Neuromuscular response to a single session of whole-body vibration in children with cerebral palsy: A pilot study

BackgroundWhole-body vibration (WBV) is a relative new intervention paradigm that could reduce spasticity and improve motor function in children with cerebral palsy (CP). We investigated neuromuscular response to a single session of side-alternating WBV with different amplitudes in children with CP.MethodsTen children with spastic CP aged 7–17 years at GMFCS level I-III participated in this pilot study. Participants received two sessions of side-alternating WBV with the same frequency (20 Hz) but different amplitudes (low-amplitude: 1 mm and high-amplitude: 2 mm). Each session included six sets of 90 s of WBV and 90 s of rest. Before and after each WBV session, we used (a) the modified Ashworth scale to evaluate the spasticity of the participants' leg muscles, (b) a quiet standing task to analyze center-of-pressure (CoP) pattern and postural control, and (c) overground walking trials to assess spatiotemporal gait parameters and joint range-of-motion (RoM).ResultsBoth WBV sessions similarly reduced the spasticity of the ankle plantarflexors, improved long-range correlation of CoP profile during standing, and reduced muscle activity of tibialis anterior during walking. The high-amplitude WBV further increased ankle RoM during walking.ConclusionsThis study demonstrates that a single session of WBV with either a low or a high amplitude can reduce spasticity, enhance standing posture, and improve gait patterns in children with CP. It suggests that low-amplitude WBV may induce similar neuromuscular response as high-amplitude WBV in children with spastic CP and can provide positive outcomes for those who are not able to tolerate stronger vibration.     

Lesser magnitudes of lower extremity variability during terminal swing characterizes walking patterns in children with autism

BackgroundAnecdotally, children with Autism Spectrum Disorder have highly variable lower extremity walking patterns, yet, this has not been sufficiently quantified. As such, the purpose of this study was to examine walking pattern variability by way of lower extremity coordination and spatio-temporal characteristics in children with autism compared with individuals with typical development during over-ground walking.MethodsBilateral continuous relative phase variability was computed for the thigh-leg, leg-foot, and thigh-foot segment couples for 11 children with autism and 9 children with typical development at each gait sub-phase. Furthermore, left and right stride lengths and stride width were computed and compared. The Model Statistic was utilized to test for statistical differences in variability between each child with autism to an aggregate group with typical development. Effect sizes were computed to determine the meaningfulness between responses for children with autism and typical development. Coefficient of variation and effect sizes were computed for stride lengths and stride width.FindingsAnalysis revealed that children with autism exhibited differences in variability in each gait sub-phase. Notably, all but two children with autism exhibited lesser variability in all segment couples during terminal swing. Differences in stride lengths were relatively minimal, however, greater coefficient of variation magnitudes in stride width were observed in children with autism.InterpretationThis finding reveals that children with autism may have limited or a preferred movement strategy when preparing the foot for ground contact. The findings from this study suggest variability may be an identifiable characteristic during movement in children with autism.     

Effect of rhythmic auditory stimulation on gait performance in children with spastic cerebral palsy

The purpose of this study was to use Rhythmic Auditory Stimulation (RAS) for children with spastic cerebral palsy (CP) in a clinical setting in order to determine its effectiveness in gait training for ambulation. RAS has been shown to improve gait performance in patients with significant gait deficits. All 25 participants (6 to 20 years old) had spastic CP and were ambulatory, but needed to stabilize and gain more coordinated movement. Participants were placed in three groups: the control group, the therapist-guided training (TGT) group, and the self-guided training (SGT) group. The TGT group showed a statistically significant difference in stride length, velocity, and symmetry. The analysis of the results in SGT group suggests that the self-guided training might not be as effective as therapist-guided depending on motivation level. The results of this study support three conclusions: (a) RAS does influence gait performance of people with CP; (b) individual characteristics, such as cognitive functioning, support of parents, and physical ability play an important role in designing a training application, the effectiveness of RAS, and expected benefits from the training; and (c) velocity and stride length can be improved by enhancing balance, trajectory, and kinematic stability without increasing cadence.     

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).

     

Preoperative and postoperative gait evaluation in cerebral palsy

The purpose of the study was to evaluate objectively and quantitatively the possible effects of surgical correction for equinus deformity on the gait of children with cerebral palsy (CP). Evaluation criteria selected were based on time and distance parameters of stride during gait. Ten children with confirmed diagnoses of CP took part in the study. They were tested before surgery and after surgery at four-month intervals for a period of up to one year. Results were compared to published data obtained on able-bodied, growing children to determine whether progress after the operation was faster than that expected in normal growth. Gait improvement was demonstrated by a decrease in support time and an increase in walking speed and stride length. Overall improvement was sometimes preceded by an initial, temporary deterioration. Results indicate that the time and distance parameters of stride can provide reliable objective evaluation of gait improvement after tendo Achilles lengthening in children with CP.     

The role of head stabilization in locomotion in children with cerebral palsy

ObjectiveThe objective of the present study was to highlight the role of head stabilization and to analyze multisegment head-trunk coordination during gait in children with cerebral palsy (CP).Material and methodPostural control was measured and compared in a group of 16 CP subjects and a control group of 16 healthy subjects. The subjects had to walk along an out-and-back course at their freely chosen gait speed. For each gait cycle, motion analysis techniques were used to calculate the amplitude of the head angle (relative to the trunk) in the sagittal and frontal planes.ResultsKinematic analysis revealed a number of significant intergroup differences, with a more pronounced variation in the head angle (relative to the trunk) in the CP group than in the control group. There were no significant intergroup differences in terms of the angular amplitude of the head in the sagittal plane.ConclusionThe greater variability of the head angle in the frontal plane in the CP subjects might reflect the presence of greater head roll as a compensatory strategy. These finding suggest that the clinical evaluation of posture during gait in children with CP should be reconsidered.     

Coordination of dynamic balance during gait training in people with acquired brain injury

Clark RA, Williams G, Fini N, Moore L, Bryant AL. Coordination of dynamic balance during gait training in people with acquired brain injury.ObjectiveTo investigate movement of the center of mass (COM) during different gait training methods in people with neurologic conditions.DesignCoordination of the gait cycle, represented by mediolateral COM displacement amplitude, timing, and stability, was assessed during a variety of gait training methods performed in a single session.SettingGait laboratory.ParticipantsPeople who were unable to walk unassisted due to an acquired brain injury (n=17) and healthy control subjects (n=25).InterventionsThe participants performed 7 alternative gait training methods in a randomized order. These were therapist manual facilitation, the use of a gait assistive device, treadmill walking with handrail support, and 4 variations of body weight–support treadmill training with combinations of handrail and/or therapist support.Main Outcome MeasuresMediolateral COM movement was analyzed in terms of displacement amplitude (overall range of motion), timing (relative to stride time), and stability (steadiness of the movement). Normative values for these measures were acquired from 25 healthy participants walking at a self-selected comfortable pace.ResultsBody weight–support treadmill training without any additional support resulted in significantly (P<.05) greater amplitude, altered timing, and reduced movement stability compared with nonpathologic gait. Allowing handrail support or therapist facilitation reduced this effect and resulted in treadmill training (± body weight support) having lower movement amplitudes when compared with the other training methods. Therapist manual facilitation most closely matched nonpathologic gait for timing and stability.ConclusionsIn the context of overall dynamic gait coordination, no single method of training provides the optimal stimulus. A training program that uses a variety of techniques may provide a beneficial rehabilitation response.     

Treadmill training with an incline reduces ankle joint stiffness and improves active range of movement during gait in adults with cerebral palsy

Purpose: We investigated if 30?min of daily treadmill training with an incline for 6 weeks would reduce ankle joint stiffness and improve active range of movement in adults with cerebral palsy (CP).

Methods: The study was designed as a randomized controlled clinical trial including 32 adults with CP (GMFCS 1–3) aged 38.1 SD 12 years. The training group (n?=?16) performed uphill treadmill training at home daily for 30?min for 6 weeks in addition to their usual activities. Passive and reflex mediated stiffness and range of motion (ROM) of the ankle joint, kinematic and functional measures of gait were obtained before and after the intervention/control period. Intervention subjects trained 31.4 SD 10.1 days for 29.0 SD 2.3?min (total) 15.2?h.

Results: Passive ankle joint stiffness was reduced (F?=?5.1; p?=?0.031), maximal gait speed increased (F?=?42.8, p?F?=?5.3, p?F?=?12.5; p?Conclusion: Daily treadmill training with an incline for 6 weeks reduces ankle joint stiffness and increases active ROM during gait in adults with CP. Intensive gait training may thus be beneficial in preventing and reducing contractures and help to maintain functional gait ability in adults with CP.

• Implications for rehabilitation

• Uphill gait training is an effective way to reduce ankle joint stiffness in adult with contractures.

• 6 weeks of daily uphill gait training improves functional gait parameters such as gait speed and dorsal flexion during gait in adults with cerebral palsy.

     

Effect of upper extremity load on pelvic movements during wheeled upright walker use

[Purpose] This study aimed to elucidate the effects of upper extremity loading on pelvic movements during wheeled upright walker use. [Participants and Methods] Thirteen healthy male adults participated in this intervention study. Participants walked under five conditions with targeted loads on their upper extremities of 0%, 10%, 20%, 30%, and 40% of their body weights using a wheeled upright walker with armrests. Measured items included gait velocity and stride length; the angle of the maximum trunk anterior tilt; the range of motion of the trunk and pelvis in the movements of obliquity, tilt, and rotation; and the amplitude of the center of mass in the vertical and lateral directions captured and calculated using a three-dimensional motion analysis system. [Results] Increasing the load on the upper extremities did not shorten the stride or restrict pelvic movement during gait using upright walker use. The range of pelvic rotation with walker use increased versus that of the standard gait. [Conclusion] The pelvis showed quantitative movements during gait using the wheeled upright walker with armrests. These results could be helpful in the development of robotic assistive devices.     

Effect of treadmill training with body weight support on gait and gross motor function in children with spastic cerebral palsy

OBJECTIVE: To examine the effect of treadmill training with body weight support (TBWS) on gait and gross motor function in children with spastic cerebral palsy (CP). DESIGN: Eight children with spastic CP participated in the study. Their temporal-distance gait parameters, Gross Motor Function Measure, muscle tone, and selective motor control were assessed three times: two times under their regular therapeutic treatment (condition A), and one time after receiving the TBWS treatment in addition to their regular therapeutic treatments (condition B). There were two treatment schedules, AAB and ABA. Except for the first one (taken at study entry), the assessments were always taken after 12 wks of treatment. The children were equally divided into two groups and randomly assigned to the two schedules. The two groups were matched according to category of the Gross Motor Function Classification System. RESULTS: The TBWS treatment significantly improved the children's gait (increases in stride length and decreases in double-limb support percentage of gait cycle) and their Gross Motor Function Measure (dimension D and E scores as well as the total score). No significant improvements on muscle tone or selective motor control were noted. CONCLUSIONS: The TBWS treatment improved some gait parameters and gross motor functions in children with spastic CP.     

Abstract 6: Treadmill training with partial body weight support in children with cerebral palsy

Objective: To examine the effects on the gait pattern of treadmill training with partial body weight support using the gait analysis system in children with cerebral palsy (CP). Design: Open, nonrandomized, baseline-treatment study. Setting: Tertiary university hospital outpatient rehabilitation clinic in general community. Participants: 20 children under 10 years of age (mean, 5.2y) who were at level III or IV of Gross Motor Function Classification System, and were diagnosed as CP spastic diplegic type. They had received comprehensive rehabilitative management through the outpatient clinic for more than 1 year, but did not show specific improvements in their gait patterns. Intervention: 3 weeks of additional treadmill training, 5 times a week, for 20 minutes a session. Main Outcome Measures: Walking distance for 1 minute, muscle strength of both lower limbs, and gait analysis using a gait analysis system 1 week before the study onset, and within 1 week after the end of therapy. Results: Muscle strength of both lower limbs did not change. Walking distance for 1 minute was much increased from 2.7 to 8.1m. On liner parameters of gait analysis, there were significant improvements in speed (.17-.29m/s), cadence (55.4-77.4 steps/min), and stride length (.31-.40m). But kinematic parameters did not change significantly. Conclusions: Treadmill training with partial body weight support is an effective treatment method to achieve better gait ability and walking velocity in children with cerebral palsy. Therefore, it could be an adjunctive tool to improve the ambulatory function in children with CP.     

Functional electrical stimulation changes dynamic resources in children with spastic cerebral palsy

BACKGROUND AND PURPOSE: Children with cerebral palsy (CP) often are faced with difficulty in walking. The purpose of this experiment was to determine the effects of functional electrical stimulation (FES) applied to the gastrocnemius-soleus muscle complex on the ability to produce appropriately timed force and reduce stiffness (elastic property of the body) and on stride length and stride frequency during walking. SUBJECTS AND METHODS: Thirteen children with spastic CP (including 4 children who were dropped from the study due to their inability to cooperate) and 6 children who were developing typically participated in the study. A crossover study design was implemented. The children with spastic CP were randomly assigned to either a group that received FES for 15 trials followed by no FES for 15 trials or a group that received no FES for 15 trials followed by FES for 15 trials. The children who were having typical development walked without FES. Kinematic data were collected for the children with CP in each walking condition and for the children who were developing typically. Impulse (force-producing ability) and stiffness were estimated from an escapement-driven pendulum and spring system model of human walking. Stride length and stride frequency also were measured. To compare between walking conditions and between the children with CP and the children who were developing typically, dimensional analysis and speed normalization procedures were used. RESULTS: Nonparametric statistics showed that there was no significant difference between the children with CP in the no-FES condition and the children who were developing typically on speed-normalized dimensionless impulse. In contrast, the children with CP in the FES condition had a significantly higher median value than the children who were developing typically. The FES significantly increased speed-normalized dimensionless impulse from 10.02 to 16.32 when comparing walking conditions for the children with CP. No significant differences were found between walking conditions for stiffness, stride length, and stride frequency. DISCUSSION AND CONCLUSION: The results suggest that FES is effective in increasing impulse during walking but not in decreasing stiffness. The effect on increasing impulse does not result in more typical spatiotemporal gait parameters.     

Activity-specific aquatic therapy targeting gait for a patient with incomplete spinal cord injury

Introduction: Aquatic therapy can lead to improved mobility and health in individuals with various conditions. This case report looks at an activity-specific aquatic therapy targeting gait for a patient with incomplete spinal cord injury (iSCI). Case report: The patient participated in an individualized aquatic therapy program two times a week for 6 weeks. Assessment occurred prior to the intervention. There were two follow-up assessments after the intervention. Follow-up assessment 1 was completed within the same week as the final intervention. Follow-up assessment 2 was completed 4 weeks after the first follow-up to assess for carryover. Results: Improvements that met minimal detectable change and minimal clinically important difference were noted in The Walking for Spinal Cord Injury Index-II, Spinal Cord Injury Functional Ambulation Index gait parameters, and gait speed. Discussion: An activity-specific aquatic therapy program improved gait in a patient with iSCI. The properties of water create a practical environment for safe practice of skills. Further studies are warranted in large samples.     

The effect of a task-specific locomotor training strategy on gait stability in patients with cerebellar disease: a feasibility study

Purpose: There is a lack of evidence-based recommendations for the physiotherapeutic intervention specifically for locomotor training in patients with cerebellar ataxia. The purpose of this study is to determine the feasibility and effect of a more specific rehabilitation strategy that aims to improve gait quality in patients with cerebellar ataxia.

Methods: Nineteen patients with degenerative cerebellar ataxia were recruited to participate in the study. The patients participated in a 12-week locomotor training program, two times per week for 1.5?h per session (a total of 24 training sessions). The treatment approach emphasized the relearning of proper gait movement strategies through intensive practice that enhances the patient's perception and control of the essential components of normal gait movement.

Results: A quantitative analysis of step-by-step gait performance indicated that postural sway during locomotion was reduced, and the gait movement pattern became more consistent after the 12-week locomotor training program. These improvements in gait stability persisted over the 3-month period following intervention.

Conclusion: This study provides preliminary evidence that learning-based rehabilitation strategies targeting disease-specific locomotion symptoms may be helpful for reducing ataxic gait and improving motor control during walking in patients with cerebellar dysfunction.

• Implications for rehabilitation

• Physiotherapeutic interventions that aim to promote gait stability in cerebellar patients need to create a specific learning context that improve disease-related gait deficits.

• It is desirable to use explicit instructions to facilitate the conscious awareness and control of body center and posture.

• As patients reacquire the fundamental gait ability, providing training experience with various locomotor tasks that facilitate the transfer of learning may be helpful to increase generalizability of locomotor intervention.

     

Walking on uneven ground: How do patients with unilateral cerebral palsy adapt?

BackgroundChildren with cerebral palsy experience movement disorders that influence gait stability. It is likely that gait stability further decreases when walking on uneven compared to even ground. Therefore, the aim of this study was to investigate gait on uneven ground in children with unilateral cerebral palsy.MethodsTwenty children with unilateral cerebral palsy and twenty typically developing children performed a three-dimensional gait analysis when walking on even and uneven ground. Spatio-temporal parameters, full-body joint kinematics and centre of mass displacements were compared.FindingsOn uneven versus even ground, both groups showed decreased cadence, increased stance phase and double support time, increased toe clearance height, and increased knee and hip flexion during swing phase. Whereas only the typically developing children walked slower and had increased dorsiflexion and external foot progression during stance phase, only the patients showed increased stride width, increased elbow flexion (affected and non-affected side), and kept the centre of mass more medial when standing on the affected leg.InterpretationPatients and healthy children use similar adaptation mechanisms when walking on uneven ground. Both groups increased the toe clearance height by increasing knee and hip flexion during swing. However, whereas patients enlarge their base of support by increasing stride width, healthy children do so by increasing their external foot progression angle. Furthermore, patients seem to feel more insecure and hold their arms in a position to prepare for falls on uneven ground. They also do not compensate with their non-affected side for their affected side on uneven ground.     

Plantarflexor training affects propulsive force generation during gait in children with spastic hemiplegic cerebral palsy: a pilot study

[Purpose] The purpose of this preliminary study was to assess the trade-off relationship between the hip and ankle joints after plantarflexor training in children with spastic hemiplegic cerebral palsy (CP). [Subjects and Methods] Three boys aged 9, 10, and 13 years with spastic hemiplegic CP participated in the study. Gait analysis was performed using a three-dimensional motion analysis device and a floor reaction force detection device before and after plantarflexor training. Data on gait speed and stride length for both sides were collected. Peak hip and ankle powers in the sagittal plane and ankle-to-hip power ratio (A2/H3 ratio) were calculated. Plantarflexor training comprised heel raises and exercise band resistance at the participant’s home (3 times/week for 12 weeks). [Results] The A2/H3 ratio increased significantly on both sides in two of three subjects after training. Peak A2 power increased significantly on both sides in subject 3 and on the affected side of subject 2. Peak H3 power decreased significantly on the non-affected side of subjects 1 and 2. [Conclusion] This study confirmed that two of three subjects demonstrated a trade-off relationship between the hip and ankle joints during gait after plantarflexor training.     

Effect of Strength Training of Ankle Plantarflexors on Selective Voluntary Motor Control,Gait Parameters,and Gross Motor Function of Children with Cerebral Palsy

[Purpose] The purpose of this study was to investigate the effect of ankle plantarflexor strength training on selective voluntary motor control, gait parameters, and gross motor function of children with cerebral palsy (CP), focusing on changes in the strength and muscle activity of the ankle plantarflexors. [Methods] Six children aged between 4 and 10 years with CP participated in a 6 week strengthening program. The subjects were evaluated before and after the intervention in terms of ankle plantarflexor strength, muscle activity, gait velocity, cadence, step length, and D (standing) and E (walking, running, and jumping) dimensions of the Gross Motor Function Measure (GMFM). The data were analyzed using the non-parametric Wilcoxon signed-rank test. [Results] The strength of the plantarflexors increased in the majority of subjects. Significant and clinically meaningful post-intervention improvements in subject''s gait velocity, cadence, and step length were found. [Conclusion] The controlled ankle plantarflexor strengthening program may lead to improvements in strength and spatiotemporal gait parameters of children with CP.Key words: Ankle plantarflexor, Strengthening exercise, Gait parameter     

Improving spatiotemporal gait parameters in spastic diplegic children using treadmill gait training

BackgroundEven though several physiotherapy techniques help to improve the spatiotemporal gait parameters of diplegic children, the efficacy of treadmill gait training together with conventional treatment techniques on spatiotemporal parameter improvement needs more investigation.ObjectiveThis study's main purpose is to investigate the effect of treadmill gait training as an adjunct to conventional physiotherapy treatment on the spatiotemporal gait parameters of diplegic children.MethodsTwenty diplegic children were distributed randomly into two equal groups (a control group of ten children who received a traditional treatment and an experimental group of ten children who received the traditional treatment together with treadmill gait training). Gait data were collected using a Vicon three-dimensional motion analysis system during regular walking.ResultsWalking speed, cadence, step length, stride length, and single limb support were enhanced in both groups (p < 0.05). Cadence and walking speed increased by 6.5 steps/min and 0.2 m/sec respectively in the experimental group, compared to the control group. Also, step length, stride length and single limb support time increased by 0.13 m, 0.27 m, and 0.07 s respectively in the experimental group, compared to the control group.ConclusionThe use of treadmill gait training together with conventional physical therapy treatment enhances the walking performance of diplegic children by improving several spatiotemporal gait parameters. Furthermore, walking balance is improved by increasing the single-leg support time.     

Gait deficits and dynamic stability in children and adolescents with cerebral palsy: A systematic review and meta-analysis

Background: Studies have demonstrated that ambulatory children and adolescents with cerebral palsy demonstrate atypical gait patterns. Out of numerous gait variables, identification of the most deteriorated gait parameters is important for targeted and effective gait rehabilitation. Therefore, this study aimed to identify the gait parameters with the most discriminating nature to distinguish cerebral palsy gait from normal gait.Methods: Multiple databases were searched to include studies on ambulatory children and adolescents with cerebral palsy that included gait (spatio-temporal, kinematic, and kinetic) and dynamic stability variables.Findings: Of 68 studies that met the inclusion criteria, 35 studies were included in the meta analysis. Effect size was used to assess the discriminative strength of each variable. A large effect (≥ 0.8) of cerebral palsy on double limb support time (Standardized Mean Difference = 0.98), step length (Standardized Mean Difference = 1.65), step width (Standardized Mean Difference = 1.21), stride length (Standardized Mean Difference = 1.75), and velocity (Standardized Mean Difference = 1.42) was observed at preferred-walking speed. At fast-walking speed, some gait variables (i.e. velocity and stride length) exhibited larger effect size compared to preferred-walking speed. For some kinematic variables (e.g. range of motion of pelvis), the effect size varied across the body planes.Interpretation: Our systematic review detects the most discriminative features of cerebral palsy gait. Non-uniform effects on joint kinematics across the anatomical planes support the importance of 3D gait analysis. Differential effects at fast versus preferred speeds emphasize the importance of measuring gait at a range of speeds.