplegics (30.4%). Differences were also found between hemiplegic and diplegic subjects in terms of factors associated with pelvic retraction. Clinical and dynamic tightness of the gastro-soleus were the most significant features associated with pelvic retraction among hemiplegic subjects. Clinical and dynamic flexion and internal rotation of the hip were the most significant features associated with retraction in the diplegic population. This study suggests that pelvic retraction is multifactorial in origin and secondary to both static clinical measures as well as dynamic features during gait.     

The variability of goniometric measurements in ambulatory children with spastic cerebral palsy

This study assessed the variability of six goniometric measurements commonly used in the assessment of children with cerebral palsy (CP). Three experienced paediatric physiotherapists recorded three consecutive measurements of six joint ranges from 12 children with spastic CP. A fourth measurement was recorded 1 week later. The order of measurement with regards to both joint measurement and tester, was randomised to ensure a balanced experimental design. A blinded procedure was adopted with masked goniometers and a second assessor present to record the measurement. Results, analysed using generalizability theory, showed same day and different day measurement error of +/-10-14 degrees (95% confidence limits) for the foot/thigh angle, abduction and internal rotation of the hip. The source of this was child-assessor and residual error. For ankle dorsiflexion and the popliteal angles, same day measurement error was similar. However, for joint ranges recorded on different days, error ranged from +/-18-28 degrees. The major source of this was systematic differences in measurements recorded on different days. Results show a need for caution when using goniometric measurements in clinical decision making, particularly in the more tone dependent biarticular muscles after an initial assessment.     

A stair-climbing test for ambulatory assessment of children with cerebral palsy

The purpose of this study was to develop a stair-climbing test to measure energy cost (EC) and mechanical efficiency (ME) in children with cerebral palsy (CP) to evaluate ambulation-related motor function and its changes after intervention or maturation. Five normally developed (ND) and 10 children with CP were tested. The gross ME (MEg) was calculated from the work done (W) and the total energy cost (oxygen consumption) measured while repeatedly ascending and descending four steps for approximately 5 min without subtracting the resting metabolic rate. The MEg was significantly lower in CP than ND (3% versus 20%, P < 0.001). The test was repeated in the 10 children with CP after a 4-month therapy recess. The MEg values correlated with the initial tests, with a small, significant increase of 2%. When calculating net ME (MEn) from W and the energy cost above resting, the correlation of MEn values before and after therapy was inferior to that using MEg values. Similarly, individual ME values obtained by estimating energy cost from the increase in heart rate (HR) during stair-climbing also correlated poorly, with large variability. These results show that MEg may be used to evaluate changes in motor function resulting from age-related development or therapy. MEg is as good or superior to MEn; the extra time required to obtain resting energy cost and heart rate values is not necessary when measurements are desired within the same individual.     

Hip deformities in walking patients with cerebral palsy

Hip deformities in walking patients with cerebral palsy are rare. Nineteen diplegic and four hemiplegic patients with unilateral hip subluxation were studied to determine whether or not characteristic gait patterns could be identified. All were examined clinically and radiologically as well as undergoing observational and instrumented three dimensional gait analysis. Twenty one of the patients compensated for the subluxation with an ipsilateral trunk lean and contralateral pelvic drop. These patterns were quantified in the kinematic and kinetic variables measured. We conclude that hip abductor weakness should be considered as the cause of the deformity.     

Distal hamstring lengthening in ambulatory children with cerebral palsy: primary versus revision procedures

To document the benefits and limitations of distal hamstring lengthening (HL), 61 children (105 limbs) with cerebral palsy treated by distal HL with complete preoperative and postoperative evaluations were reviewed. There was significant improvement in popliteal angle, fixed knee flexion contracture, knee angle at foot contact (FC), and mid-stance knee extension after HL. On the other hand, the hip power generation peak decreased, and the anterior pelvic tilt increased. For the repeated HL (22 limbs), the fixed knee flexion contracture and knee flexion at FC improved. In a group of ten patients (17 limbs) with further postoperative follow up evaluations, the only significant clinical finding related to hamstring function between the first postoperative and the follow up evaluations with no intervening surgery was an increase in the popliteal angle of 20°. Because the popliteal angle may increase over time after HL with no other directly related gait changes, the indications for repeated HL should include fixed knee flexion contracture and increased knee flexion at FC. The increase in the popliteal angle alone should not be considered an indication for repeated HL.     

Association of back pain and pelvic tilt during gait in individuals with cerebral palsy

BackgroundBack pain prevalence may increase with lumbar lordosis during standing in individuals with cerebral palsy (CP). Multiple interventions undertaken in individuals with CP have been shown to increase anterior pelvic tilt.Research questionAre pelvic tilt and trunk tilt (proxy measurements for lumbar lordosis) during gait associated with back pain prevalence in ambulatory individuals with CP?MethodsA retrospective investigation was performed among all patients with cerebral palsy visiting a single clinical motion analysis laboratory over a 3.5 year period (January 2015 – May 2018) who also had complete pain questionnaire data. Back pain prevalence and its association with sagittal plane kinematic parameters (pelvic tilt and trunk tilt) were analyzed.ResultsAmong the 700 patients that met the inclusion criteria, 594 were children and 106 were adults. Back pain prevalence was 11.1% in children and 36.8% in adults. As pelvic tilt and age increased, back pain increased (odds ratio 95% confidence interval: 1.002–1.061 and 1.052–1.109, respectively). Walking with an assistive device was not associated with back pain, nor was trunk tilt.SignificanceBack pain was more common with increasing age in ambulatory individuals with CP. After controlling for assistive device use and age, there was a weak relationship between pelvic tilt and back pain. Future studies are needed to determine if this is this a causal relationship.     

The prevalence of pineal cyst in patients with cerebral palsy

PURPOSE

Pineal cysts are common incidental findings during magnetic resonance imaging (MRI) examinations. The etiology of pineal cyst development is still unclear. We aimed to determine whether there is an association between periventricular leukomalacia and pineal cyst prevalence.

METHODS

Clinical and MRI data of 201 patients with periventricular leukomalacia (110 female, 91 male; mean age, 6 years; range, 2–18 years) and 687 control patients (355 female, 332 male; mean age, 6 years¸ range, 2–18 years) who did not have any evidence of periventricular leukomalacia were independently evaluated by two radiologists for presence or absence of pineal cyst.

RESULTS

Pineal cysts were detected in 32.3% of the study group (65/201) and 8.4% of the control group (58/687) (P < 0.001). Patients with periventricular leukomalacia were more likely to have a pineal cyst. In terms of pineal cyst detection on MRI, interobserver reliability was high between the two radiologists.

CONCLUSION

The prevalence of pineal cysts is higher in patients with periventricular leukomalacia. We suggest that an ischemic process may have a role in the etiopathogenesis of pineal cyst development.Pineal cysts are among the most common incidental findings during magnetic resonance imaging (MRI) examinations (1). They are usually well-demarcated fluid-filled lesions of variable size, composed of three layers; an outer layer of fibro-collagenous rim, an intermediate pinealocyte layer, and an inner layer of hypocellular glial tissue (2). Although the etiology of pineal cysts is still unclear, several theories have been proposed. Pineal cysts could be developed secondary to focal degeneration of pineal gland or distension of pineal diverticulum remnant (3). Laure-Kamionowska et al. (4). suggested that pineal cysts occur due to hemorrhage or necrosis of pineal gland during the fetal life. In addition, another possibility for cyst development is necrosis or cavitation of pineal gland following the ischemic degeneration of intrapineal glial plate (5). Ischemia is also a major predisposing factor for periventricular leukomalacia (PVL), which can subsequently lead to cerebral palsy.In this study, we aimed to investigate whether there is an increase in the prevalence of pineal cysts in pediatric patients with PVL. To the best of our knowledge, there is only one previously published report that mentioned a possible association between hypoxic ischemic encephalopathy and pineal cyst existence (6). Although pineal cysts are known as innocent entities, radiologists and clinicians should be aware of their presence, since they may cause some symptoms including headache, precocious puberty, and even death, probably secondary to pineal apoplexy.     

Single-session reliability of discrete gait parameters in ambulatory children with cerebral palsy based on GMFCS level

The single-session reliability of 28 discrete spatiotemporal and kinematic variables was evaluated from computerized gait analysis (CGA) in 33 ambulatory children with cerebral palsy (CP), subcategorized according to Gross Motor Function Classification System (GMFCS) Levels I (n = 11), II (n = 12) and III (n = 10). Nineteen boys and 14 girls participated, mean age = 8 years 1 month (S.D. = 3 years 0 month). Intraclass correlation coefficients (ICCs) estimated reliability, and the number of strides required to obtain an ICC of at least 0.90 was determined. The reliability of discrete gait parameters was dependent upon GMFCS level, with children in GMFCS Level I exhibiting the highest reliability (ICC range = 0.70–0.96). GMFCS Levels II and III had lower levels of reliability with ICC values varying from 0.54 to 0.95 and 0.45 to 0.98, respectively. With the exclusion of pelvis range of motion (ROM), an average of four strides provided a reliability estimate of at least 0.90 for GMFCS Level I, while six strides were needed for children in Levels II and III. On the basis of the intrasession reliability results from the present study, further work is recommended to examine the test–retest reliability of these gait parameters in children with CP.     

Predictors of pelvic retraction in children with cerebral palsy derived from gait parameters and clinical testing

Excessive pelvic rotation in the transverse plane is common in patients with cerebral palsy. Knowing the underlying reasons is important for clinical decision making, since changes in pelvic retraction might have an effect on internally rotated gait. We hypothesized that the contralateral leg contributes considerably to pelvic rotation on the retracted side. Therefore the aim of this study is to calculate predictors for pelvic retraction using both, parameters from the retracted and from the contralateral protracted side. Thirty-two children with diplegia and 18 children with hemiplegia were examined by three-dimensional gait analysis followed by a clinical examination protocol. Stepwise multilinear regression of the response value mean pelvic retraction during stance phase was performed on 10 potential predictors of dynamic gait data and 10 corresponding predictors of clinical data of the retracted and the contralateral protracted side. Gait analysis revealed ankle push-off energy on the protracted side as the best predictors in hemiplegic patients explaining 59% of the variance in pelvic retraction. In diplegic patients external hip rotation of the protracted side was most accurate in predicting pelvic retraction (27%). Best clinical predictors for hemiplegic patients were ankle dorsiflexion on the retracted side (46%) and for diplegic patients it was the knee extension strength on the protracted side together with hip rotation on the retracted side (36%). In hemiplegic patients ankle push-off energy of the contralateral side is a significant compensation mechanism that might cause increased pelvic retraction to compensate for the weakness of the involved side. In diplegic patients prediction of pelvic retraction was only moderate and requires further investigation.     

Physical fitness,everyday physical activity,and fatigue in ambulatory adults with bilateral spastic cerebral palsy

This study assessed physical fitness and its relationships with everyday physical activity (PA) and fatigue in cerebral palsy (CP). Participants were 42 adults with ambulatory bilateral spastic CP (mean age 36.4 ± 5.8 years; 69% males; 81% with good gross motor functioning). Progressive maximal aerobic cycle tests determined VO_2peak (L/min). Objective levels of everyday PA were measured with accelerometry and self‐reported levels of everyday PA with the Physical Activity Scale for Individuals with Physical Disabilities. Fatigue was assessed with the Fatigue Severity Scale. The average aerobic capacity of adults with CP was 77% of Dutch reference values. Participants were physically active during 124 min/day (85% of Dutch reference values), and half experienced fatigue. In women, lower physical fitness was related to lower self‐reported levels of PA (R_p=0.61, P=0.03), and in men to higher levels of fatigue (R_p=?0.37, P=0.05). Other relationships were not significant. Results suggest that ambulatory adults with CP have low levels of physical fitness, are less physically active than able‐bodied age mates and often experience fatigue. We found little evidence for relationships between the level of physical fitness and everyday PA or fatigue.     

Rectus femoris transfer in cerebral palsy patients with stiff knee gait

BackgroundAlthough several studies have reported on the outcomes of rectus femoris transfer (RFT), few have investigated the multiple factors that could affect the results. Therefore, we evaluated the outcomes of RFT and analyzed factors that influence improvement and annual change in knee motion after surgery in patients with cerebral palsy (CP).MethodsWe reviewed ambulatory patients with CP who were followed up after they had undergone RFT as part of a single-event multilevel surgery (SEMLS) and who had undergone preoperative and postoperative three-dimensional (3D) gait analysis between January 1995 and December 2012. Relevant kinematic values, including peak knee flexion, knee range of motion, and timing of peak knee flexion in the swing phase and gait deviation index (GDI) score, were the outcome measures. Improvements in rate of angle and GDI score were adjusted by multiple factors such as sex, Gross Motor Function Classification System (GMFCS) level, anatomic type of CP, and concomitant surgeries as the fixed effects, and follow-up duration, laterality, and each subject as the random effects, all of which was performed using a linear mixed model.ResultsA total of 290 patients (487 limbs) and 612 3D gait analysis (2–4 per patient) results were finally included in this study. At 2 years after RFT, estimated mean peak knee flexion (1.2°, p = 0.005), estimated mean knee range of motion (10.7°, p < 0.001), and estimated mean GDI score (7.3, p < 0.001) increased significantly. Peak knee flexion in the swing phase occurred 5.4% earlier after surgery compared with that at baseline (p < 0.001). In serial postoperative gait analyses, peak knee flexion in the swing phase occurred 0.8% earlier per year in patients with GMFCS level I or II (p = 0.021).ConclusionsRFT as part of a SEMLS was effective in treating stiff knee gait. In serial postoperative gait analyses, patients with GMFCS level I or II showed better prognosis than those with level III with regard to timing of peak knee flexion in the swing phase.Level of evidencePrognostic level IV.     

Cost savings for single event multilevel surgery in comparison to sequential surgery in ambulatory children with cerebral palsy

BackgroundThe purpose of this study was to determine the differences in billable provider charges between single event multilevel surgery (SEMLS) based on comprehensive gait analysis and a staged surgical approach (SSA) without comprehensive gait analysis for the orthopedic treatment of ambulatory children with cerebral palsy (CP).MethodsThe charges associated with nine common orthopedic surgical combinations (both unilateral and bilateral, soft tissue or soft tissue plus bony) for children with CP were determined and compared between SEMLS and SSA. The charges included surgical, anesthesia, operating room, recovery room, hospital stay, physical therapy, and, for SEMLS only, comprehensive computerized gait analysis.ResultsTotal charges to complete each combination was higher for SSA than for SEMLS. The differential ranged from $10,247 to $75,069 with the percentage difference ranging from 20% to 47%. The mean difference was $43,606 (p = 0.0002). The dollar difference (r = 0.98, p < 0.0001) and percentage difference (r = 0.79, p = 0.01) were both related to the total charge of the SEMLS surgery.SignificanceFinancial costs are lower for SEMLS vs. SSA for the treatment of multilevel gait issues in children with CP. The cost of gait analysis is much smaller than the cost differential between SEMLS and SSA. Although some patients who have SEMLS may need additional orthopedic surgery with associated costs, this is also possible for SSA. Therefore, due to the many benefits of SEMLS, which also include more informed treatment decision-making as well as reduced time away from school and work (for caregivers), SEMLS guided by gait analysis is recommended over SSA for the treatment of gait disorders in children with CP.     

MRI of patients with cerebral palsy and normal CT scan

Summary Three children with clinical evidence of cerebral palsy (CP) and normal cerebral computed tomography (CT) scans were evaluated by magnetic resonance imaging (MRI) to identify CT-undetectable white matter lesions in the watershed zones of arterial territories. The two patients with spastic diplegia showed bilateral lesions either in the subcortical regions or in the occipital periventricular regions. The patient with congenital hemiplegia exhibited unilateral lesions in the periventricular region. We conclude that MRI is more informative than CT for the evaluation of patients with CP.     

Changes in intersegmental stability during gait in patients with spastic cerebral palsy

BackgroundDysfunction in peripheral and neural structure with spastic cerebral palsy (CP) causes impaired performance and stability of various behaviors. Recent progress of quantification methods for the stability properties, which is based on the uncontrolled manifold hypothesis, has been applied to various neurological disorders. A prior study revealed that the ability for purposeful regulation of stability properties is weakened with CP during finger and hand actions. Successive regulation of stability properties is crucial for human locomotion; therefore, it is imperative to quantify the changes in the intersegmental coordination as to the stable performance in CP individuals during gait.Research questionWe hypothesized that (1) Spastic CP group will show smaller step length and gait velocity with larger variability, and (2) Spastic CP group will show no changes in average stability indices for both the COM and head position stabilization, while the smaller difference between stable and unstable posture during the gait cycle.MethodsWhole-body kinematic data during walking were collected from CP and control subjects. Step length, velocity, and coefficient of variation (CV) were calculated as spatiotemporal parameters. We quantified the intersegmental stability index in time-series during gait for the stabilization of the whole-body COM and head position.ResultsThe CP subjects showed smaller step length and velocity with larger CV than the controls. However, the CP group showed a significantly less difference in the stability indices between the single- and double-limb support phases as compared to the controls for both the COM and head position stabilization.SignificancePresent study is the first to document the quantification of changing intersegmental stability in the spastic CP during locomotion. The dysfunction of intentional modulation of stability properties in CP individuals may be a more common problem, which is not limited to a specific body effector.     

Transverse plane rotation of the foot and transverse hip and pelvic kinematics in diplegic cerebral palsy

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.     

What is the price for the Duchenne gait pattern in patients with cerebral palsy?

Duchenne gait is characterized by trunk lean towards the affected stance limb with the pelvis stable or elevated on the swinging limb side during single limb stance phase. We assessed the relationship between hip abduction moments and trunk kinetics in patients with cerebral palsy showing excessive lateral trunk motion. Data of 18 subjects with bilateral spastic cerebral palsy (CP) and 20 aged matched typically developing subjects (TD) were collected retrospectively. Criteria for patient selection were barefoot walking without aid presenting with excessive lateral trunk motion. Subjects had been monitored by conventional 3D gait analysis of the lower extremity including four markers for monitoring trunk motion. Post-hoc, a generic musculoskeletal full body model (OpenSim 3.3) assuming a rigid trunk articulated to the pelvis by a single ball joint was applied for analyzing joint kinematics and kinetics of the lower limb joints including this spine joint. Joint angle ranges of motion, maximum joint moments and powers in the frontal plane as well as mechanical work were calculated and averaged within groups showing prominent differences between groups in all parameters. To the best of our knowledge, this is the first work explicitly looking into the kinetics of Duchenne gait in patients with CP, clinically known as compensation for unloading hip abductor muscles. The results show that excessive lateral trunk motion may indeed be an extremely effective compensation mechanism to unload the hip abductors in single limb stance but for the price of a drastic increase in demand on trunk muscle effort and work.