Walking activity patterns in youth with cerebral palsy and youth developing typically

Abstract

Purpose: To describe daily walking stride rate patterns of young children with cerebral palsy (CP) as compared to a typically developing youth (TDY) cohort relative to age and functional level. Method: A cross-sectional comparison cohort study compared 209 youth with CP with 368 TDY aged 2–13 years. Youth with CP had Gross Motor Function Classification System (GMFCS) levels I–III with 60% bilateral involvement and 79% spastic. Five days of StepWatch data were averaged and classified into low, moderate and high stride rates. Group differences were examined by t-test and analysis of variance. Results: Children with CP walk significantly less each day than TDY (F?=?245, p?≤?0.001) and differ by GMFCS (F?=?1.51, p?<?0.001). TDY walk a similar number of strides in low and moderate stride rates each day while youth with CP do not. TDY attained high stride rates (>60 strides/min) for 8?min/d with levels I–III at 4.0, 3.2 and 0.53?min/d, respectively. Conclusions: The relative relationship of walking intensity levels within total daily stride activity differs for youth with CP as compared to TDY. The influence of functional walking ability on walking stride activity levels and intensity does not appear to differ significantly across age groups.

• Implications for Rehabilitation

• Limitation in the ability to attain moderate stride-rate intensity, regardless of total number of strides taken each day for ambulatory youth with CP, is a potential area of focus for intervention.

• Understanding of stride activity levels and intensity in youth with CP may be employed to focus rehabilitation strategies to enhance habitual walking activity.

• Community-based stride rate data has potential as an effectiveness outcome for rehabilitation strategies focused on walking (i.e. orthopedic surgery, orthoses and injections therapies).

     

Tactile function in children with unilateral cerebral palsy compared to typically developing children

Purpose: Tactile deficits have been understudied in children with unilateral cerebral palsy (UCP) using a limited range of tactile assessments. This study aims to characterize performance across a comprehensive battery of tactile registration and perception assessments in children with UCP and typically developing children (TDC). Methods: Fifty-two children with UCP (Gross Motor Function Classification System I = 34, II = 18; Manual Ability Classification System I = 36, II = 16) and 34 TDC were assessed using Semmes Weinstein Monofilaments (tactile registration), and single-point localization, double simultaneous, static and moving two-point discrimination, stereognosis, and texture perception (tactile perception). Results: Children with UCP performed consistently worse with their impaired hand than their unimpaired hand (Z = 2.77–5.61; p < 0.005). Both hands of children with UCP performed worse than either hand of TDC (Z = ?2.08 to 5.23; p = 0.037–< 0.001). Forty percent of children with UCP had tactile registration and perception deficits, 37% had perception deficits only and 23% had no tactile deficit. The larger the tactile registration deficit, the poorer the performance on all tactile perceptual tests (r = 0.568–0.670; p < 0.001). Conclusions: Most children with UCP demonstrate poor tactile perception and over one-third also demonstrate poor tactile registration. We contend that tactile dysfunction may contribute to functional impairment and is a possible target for intervention.

Implications for Rehabilitation:

• Cerebral palsy (CP) is the most prevalent physical disability in childhood, with an incidence of approximately 2 cases per 1000 live births; about 35% of children with CP have unilateral cerebral palsy (UCP).

• Assessment and treatment has been focused on the motor impairment; however, it is known that children with UCP are also likely to have sensory impairment.

• Understanding the nature and severity of sensory, specifically tactile, impairment in children with UCP will assist therapists to direct treatment accordingly and possibly impact the motor impairment.

     

Ambulatory physical activity performance in youth with cerebral palsy and youth who are developing typically

BACKGROUND AND PURPOSE: Assessment of walking activity in youth with cerebral palsy (CP) has traditionally been "capacity-based." The purpose of this study was to describe the day-to-day ambulatory activity "performance" of youth with CP compared with youth who were developing typically. SUBJECTS: Eighty-one youth with CP, aged 10 to 13 years, who were categorized as being in Gross Motor Function Classification System (GMFCS) levels I to III and 30 age-matched youth who were developing typically were recruited. METHODS: Using a cross-sectional design, participants wore the StepWatch monitor for 7 days while documenting average daily total step counts, percentage of time they were active, ratio of medium to low activity levels, and percentage of time at high activity levels. RESULTS: The youth with CP demonstrated significantly lower levels of all outcomes than the comparison group. DISCUSSION AND CONCLUSION: Daily walking activity and variability decreased as functional walking level (GMFCS level) decreased. Ambulatory activity performance within the context of the daily life for youth with CP appears valid and feasible as an outcome for mobility interventions in CP.     

Self-reported health status and quality of life in youth with cerebral palsy and typically developing youth

Bjornson KF, Belza B, Kartin D, Logsdon RG, McLaughlin J. Self-reported health status and quality of life in youth with cerebral palsy and typically developing youth.

Objective

To describe self-reported health status and quality of life (QOL) of ambulatory youths with cerebral palsy (CP) compared with sex- and age-matched typically developing youth (TDY).

Design

Prospective cross-sectional cohort comparison.

Setting

Community-based.

Participants

A convenience sample of 81 youth with CP (age range, 10−13y) with Gross Motor Function Classification System (GMFCS) levels I through III and 30 TDY participated. They were recruited from 2 regional children’s hospitals and 1 regional military medical center.

Interventions

Not applicable.

Main Outcome Measures

Participants completed the Child Health Questionnaire−Child Form (CHQ-CF87) for health status and the Youth Quality of Life for QOL.

Results

Youth with CP reported significantly lower health status than age- and sex-matched TDY in the following CHQ-CF87 subscales: role/social behavioral physical, bodily pain, physical function, and general health (CP mean rank, 46.8−55.2; TDY mean rank, 62.2−80.9). There were significant differences across GMFCS levels. There were no significant differences in self-reported QOL.

Conclusions

Self-reported health status, but not QOL, appears sensitive to the functional health issues experienced by ambulatory youth with CP. Pain management and psychosocial support may be indicated for them.     

Influence of age on step activity patterns in children with cerebral palsy and typically developing children

Stevens SL, Holbrook EA, Fuller DK, Morgan DW. Influence of age on step activity patterns in children with cerebral palsy and typically developing children.ObjectiveTo document the influence of age on step activity patterns in children with cerebral palsy (CP) and typically developing (TD) children.DesignCross-sectional.SettingAll step activity data were collected in free-living environments.ParticipantsChildren with CP (n=27; age, 4–18y; 22 boys, 5 girls; Gross Motor Function Classification System levels I and II) and 27 age- and sex-matched TD children were recruited through public advertisements and contacts with local clinicians. CP and TD participants were stratified into younger (<10y; n=14) and older (10–18y; n=13) age groups.InterventionDaily step activity was monitored using a step activity monitor that was individually programmed to account for the gait characteristics of each participant. Step activity data were collected in 1-minute epochs during waking hours on 3 weekdays and 1 weekend day. Stored data were analyzed to yield average values of daily step activity, percentage of inactive time (0 steps) over the entire day, and percentage of total daily active time spent in low step activity (1–15 steps/min), medium step activity (16–40 steps/min), and high step activity (>40 steps/min).Main Outcome MeasuresDaily step activity, percentage of inactive time, and percentage of active time spent in low-, moderate-, and high-intensity step activity.ResultsA significant (P<.05) interaction was observed between age (younger, older) and condition (CP, TD) for daily step activity, percentage of inactive time, and percentage of active time spent in low- and high-intensity step activity. The main effect of age was significant for each physical activity measure except for relative high-intensity step activity, and the main effect of condition was significant for all physical activity measures. Follow-up analyses (P<.025) revealed that older children with CP took fewer daily steps and displayed higher relative levels of inactivity and low-intensity activity and lower relative levels of high-intensity activity compared with older TD children. Older children with CP also exhibited lower daily step activity, demonstrated higher relative levels of inactivity and low-intensity activity, and displayed lower relative levels of moderate-intensity activity compared with younger children with CP.ConclusionsCompared with younger children with CP and age- and sex-matched TD youth, older youth with CP generally displayed step activity patterns typified by lower levels of physical activity and a greater degree of inactivity. These findings highlight the need to provide multiple opportunities for adolescents with CP to engage in a variety of physical activities that are appropriate to their needs, abilities, and preferences and that can aid in maintaining functional mobility, health, and quality of life.     

A comparison of leg stiffness in running between typically developing children and children with cerebral palsy

BackgroundLeg stiffness is important during running to increase velocity and maximise efficiency by facilitating use of the stretch-shortening cycle. Children with cerebral palsy who have neuromuscular impairments may have altered leg stiffness. The aim of this study was to describe leg stiffness during running in typically developing children and those with cerebral palsy in Gross Motor Function Classification Scale levels I and II at a range of speeds.MethodsThis cross-sectional study examined kinematic data collected from typically developing children (n = 21) and children with cerebral palsy (Gross Motor Function Classification Scale level I n = 25, Gross Motor Function Classification Scale level II n = 13) during jogging, running and sprinting. Derived variables were resultant ground reaction force, change in leg length and three-dimensional leg stiffness. Linear mixed models were developed for statistical analysis.FindingsChildren with cerebral palsy had reduced stiffness when jogging (Gross Motor Function Classification Scale level I affected t = 3.81 p < 0.01; non-affected t = 2.19 p = 0.03; Gross Motor Function Classification Scale level II affected t = 2.04 p = 0.04) and running (Gross Motor Function Classification Scale level I affected t = 3.23 p < 0.01) compared to typically developing children. Affected legs were less stiff than non-affected legs only in Gross Motor Function Classification Scale level I during running (t = 2.26 p = 0.03) and sprinting (t = 2.95 p < 0.01).InterpretationChildren with cerebral palsy have atypical leg stiffness profiles which differ according to functional classification.     

Differences in seated postural control in children with spastic cerebral palsy and children who are typically developing

OBJECTIVE: To quantitatively evaluate the difference of posture control in sitting position between children with spastic cerebral palsy and normal subjects. DESIGN: Twenty children with spastic cerebral palsy who could sit independently and 20 age- and sex-matched normal children were enrolled. The Chatteex Balance System was used to evaluate static and dynamic posture control as the subjects were sitting on a bench. The sway distance in sagittal and lateral directions, sway ratio, and sway index in both the static and dynamic sitting positions were recorded by the Chatteex Balance System. RESULTS: There was a significantly lower static and dynamic sway ratio and a greater static sway index and dynamic lateral sway distance in the study group. The dynamic sway index in the study group was greater than the index in the control group, although it did not reach statistical significance. CONCLUSIONS: Children with diplegic cerebral palsy did perform significantly worse in sitting posture control compared with normal subjects of similar chronological age. The sway index and sway ratio proved to be the objective and sensitive indicators that can be used to distinguish children with cerebral palsy from normal peer groups.     

Lower extremity muscle activity during cycling in adolescents with and without cerebral palsy

BACKGROUND: In individuals with cerebral palsy, adaptation and plasticity in the neuromuscular system can lead to detrimental changes affecting gait. Cycling may be an effective method to improve mobility. The biomechanics of cycling in adolescents with cerebral palsy have been studied, but further analysis of the frequency and amplitude characteristics of the electromyographic signals can assist with interpretation of the cycling kinematics. METHODS: Data were analyzed from 10 adolescents with typical development (mean=14.9, SD=1.4 years) and 10 adolescents with cerebral palsy (mean=15.6, SD=1.8 years) as they cycled at two different cadences. Analyses of the lower extremity electromyographic signals involved frequency and amplitude analysis across the cycling revolution. FINDINGS: Examination of cycling cadence revealed that adolescents with cerebral palsy had altered electromyographic characteristics in comparison to adolescents with typical development across the entire crank revolution for all muscles. Analyses of individual muscles indicated both inappropriate muscle activation and weakness. INTERPRETATION: A more comprehensive analysis of electromyographic activity has the potential to provide insight into how a task is accomplished. In this study, the control of the several muscles, especially the rectus femoris, was significantly different in adolescents with cerebral palsy. This, combined with muscle weakness, may have contributed to the observed deviations in joint kinematics. Interventions that increase muscle strength with feedback to the nervous system about appropriate activation timing may be beneficial to allow individuals with cerebral palsy to cycle more efficiently.     

Change of dynamic gastrocnemius and soleus muscle length after block of spastic calf muscle in cerebral palsy

OBJECTIVE: The purpose of this study was to evaluate the efficacy of gastrocnemius and soleus muscle length measured by gait analysis for characterizing the spastic calf muscles in ambulant cerebral palsy. METHODS: A total of 20 limbs in the 16 children with diplegic or hemiplegic cerebral palsy showing spasticity of the calf muscle were analyzed by three-dimensional gait analysis before and after botulinum toxin injection. RESULTS; The mean maximal ankle dorsiflexion angle, the minimal knee flexion angle in stance, and the dynamic gastrocnemius and soleus muscle lengths increased after the block. Paradoxically the dynamic gastrocnemius muscle lengths decreased in the eight patients after the block, all of whom had a common characteristic of the genu recurvatum. In contrast, dynamic soleus length, knee angle, and ankle angle improved after the injection. CONCLUSION: Gastrocnemius length and soleus length are useful variables to evaluate the antispastic effect of botulinum toxin in patients with cerebral palsy. When the genu recurvatum is present, the soleus muscle length is more informative than gastrocnemius length.     

Differences in habitual physical activity levels of young people with cerebral palsy and their typically developing peers: a systematic review

Purpose: To examine whether an 8-week period of side-alternating whole-body vibration (WBV) exercise is an acceptable and effective exercise intervention to improve and maintain functional performance in multiple sclerosis people. Methods: A total of 15 participants with MS (11 women [mean age 50.2 ± 6.9 years; body mass 65.7 ± 19.2 kg; height 165.3 ± 6.1 cm; EDSS 3.5 ± 0.9] and 4 males [mean age 50.5 ± 5.2 years; body mass 85.3 ± 16.0 kg; height 175.3 ± 3.2 cm; EDSS 3.4 ± 0.5]) were selected for this study. Quality of life, timed up-and-go, functional reach, standing balance and 10-m walk test were performed prior to and after 4 and 8 weeks of vibration exercise, and 2 weeks after cessation of vibration exercise. Results: There was no evidence of vibration exercise producing any anxiety or discomfort. Compared with baseline measurements, the 10-m walk test showed significant improvements in 2, 8 and 10 m times at 8 week (p < 0.05) and 2 week post-vibration (p < 0.05). Timed up-and-go demonstrated a significant and positive time effect (p < 0.05). Standing balance showed significant improvements from baseline, at 4- (p < 0.05) and 2-weeks post-vibration (p < 0.05). Conclusion: This is the first study to investigate side-alternating WBV as an exercise training modality for MS people. From an active MS population, this study has shown that WBV training not only improved the standing balance and walking time but there were also no adverse effects from using this modality.

Implications for Rehabilitation

• Muscle weakness and fatigue are reported by most patients with multiple sclerosis (MS).

• Whole-body vibration (WBV) has gained popularity as an exercise modality in participants with either normal or compromised health.

• WBV is a safe and effective exercise intervention for persons with MS to improve and maintain functional ability and quality of life.

     

Effects of cane use on walking parameters and lower limb muscle activity in adults with spastic cerebral palsy: a cross-sectional study

[Purpose] Adults with cerebral palsy often use a cane as a walking aid because of their decreased gait ability. However, it is unclear whether this affects lower limb muscle activity during walking. The purpose of this study was to clarify the influence of using a cane during walking on the spatio-temporal parameters of walking, lower limb muscle activity, and lower limb muscle coactivation in adults with spastic cerebral palsy. [Participants and Methods] Eleven participants with cerebral palsy were included. The spatio-temporal parameters of walking, lower limb muscle activity, and coactivation of lower limb muscle were measured during a 10 m trial with no cane, one cane, and two canes. [Results] Walking speed was lower and the stride time longer when using two canes than when using no cane. All muscle activities significantly reduced when using two canes. No significant difference was observed between using no cane and one cane, except for walking speed. In addition, there was no significant difference in coactivation between the conditions. [Conclusion] This study revealed that when two canes were used, the walking speed was reduced, and lower limb muscle activity was reduced, reducing the burden. In contrast, the movement pattern was not suggested to have changed.     

Cortical thickness of the frontopolar area in typically developing children and adolescents

The development of the frontopolar cortex (FPC) through late childhood and adolescence was investigated using measures of cortical thickness. T(1)-weighted structural MRIs from 35 typically developing participants aged 8-20 years were used to construct 3D models of the brain, from which cortical thickness was measured. There was a significant inverse association between age and cortical thickness, such that cortical thickness decreased as age increased between 8 and 20 years. There was no effect of laterality or gender on cortical thickness.     

Walking activity of children with cerebral palsy and children developing typically: a comparison between the Netherlands and the United States

Abstract

Purpose: To compare walking activity of children with and without cerebral palsy (CP) between the Netherlands and the United States. Methods: A cross-sectional analysis on walking activity data from an international retrospective comparison study including a convenience sample of 134 walking children aged 7–12 years with spastic CP, classified as Gross Motor Function Classification System (GMFCS) level I (N?=?64), II (N?=?49) or III (N?=?21), and 223 typically developing children (TDC) from the Netherlands and the United States. Walking activity was assessed during a one-week period using a StepWatch? activity monitor. Outcomes were the daily number of strides, daily time being inactive and spent at low (0–15 strides/min), moderate (16–30 strides/min) and high stride rate (31–60 strides/min). Walking activity was compared between countries using multiple linear regression analyses. Results: Walking activity of TDC was not significantly different between countries. Compared to their American counterparts, Dutch children in GMFCS level I and II showed less walking activity (p?<?0.05), whereas Dutch children in GMFCS level III showed more walking activity (p?<?0.05). Conclusion: The absence of differences in walking activity between Dutch and American TDC, and the presence of differences in walking activity between Dutch and American children with CP suggest that between-country differences affect walking activity differently in children with CP.

• Implications for Rehabilitation

• Physical activity of children with CP should be promoted in both the United States and the Netherlands.

• The between-country differences in walking activity illustrate that apart from the severity of the CP walking activity seems to be influenced by environmental aspects.

• In the promotion of physical activity, practitioners should pay attention to environmental barriers that families may experience for increasing physical activity.

     

Patterns of upper limb muscle activation in children with unilateral spastic cerebral palsy: Variability and detection of deviations

BackgroundThe aim of this study was two-fold: (1) to quantify the variability of upper limb electromyographic patterns during elbow movements in typically developing children and children with unilateral spastic cerebral palsy, and to compare different amplitude normalization methods; (2) to develop a method using this variability to detect (a) deviations in the patterns of a child with unilateral spastic cerebral palsy from the average patterns of typically developing children, and (b) changes after treatment to reduce muscle activation.MethodsTwelve typically developing children ([6.7–15.9yo]; mean 11.0 SD 3.0yo) and six children with unilateral spastic cerebral palsy ([7.9–17.4yo]; mean 12.4 SD 4.0yo) attended two sessions during which they performed elbow extension-flexion and pronation-supination movements. Surface electromyography of the biceps, triceps, brachioradialis, pronator teres, pronator quadratus, and brachialis muscles was recorded. The Likelihood method was used to estimate the inter-trial, inter-session, and inter-subject variability of the electromyography patterns for each time point in the movement cycle. Deviations in muscle patterns from the patterns of typically developing children and changes following treatment were evaluated in a case study of a child with cerebral palsy.FindingsNormalization of electromyographic amplitude by the mean peak yielded the lowest variability. The variability data were then used in the case study. This method detected higher levels of activation in specific muscles compared with typically developing children, and a reduction in muscle activation after botulinum toxin A injections.InterpretationUpper limb surface electromyography pattern analysis can be used for clinical applications in children with cerebral palsy.     

Pectoralis minor muscle elongation and scapulothoracic motion do not differ in individuals with short versus typical resting pectoralis minor muscle length: a cross-sectional study

Background

Individuals with short resting pectoralis minor muscle length have been shown to have aberrant scapulothoracic motion when compared to individuals with long resting pectoralis minor muscle length. However, the degree to which the pectoralis minor muscle can be lengthened and whether or not scapulothoracic motion differs between individuals with short and typical resting pectoralis minor muscle length is unknown.

手持式电子肌力测定仪在痉挛型脑瘫儿童下肢肌力测定中的信度研究

目的探讨手持式电子肌力测定仪在痉挛型脑瘫儿童下肢肌力测定中的信度。 方法以2009年2月至11月在复旦大学附属儿科医院康复中心接受康复治疗的28例3岁以上的痉挛型脑瘫患儿为研究对象,采用手持式肌力测定仪（HHD）标准化操作方法测定患儿下肢髋、膝、踝等部位肌群的肌力,任意选取20例患儿在接受第1次HHD测定后休息10 min,再由同一测试者进行重复测试,通过比较前后测试结果间的相关性来确定HHD的重测信度;在非同一天任意选取15例患儿在接受第1次HHD测定后休息10 min,再由不同测试者进行重复测试,通过比较前后测试结果间的相关性来确定HHD的不同测试者间信度。 结果HHD在测定痉挛型脑瘫患儿下肢肌群时有良好的重测信度（ICC值在0.74～0.97之间）和不同测试者间信度（ICC值在0.63～0.97之间）,其中髋屈曲、足跖屈和膝伸展肌群的重测信度最高（ICC值在0.94～0.97之间）,髋屈曲、足背屈的不同测试者间信度最高（ICC值在0.90～0.97之间）。 结论采用标准化的测试方法,手持式电子肌力测定仪在痉挛型脑瘫儿童下肢肌力测定中具有良好的重测信度和不同测试者间信度,可以良好地评价脑瘫患儿的下肢肌力。     

Isometric muscle strength and mobility capacity in children with cerebral palsy

Purpose: To determine the relationship between isometric leg muscle strength and mobility capacity in children with cerebral palsy (CP) compared to typically developing (TD) peers. Method: Participants were 62 children with CP (6–13 years), able to walk with (n?=?10) or without (n?=?52) walking aids, and 47 TD children. Isometric muscle strength of five muscle groups of the leg was measured using hand-held dynamometry. Mobility capacity was assessed with the 1-min walk, the 10-m walk, sit-to-stand, lateral-step-up and timed-stair tests. Results: Isometric strength of children with CP was reduced to 36–82% of TD. When adjusted for age and height, the percentage of variance in mobility capacity that was explained by isometric strength of the leg muscles was 21–24% (walking speed), 25% (sit-to-stand), 28% (lateral-step-up) and 35% (timed-stair) in children with CP. Hip abductors and knee flexors had the largest contribution to the explained variance, while knee extensors showed the weakest correlation. Weak or no associations were found between strength and mobility capacity in TD children. Conclusion: Isometric strength, especially hip abductor and knee flexor strength, is moderately related to mobility capacity in children with CP, but not in TD children. To what extent training of these muscle groups will lead to better mobility capacity needs further study.

• Implications for Rehabilitation

• Strength training in children with cerebral palsy (CP) may be targeted more specifically at hip abductors and knee flexors.

• The moderate associations imply that large improvements in mobility capacity may not be expected when strength increases.