Cerebral palsy

Admin2 · Jan 13, 2006

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The latest American Family Physician has a good full text (free access) overview of Cerbral palsy:

The presentation of cerebral palsy can be global mental and physical dysfunction or isolated disturbances in gait, cognition, growth, or sensation. It is the most common childhood physical disability and affects 2 to 2.5 children per 1,000 born in the United States. The differential diagnosis of cerebral palsy includes metabolic and genetic disorders. The goals of treatment are to improve functionality and capabilities toward independence. Multispecialty treatment teams should be developed around the needs of each patient to provide continuously updated global treatment care plans. Complications of cerebral palsy include spasticity and contractures; feeding difficulties; drooling; communication difficulties; osteopenia; osteoporosis; fractures; pain; and functional gastrointestinal abnormalities contributing to bowel obstruction, vomiting, and constipation. Valid and reliable assessment tools to establish baseline functions and monitor developmental gains have contributed to an increasing body of evidenced-based recommendations for cerebral palsy. Many of the historical treatments for this ailment are being challenged, and several new treatment modalities are available. Adult morbidity and mortality from ischemic heart disease, cerebrovascular disease, cancer, and trauma are higher in patients with cerebral palsy than in the general population. (Am Fam Physician 2006;73:91-100, 101-2. Copyright © 2006 American Academy of Family Physicians.)
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Link to article

NewsBot · Mar 26, 2008

Qualitative Versus Quantitative Radiographic Analysis of Foot Deformities in Children With Hemiplegic Cerebral Palsy.
Westberry DE, Davids JR, Roush TF, Pugh LI.
J Pediatr Orthop. 2008 April/May;28(3):359-365.

BACKGROUND:: Qualitative assessments of standing plain radiographs are frequently used to determine treatment strategies and assess outcomes for the management of a wide range of foot and ankle conditions in children. A quantitative technique for such analyses would presumably be more precise and reliable. The goal of this study was to compare qualitative and quantitative techniques for the assessment of plain radiographs of the foot and ankle in children with hemiplegic type cerebral palsy (CP).

METHODS:: Standing anteroposterior and lateral radiographs of the foot and ankle of the involved side for 49 children with hemiplegic CP were analyzed qualitatively by 2 pediatric orthopaedists, based upon a 3-segment (hindfoot, midfoot, and forefoot) foot model. Quantitative assessment of the same radiographs was performed by 2 examiners, using 6 radiographic measurements developed to describe the alignment of the foot based upon the same 3-segment model. Intraobserver and interobserver reliability was determined for both the qualitative and the quantitative techniques. The qualitative and quantitative techniques were compared to determine agreement.

RESULTS:: The qualitative technique demonstrated poor-to-fair interobserver reliability (percent agreement range, 23%-31%; weighted kappa range, 0.291-0.568). The quantitative technique demonstrated good-to-excellent intraobserver (correlation coefficient range, 0.81-0.99) and interobserver (correlation coefficient range, 0.81-0.97) reliability. Percent agreement between the quantitative and the qualitative techniques for the assessment of foot segmental alignment for each examiner ranged from 22.2% to 100% (mean agreement for examiner 1 was 51% [correlation coefficient range, 0.04-0.48]; mean agreement for examiner 2 was 65.3% [correlation coefficient range, 0.22-0.85]). Percent agreement between the quantitative technique and both observers ranged from 11.1% to 83.3% (mean agreement was 36.7% [correlation coefficient range, 0.17-0.94]).

DISCUSSION:: Reliable quantitative radiographic analysis of the segmental alignment of the involved foot and ankle in children with hemiplegic CP is possible and is more precise and reliable than traditional qualitative techniques. Quantitative techniques can identify a wider range of foot segmental malalignments and should facilitate deformity analysis, preoperative planning, assessment of outcome, and comparison of results between centers.
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NewsBot · Aug 5, 2008

Changes in dynamic foot pressure after surgical treatment of valgus deformity of the hindfoot in cerebral palsy.
Park KB, Park HW, Lee KS, Joo SY, Kim HW.
J Bone Joint Surg Am. 2008 Aug;90(8):1712-21

BACKGROUND: Calcaneal lengthening osteotomy and extra-articular arthrodesis of the subtalar joint are two methods used for the correction of valgus deformity of the heel and forefoot abduction. The purpose of this study was to compare the operative results of these procedures in patients with cerebral palsy who were able to walk. We focused primarily on changes in radiographic parameters and how altered mobility of the subtalar joint by the two operative methods would modify pressure distribution over the plantar surface of the foot.

METHODS: A total of eighty-one feet in forty-seven patients were included in the study. The mean age at the time of surgery was eight years and one month, and the mean follow-up period was thirty-nine months. The subjects were divided into two groups; Group I consisted of thirty-seven feet in twenty-two patients who underwent a calcaneal lengthening osteotomy, and Group II comprised forty-four feet in twenty-five patients who underwent an extra-articular subtalar arthrodesis. Preoperative and final follow-up radiographs and dynamic pedobarographs were used to evaluate the results.

RESULTS: The feet in both groups were found to be similarly deformed before surgery, by radiographic measurements and dynamic foot-pressure analysis. Both operative procedures led to improved radiographic indices; however, calcaneal pitch failed to improve after the subtalar arthrodesis. After surgery, the relative vertical impulse was decreased for the hallux, first metatarsal head, and medial aspect of the midfoot in both groups, while it was increased for the lateral aspect of the midfoot and calcaneus. On the other hand, postoperatively, the relative vertical impulse of the medial aspect of the midfoot was higher and the relative vertical impulse of the first through fourth metatarsal heads was lower in the group that had subtalar arthrodesis compared with the group that had a calcaneal lengthening osteotomy and the normal control subjects.

CONCLUSIONS: Extra-articular subtalar arthrodesis appears to be an effective means to achieve predictable correction of severe valgus deformity of the heel in patients with cerebral palsy who are able to walk; however, supination deformity of the forefoot remains and calcaneal equinus is not corrected. On the other hand, we believe that the calcaneal lengthening osteotomy is the treatment of choice because postoperative foot-pressure distribution more closely approximates the normal foot-pressure distribution.
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NewsBot · Sep 2, 2008

Effect of ankle-foot orthoses on walking efficiency and gait in children with cerebral palsy.
Brehm MA, Harlaar J, Schwartz M.
J Rehabil Med. 2008 Jul;40(7):529-34.

OBJECTIVE: To determine the effect of ankle-foot orthoses on walking efficiency and gait in a heterogeneous group of children with cerebral palsy, using barefoot walking as the control condition.

DESIGN: A retrospective study. METHODS: Barefoot and ankle-foot orthosis data for 172 children with spastic cerebral palsy (mean age 9 years; hemiplegia: 21, diplegia: 97, and quadriplegia: 54) were compared. These data consisted of non-dimensional speed, net non- notdimensional energy cost of walking (NN-cost), and NN-cost as a percentage of speed-matched controls (NN-costpct). For 80 of these children the Gillette Gait Index and data for 3D gait kinematics and kinetics were also analyzed.

RESULTS: Speed was 9% faster (p<0.001), NN-cost was 6% lower (p=0.007), and NN-costpct was 9% lower (p=0.022) when walking with an ankle-foot orthosis. The Gillette Gait Index remained unchanged (p=0.607). Secondary subgroup analysis for involvement pattern showed a significant improvement in NN-costpct only for quadriplegics (20%, p=0.004), whereas it remained unchanged for patients with hemiplegia and diplegia. Changes in the minimum knee flexion angle in stance phase and in terminal swing were found to be significantly related to the change in NN-costpct (p=0.013 and p=0.022, respectively).

CONCLUSION: The use of an ankle-foot orthosis resulted in a significant decrease in the energy cost of walking of quadriplegic children with cerebral palsy, compared with barefoot walking, whereas it remained unchanged in hemiplegic and diplegic children with cerebral palsy. Energy cost reduction was related to both a faster and more efficient walking pattern. The improvements in efficiency were reflected in changes of stance and swing phase knee motion, i.e. those children whose knee flexion angle improved toward the typical normal range demonstrated a decrease in energy cost of walking, and vice versa.
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NewsBot · Sep 18, 2009

Orthopaedic issues in the musculoskeletal care of adults with cerebral palsy.
Horstmann HM, Hosalkar H, Keenan MA.
Dev Med Child Neurol. 2009 Oct;51 Suppl 4:99-105.

AIMS: Orthopaedic care of adults with cerebral palsy (CP) has not been well documented in orthopaedic literature. This paper focuses on some of the common problems which present themselves when adults with CP seek orthopaedic intervention. In particular, we review the most common orthopaedic issues which present to the Penn Neuro-Orthopaedics Program.

METHOD: A formal review of consecutive surgeries performed by the senior author on adults with CP was previously conducted. This paper focuses on the health delivery care for the adult with orthopaedic problems related to cerebral palsy. Ninety-two percent of these patients required lower extremity surgery. Forty percent had procedures performed on the upper extremities.

RESULTS: The majority of problems seen in the Penn Neuro-Orthopaedics Program are associated with the residuals of childhood issues, particularly deformities associated with contractures. Patients are also referred for treatment of acquired musculoskeletal problems such as degenerative arthritis of the hip or knee. A combination of problems contribute most frequently to foot deformities and pain with weight-bearing, shoewear or both, most often due to equinovarus. The surgical correction of this is most often facilitated through a split anterior tibial tendon transfer. Posterior tibial transfers are rarely indicated. Residual equinus deformities contribute to a pes planus deformity. The split anterior tibial tendon transfer is usually combined with gastrocnemius-soleus recession and plantar release. Transfer of the flexor digitorum longus to the os calcis is done to augment the plantar flexor power. Rigid pes planus deformity is treated with a triple arthrodesis. Resolution of deformity allows for a good base for standing, improved ability to tolerate shoewear, and/or braces. Other recurrent or unresolved issues involve hip and knee contractures. Issues of lever arm dysfunction create problems with mechanical inefficiency. Upper extremity intervention is principally to correct contractures. Internal rotation and adductor tightness at the shoulder makes for difficult underarm hygiene and predispose a patient to a spiral fracture of the humerus. A tight flexor, pronation pattern is frequently noted through the elbow and forearm with further flexion contractures through the wrist and fingers. Lengthenings are more frequently performed than tendon transfers in the upper extremity. Arthrodesis of the wrist or on rare occasions of the metacarpal-phalangeal joints supplement the lengthenings when needed.

CONCLUSIONS: The Penn Neuro-Orthopaedics Program has successfully treated adults with both residual and acquired musculoskeletal deformities. These deformities become more critical when combined with degenerative changes, a relative increase in body mass, fatigue, and weakness associated with the aging process.
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NewsBot · Jul 16, 2010

Gait compensations caused by foot deformity in cerebral palsy.
Stebbins J, Harrington M, Thompson N, Zavatsky A, Theologis T.
Gait Posture. 2010 Jun 1. [Epub ahead of print]

Cerebral palsy (CP) is a complex syndrome, with multiple interactions between joints and muscles. Abnormalities in movement patterns can be measured using motion capture techniques, however determining which abnormalities are primary, and which are secondary, is a difficult task. Deformity of the foot has anecdotally been reported to produce compensatory abnormalities in more proximal lower limb joints, as well as in the contralateral limb. However, the exact nature of these compensations is unclear. The aim of this paper was to provide clear and objective criteria for identifying compensatory mechanisms in children with spastic hemiplegic CP, in order to improve the prediction of the outcome of foot surgery, and to enhance treatment planning. Twelve children with CP were assessed using conventional gait analysis along with the Oxford Foot Model prior to and following surgery to correct foot deformity. Only those variables not directly influenced by foot surgery were assessed. Any that spontaneously corrected following foot surgery were identified as compensations. Pelvic rotation, internal rotation of the affected hip and external rotation of the non-affected hip tended to spontaneously correct. Increased hip flexion on the affected side, along with reduced hip extension on the non-affected side also appeared to be compensations. It is likely that forefoot supination occurs secondary to deviations of the hindfoot in the coronal plane. Abnormal activity in the tibialis anterior muscle may be consequent to tightness and overactivity of the plantarflexors. On the non-affected side, increased plantarflexion during stance also resolved following surgery to the affected side.
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NewsBot · Apr 23, 2011

Equinus foot classification in cerebral palsy: an agreement study between clinical and gait analysis assessment.
Benedetti MG, D'apote G, Faccioli S, Costi S, Ferrari A.
Eur J Phys Rehabil Med. 2011 Apr 20. [Epub ahead of print]

BACKGROUND:
Excessive ankle plantar flexion (equinus foot) is a common problem in cerebral palsy (CP) and several treatment options can be considered depending on the equinus type. Few attempts have been made to classify different forms of equinus foot for specific treatment.

AIM:
This study is aimed at defining equinus foot types in CP patients according to the Ferrari classification, integrating clinical and instrumental assessments. The hypothesis is that clinical differentiation of equinus foot can be evidenced by recurrent anomalies identifiable through gait analysis (GA), which can make the assessment, usually based only on clinician semeiotics, more objective.

DESIGN:
Clinical and instrumental assessments were performed separately by a senior CP physiatrist and a senior GA physiatrist, the latter was blind to the clinical diagnosis of equinus type.

SETTING:
Outpatients

POPULATION:
Twenty patients, 16 diplegics and 4 hemiplegics (mean age 11 years, SD 4 years 11 months).

METHODS:
Clinical assessment by means of Modified Ashworth Scale, Gross Motor Function Measure (GMFM), Observational Gait Analysis (OGA), and measurement of lower limb muscle strength by dynamometer were used to classify the equinus type. Gait analysis assessed the kinematics and EMG of affected lower limbs.

RESULTS:
Ten different equinus types were identified. Since various forms of equinus can be present in the same patient, we were able to classify a total of 61 types of equinus in 36 feet. Substantial agreement was found between Clinical and Gait Analysis equinus assignment matched in 50 out of 61 types (Index of agreement with Fleiss' Kappa 79.3 % ). In some case only Gait Analysis was able to identify the equinus type, while in others it did not confirm clinical assignment.

CONCLUSION:
Gait analysis is able to distinguish different equinus types according to Ferrari classification, making the clinical decision less arbitrary. Clinical rehabilitation impact. Correct objective diagnosis of equinus foot in CP patients is of paramount importance when choosing suitable rehabilitative interventions.
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NewsBot · Jun 3, 2011

The use of botulinum toxin A in children with cerebral palsy, with a focus on the lower limb.
Molenaers G, Van Campenhout A, Fagard K, De Cat J, Desloovere K.
J Child Orthop. 2010 Jun;4(3):183-95. Epub 2010 Mar 18.

PURPOSE: The purpose of this review is to clarify the role of botulinum toxin serotype A (BTX-A) in the treatment of children with cerebral palsy (CP), with a special focus on the lower limb. BACKGROUND: The treatment of spasticity is central in the clinical management of children with CP. BTX-A blocks the release of acetylcholine at the motor end plate, causing a temporary muscular denervation and, in an indirect way, a reduced spasticity. Children with increased tone develop secondary problems over time, such as muscle contractures and bony deformities, which impair their function and which need orthopaedic surgery. However in these younger children, delaying surgery is crucial because the results of early surgical interventions are less predictable and have a higher risk of failure and relapse. As BTX-A treatment reduces tone in a selective way, it allows a better motor control and muscle balance across joints, resulting in an improved range of motion and potential to strengthen antagonist muscles, when started at a young age. The effects are even more obvious when the correct BTX-A application is combined with other conservative therapies, such as physiotherapy, orthotic management and casts. There is now clear evidence that the consequences of persistent increased muscle tone can be limited by applying an integrated multi-level BTX-A treatment approach. Nevertheless, important challenges such as patient selection, defining appropriate individual goals, timing, dosing and dilution, accuracy of injection technique and how to measure outcomes will be questioned. Therefore, "reflection is more important than injection" remains an actual statement.
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NewsBot · Feb 9, 2012

Ankle dorsiflexor function after plantar flexor surgery in children with cerebral palsy.
Davids JR, Rogozinski BM, Hardin JW, Davis RB.
J Bone Joint Surg Am. 2011 Dec 7;93(23):e1381-7.

BACKGROUND:
Surgical lengthening is used to address both overactivity and shortening of the spastic agonist muscle in children with cerebral palsy. It has been presumed that the function of the antagonist muscle will improve when the spastic agonist muscle has been surgically lengthened. The purposes of the current study were to use quantitative gait analysis to determine the prevalence of the ankle dorsiflexor muscles (antagonist) dysfunction during the swing phase of the gait cycle and to analyze how this function is affected following surgical lengthening of the ankle plantar flexor muscles (agonist).

METHODS:
The study design was a retrospective, cohort series of fifty-three children with cerebral palsy who underwent gait analysis before and after surgical lengthening of the gastrocnemius-soleus muscle group. Data from the physical examination, gait study kinematics, and dynamic electromyography in swing phase were analyzed.

RESULTS:
The mean age at the time of the initial gait analysis was eight years and eleven months. Significant improvements were noted in ankle dorsiflexion passive range of motion (p < 0.001), ankle dorsiflexor selective control (p = 0.002), ankle dorsiflexor strength (p = 0.001), and peak and mean ankle dorsiflexion in swing phase (p < 0.001 for each) following ankle plantar flexor lengthening surgery. Active ankle dorsiflexor function in swing phase was present in 79% of the extremities prior to ankle plantar flexor surgery. Swing phase dorsiflexor function was present in 96% of the extremities following surgery, with ten extremities improving from absent to present.

CONCLUSIONS:
The kinematic data support the clinical impression that ankle dorsiflexion during swing phase is improved following ankle plantar flexor lengthening surgery in children with cerebral palsy. In the majority of patients, this was a consequence of the correction of a fixed equinus contracture of the ankle plantar flexors that was constraining preexisting ankle dorsiflexor function. Weakness of all of the muscles is common, and surgical lengthening should only be considered for the correction of recalcitrant muscle contractures. Improved function of the antagonist muscle should be anticipated and optimized by appropriately focused strength training and other modalities during rehabilitation.
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NewsBot · Aug 2, 2012

Recurrence after surgery for equinus foot deformity in children with cerebral palsy: assessment of predisposing factors for recurrence in a long-term follow-up study.
Joo SY, Knowtharapu DN, Rogers KJ, Holmes L Jr, Miller F.
J Child Orthop. 2011 Aug;5(4):289-296

BACKGROUND:
Despite the large number of studies on the recurrence after surgery for equinus foot deformity in cerebral palsy (CP) patients, only a few investigations have reported long-term recurrence rates. Furthermore, little is known on the interval between the recurrent surgeries and the factors that lead to early recurrence. This study aimed to assess the overall recurrence after surgery for equinus foot deformity in patients with CP and to assess the factors associated with recurrence. We also aimed to determine the predisposing factors for early recurrence.

METHODS:
The medical records of 186 patients (308 feet) were reviewed in order to determine the recurrence after surgery for equinus foot deformity. The type of CP, type of surgery, age at surgery, functional mobility, passive dorsiflexion of the ankle at the last follow-up visit, and subsequent treatment were recorded. Kaplan-Meier survival analysis was employed, with the end point defined as reoperation.

RESULTS:
The mean age at surgery was 6.8 ± 2.5 years (range, 2.2-13.1). With the mean follow-up period of 11.3 years (range, 7.2-17.7), the overall recurrence rate was 43.8%. The recurrence rate was highest among patients with hemiplegia (62.5%). The Kaplan-Meier survival without repeat surgery estimate was shown to be 88.6% at 5 years and 59.6% at 10 years. Among children with hemiplegia and diplegia, the younger children (≤8 years of age) showed a higher rate of recurrence compared with the older children (P = 0.04 and P = 0.01, respectively). In 41 feet (30.4%), reoperations were performed within 5 years after the primary surgery. Early recurrence was most prevalent among children with hemiplegia (50.0%). In children with diplegia and quadriplegia, the younger children underwent the secondary operation later than the older children (P = 0.04 and P = 0.02, respectively).

CONCLUSION:
Recurrence after surgery for equinus foot deformity is common and the age at surgery has a significant influence on recurrence. Recurrence can occur at any age while the child is still growing; therefore, it is advised to follow those patients until they reach skeletal maturity.
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NewsBot · Aug 16, 2012

Abnormalities in the uninvolved foot in children with spastic hemiplegia.
Joo S, Miller F.
J Pediatr Orthop. 2012 Sep;32(6):605-8.

BACKGROUND:
Although the uninvolved foot in patients with hemiplegia has been thought to be normal, we frequently observed valgus deformity of the uninvolved foot among those patients. The purpose of this study was to evaluate by dynamic pedobarograph the prevalence and pattern of foot deformity in the uninvolved limb among children with hemiplegia.

METHODS:
In this study, we included 119 patients with hemiplegia (67 males and 52 females) who underwent gait analysis from 2001 to 2008. The mean age at evaluation was 9.2±3.4 years (range, 5.1 to 19.8 y). Patient demographics, passive range of motion, kinematics, kinetics, and dynamic pedobarographic data were obtained from the medical records. Coronal index [(CI): the impulse percentage under the medial column minus the impulse percentage under the lateral column] was calculated from the pedobarographic data.

RESULTS:
Of 119 feet, 60 feet (50.4%) had a normal CI, whereas 52 feet (43.7%) showed a valgus CI. Only 7 feet (5.9%) had a varus CI. Compared with the patients with a normal CI, patients who had a valgus CI had increased ankle dorsiflexion at initial contact (-0.9±4.1 vs. 0.8±4.7, P=0.048) and knee extension moment (0.6±0.31 vs. 0.73±0.28, P=0.036) of the uninvolved foot. Actual limb-length discrepancy did not differ between the 2 groups (P=0.556).

CONCLUSIONS:
Valgus foot deformity of the uninvolved foot is common among children with hemiplegia. It is associated with increased ankle dorsiflexion and knee extension moments of the uninvolved side. Longer follow-up will be needed to evaluate the effect of the valgus foot deformity of the uninvolved limb on the gait in patients with hemiplegia.
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NewsBot · Sep 12, 2012

Importance of orthotic subtalar alignment for development and gait of children with cerebral palsy.
Carmick J.
Pediatr Phys Ther. 2012 Winter;24(4):302-7.

PURPOSE:
This case report addresses the assumption that ankle and foot orthoses assist children with cerebral palsy.

KEY POINTS:
Outcome research reports are not consistent. Clinical observations and research studies suggest that inappropriate fit and design of orthoses may contribute to poor outcomes. In particular, problems occur when the subtalar joint is out of alignment as children often compensate with unwanted movement patterns that affect progress, development, and function. Four cases are presented to demonstrate problems that can occur when ankle-foot or supramalleolar orthoses are not cast in subtalar neutral.

CONCLUSION:
Physical therapists can use their clinical observation skills to evaluate the proper fit and alignment of orthoses for children with cerebral palsy.
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NewsBot · Mar 28, 2013

Medial column stabilization improves the early result of calcaneal lengthening in children with cerebral palsy.
Huang CN, Wu KW, Huang SC, Kuo KN, Wang TM.
J Pediatr Orthop B. 2013 May;22(3):233-9.

Calcaneal lengthening is a popular surgical treatment for pronated foot deformity. The aim of this study is to assess the effectiveness of medial column stabilization in improving the results of calcaneal lengthening for pronated foot deformity in ambulatory children with cerebral palsy. Twenty-one consecutive (37 feet) children with cerebral palsy with pronated foot deformity who received calcaneal lengthening from 2004 to 2009 were reviewed. Talonavicular stabilizations were performed by either stapling alone or fusion depending on the children's age and correctability of midfoot deformity. Satisfaction rates were assessed using Mosca's radiographic, Mosca's clinical, and Yoo's clinical criteria. Talonavicular coverage angle was also measured. Results between groups with and without stabilization of the talonavicular joint were compared. Group 1 included 11 children (19 feet) who had no talonavicular stabilization. Group 2 included 10 children (18 feet) who had talonavicular fixation. Groups were further divided into subgroups A [Gross Motor Function Classification System (GMFCS)≤II] and B (GMFCS≥III). Factors including demography, geographical classification, functional status, and preoperative degree of deformity were similar between the two groups. After the operation, all four radiographic parameters improved significantly. The talonavicular coverage angle was better in group 2 than in group 1. Mosca's radiographic results were satisfactory in 73.68% of cases in group 1 and 100% in group 2; the difference was statistically significant (P=0.027). As for Mosca's clinical results, 63.16% in group 1 and 83.33% in group 2 achieved satisfactory results (P=0.156). On the basis of Yoo's criteria, the results were satisfactory in 57.89% of cases in group 1 and in 94.44% of cases in group 2 (P=0.012). Further analysis on the satisfaction rates between the subgroups showed similar results between the patients in subgroup 1A and 2A, and significantly better results in subgroup 2B than in subgroup 1B. Concurrent stabilization of the talonavicular joint is an effective method to improve clinical and radiographic results of calcaneal lengthening in children with cerebral palsy with pronated feet, and the effect is more significant in children with worse GMFCS levels.
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NewsBot · Jun 25, 2013

Optimising Ankle Foot Orthoses for children with cerebral palsy walking with excessive knee flexion to improve their mobility and participation; protocol of the AFO-CP study.
Kerkum YL, Harlaar J, Buizer AI, van den Noort JC, Becher JG, Brehm MA.
BMC Pediatr. 2013 Feb 1;13:17. doi: 10.1186/1471-2431-13-17.

BACKGROUND:
Ankle-Foot-Orthoses with a ventral shell, also known as Floor Reaction Orthoses (FROs), are often used to reduce gait-related problems in children with spastic cerebral palsy (SCP), walking with excessive knee flexion. However, current evidence for the effectiveness (e.g. in terms of walking energy cost) of FROs is both limited and inconclusive. Much of this ambiguity may be due to a mismatch between the FRO ankle stiffness and the patient's gait deviations.The primary aim of this study is to evaluate the effect of FROs optimised for ankle stiffness on the walking energy cost in children with SCP, compared to walking with shoes alone. In addition, effects on various secondary outcome measures will be evaluated in order to identify possible working mechanisms and potential predictors of FRO treatment success.

METHOD/DESIGN:
A pre-post experimental study design will include 32 children with SCP, walking with excessive knee flexion in midstance, recruited from our university hospital and affiliated rehabilitation centres. All participants will receive a newly designed FRO, allowing ankle stiffness to be varied into three configurations by means of a hinge. Gait biomechanics will be assessed for each FRO configuration. The FRO that results in the greatest reduction in knee flexion during the single stance phase will be selected as the subject's optimal FRO. Subsequently, the effects of wearing this optimal FRO will be evaluated after 12-20 weeks. The primary study parameter will be walking energy cost, with the most important secondary outcomes being intensity of participation, daily activity, walking speed and gait biomechanics.

DISCUSSION:
The AFO-CP trial will be the first experimental study to evaluate the effect of individually optimised FROs on mobility and participation. The evaluation will include outcome measures at all levels of the International Classification of Functioning, Disability and Health, providing a unique set of data with which to assess relationships between outcome measures. This will give insights into working mechanisms of FROs and will help to identify predictors of treatment success, both of which will contribute to improving FRO treatment in SCP in term.
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NewsBot · Jul 15, 2013

Press Release:
Pain control in children with cerebral palsy
New study encourages pediatricians to treat the cause, not the symptoms

Researchers at Holland Bloorview Kids Rehabilitation Hospital have found that more than 25 percent of children with cerebral palsy seen by physicians have moderate to severe chronic pain, limiting their activity. Findings indicate that pediatricians should be aware of chronic pain in this group and try to identify and treat its underlying causes.

The study, led by Dr. Darcy Fehlings, Physician Director of the Child Development Program at Holland Bloorview and Clinician Senior Scientist at the Bloorview Research Institute, was published today in top health journal Pediatrics.

"This study clearly illustrates the extent to which children with cerebral palsy, or CP experience chronic pain," says Fehlings, also an associate professor at the University of Toronto. The study systematically tracked the "Physician diagnosed" cause of pain, finding that hip pain and increased muscle tone were the most common cause of pain for children and youth. "With this knowledge, pediatricians need to be focused on accurately assessing and managing the root cause of this pain."

CP is the most common neurodevelopmental physical disability, occurring in 2 – 2.5 out of every 1000 live births in developed countries. Dr. Fehlings, who leads the Cerebral Palsy Discovery Lab at the Bloorview Research Institute, aimed to better understand the prevalence and impact of pain on children and youth with CP.

Cameron Purdy is a 13 year old boy with cerebral palsy. He and his mom Corinna have been long-time Holland Bloorview clients working with Dr. Fehlings; Corinna even lived at Holland Bloorview for three months in 2009 while Cameron recovered from a surgery.

Corinna Purdy is glad to see Dr. Fehlings' study about chronic pain in kids with CP being published. "It can be hard for kids to explain where the pain is, especially if they've lived with pain their whole life. Maybe they think it's normal, or maybe they are too shy to tell you – either way, you may not know they're in pain. Dr. Fehlings used cartoon faces instead of a 1-10 pain scale, which helped Cameron effectively communicate his pain levels."

Dr. Melanie Penner, a Fellow in Developmental Pediatrics at Holland Bloorview working with Dr. Fehlings, says Cameron and Corinna's experience is typical. "This study has underlined the importance of asking every child with CP about their pain levels. This can sometimes pose a challenge for children with communication limitations, which makes a systematic pain assessment plan crucial."

Developing a strategy to prevent, assess, and manage chronic pain for kids with CP is key to improving their health and quality of life.

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Read Dr. Fehlings' publication, "Characteristics of Pain in Children and Youth With Cerebral Palsy" in Pediatrics here: http://pediatrics.aappublications.o...ract?sid=ca8812fc-1711-4d73-8637-d5cef3cbc596
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NewsBot · Jul 17, 2013

Failure of normal development of central drive to ankle dorsiflexors relates to gait deficits in children with cerebral palsy.
Petersen TH, Farmer SF, Kliim-Due M, Nielsen JB.
J Neurophysiol. 2013 Feb;109(3):625-39.

Neurophysiological markers of the central control of gait in children with cerebral palsy (CP) are used to assess developmental response to therapy. We measured the central common drive to a leg muscle in children with CP. We recorded electromyograms (EMGs) from the tibialis anterior (TA) muscle of 40 children with hemiplegic CP and 42 typically developing age-matched controls during static dorsiflexion of the ankle and during the swing phase of treadmill walking. The common drive to TA motoneurons was identified through time- and frequency-domain cross-correlation methods. In control subjects, the common drive consists of frequencies between 1 and 60 Hz with peaks at beta (15-25 Hz) and gamma (30-45 Hz) frequencies known to be caused by activity within sensorimotor cortex networks: this drive to motoneurons strengthens during childhood. Similar to this drive in control subjects, this drive to the least affected TA in the CP children tended to strengthen with age, although compared with that in the control subjects, it was slightly weaker. For CP subjects of all ages, the most affected TA muscle common drive was markedly reduced compared with that of their least affected muscle as well as that of controls. These differences between the least and most affected TA muscles were unrelated to differences in the magnitude of EMG in the two muscles but positively correlated with ankle dorsiflexion velocity and joint angle during gait. Time- and frequency-domain analysis of ongoing EMG recruited during behaviorally relevant lower limb tasks provides a noninvasive and important measure of the central drive to motoneurons in subjects with CP.
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NewsBot · Jul 31, 2013

Long-term Outcome of Planovalgus Foot Surgical Correction in Children with Cerebral Palsy.
Kadhim M, Holmes L Jr, Miller F.
J Foot Ankle Surg. 2013 Jul 25. pii: S1067-2516(13)00259-7.

Pes planovalgus deformity results from changes in the anatomic relations among tarsal bones. Foot deformity and pain can affect the patient's ability to ambulate and are common indications for surgery. The present study was a retrospective study aimed at assessing the effectiveness and complications of subtalar fusion and calcaneal lengthening during long-term follow-up in ambulatory children with cerebral palsy. Pedobarographic measurements, ankle range of motion, and radiographic indexes were used to assess the outcome of surgery. The functional abilities of the patients were assessed using the gross motor functional classification system. Pain complaints were reported to evaluate potential risk factors. A total of 24 patients (43 feet) were included, with mean age at surgery of 11 ± 3.2 (range 4.7 to 18.3) years and mean follow-up duration of 10.9 ± 2.7 (range 6.3 to 15.4) years. Of the 43 feet, 15 were treated with calcaneal lengthening (mostly gross motor functional classification system level I and II) and 28 with subtalar fusion (mostly gross motor functional classification system level III and IV). Improvement was observed in both surgery groups during long-term follow-up. The need for additional surgery was observed more among patients with poor ambulation who were treated with subtalar fusion. Young patients who underwent surgery were more likely to develop foot pain. Foot pain was less common among children with poor functional abilities and patients who underwent subtalar fusion. Surgical correction of planovalgus deformity has good outcomes after both subtalar fusion and calcaneal lengthening, with maintenance of the deformity correction during long-term follow-up.
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NewsBot · Aug 15, 2013

Categorization of gait patterns in adults with cerebral palsy: A clustering approach
Nicolas Rocheemail address, Didier Pradon, Julie Cosson, Johanna Robertson, Claire Marchiori, Raphael Zory
Gait & Posture; Article in Press

Gait patterns in adults with cerebral palsy have, to our knowledge, never been assessed. This contrasts with the large number of studies which have attempted to categorize gait patterns in children with cerebral palsy. Several methodological approaches have been developed to objectively classify gait patterns in patients with central nervous system lesions. These methods enable the identification of groups of patients with common underlying clinical problems. One method is cluster analysis, a multivariate statistical method which is used to classify an entire data set into homogeneous groups or “clusters”. The aim of this study was to determine, using cluster analysis, the principal gait patterns which can be found in adults with cerebral palsy. Data from 3D motion analyses of 44 adults with cerebral palsy were included. A hierarchical cluster analysis was used to subgroup the different gait patterns based on spatiotemporal and kinematic parameters in the sagittal and frontal planes. Five clusters were identified (C1–C5) among which, 3 subgroups were determined, based on spontaneous gait speed (C1/C2: slow, C3/C4: moderate and C5: almost normal). The different clusters were related to specific kinematic parameters that can be assessed in routine clinical practice. These 5 classifications can be used to follow changes in gait patterns throughout growth and aging as well to assess the effects of different treatments (physiotherapy, surgery, botulinum toxin, etc.) on gait patterns in adults with cerebral palsy.
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Highlights
•This study assessed for the first time the gait pattern of adults with CP.
•It showed that five different gait patterns can be identified.
•Each gait pattern identified was related to specific kinematic parameters.
•These specific kinematic parameters can be easily checked in clinical practice.
•Results may permit to follow changes throughout growth, aging or after treatments.
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NewsBot · Sep 14, 2013

Feedback System Based on Plantar Pressure for Monitoring Toe-Walking Strides in Children with Cerebral Palsy
Pu, Fang PhD; Fan, Xiaoya BE; Yang, Yang BE; Chen, Wei MS; Li, Shuyu PhD; Li, Deyu PhD; Fan, Yubo PhD
American Journal of Physical Medicine & Rehabilitation: 31 August 2013

Objective: The aim of this study was to develop a feedback system to assist gait rehabilitation of cerebral palsy (CP) toe walkers with dynamic equinus.

Design: Plantar pressure of the forefoot and the heel was collected by sensorized insoles embedded in custom-built shoes and transmitted to a smartphone via Bluetooth. Dynamic foot pressure index of each stride was calculated by purpose-designed software running in the smartphone to distinguish toe-walking strides from normal strides in real time. An auditory signal would be produced to alert the patient each time a toe-walking stride was detected.

Results: For CP toe walkers, the one-way analysis of variance indicated a significant difference (F1,14 = 19.492, P = 0.001) in dynamic foot pressure index between the affected side (31.4 +/- 12.0) and the unaffected side (58.6 +/- 2.5). In addition, the validation test showed that this system can distinguish toe-walking strides from normal strides of children with CP with an accuracy of 95.3%.

Conclusions: This system was able to monitor the toe-walking strides of children with CP in real time and had the potential to enhance rehabilitation training efficiency and correct toe-walking gait in children with CP with dynamic equinus.
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NewsBot · Sep 16, 2013

Overview of foot deformity management in children with cerebral palsy
Julieanne P. Sees & Freeman Miller
Journal of Children's Orthopaedics; September 2013

Foot deformities in children with cerebral palsy are common. The natural history of the deformities of the feet is very variable and very unpredictable in young children less then 5 years old. Treatment for the young children should be primarily with orthotics and manual therapy. Equinus is the most common deformity, with orthotics augmented with botulinum toxin being the primary management in young children. When fixed deformity develops lengthening only the muscle which is contracted is preferred. Varus deformity of the feet is often associated with equinus, and can almost always be managed with orthotics until 8 or 10 years of age. Planovalgus is the most common deformity in children with bilateral lower extremity spasticity. The primary management is orthotics until the child no longer tolerates the orthotic; then surgical management needs to consider all the deformities and all should be corrected. This requires correcting the subtalor subluxation with calcaneal lengthening or fusion, medial midfoot correction with osteotomy or fusion.
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NewsBot · Sep 30, 2013

Repeatability and validation of Gait Deviation Index in children: Typically developing and cerebral palsy
Abir Massaad, Ayman Assi, Wafa Skalli, Ismat Ghanem
Gait & Posture; Article in Press

Highlights
•The repeatability and uncertainty of GDI (Gillette Deviation Index) were evaluated.
•Repeatability coefficient obtained on GDI for typically developing children was ±10.
•GDI is robust, not sensitive to the noise applied on its entries.
•We found a moderate correlation between GDI and GMFCS (Gross Motor Function Classification System).
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The Gait Deviation Index (GDI) is a dimensionless parameter that evaluates the deviation of kinematic gait from a control database. The GDI can be used to stratify gait pathology in children with cerebral palsy (CP). In this paper the repeatability and uncertainty of the GDI were evaluated. The Correlation between the GDI and the Gross Motor Function Classification System (GMFCS) was studied for different groups of children with CP (hemiplegia, diplegia, triplegia and quadriplegia). Forty-nine, typically developing children (TD) formed our database. A retrospective study was conducted on our 3D gait data and clinical exams and 134 spastic children were included. Sixteen TD children completed the gait analysis twice to evaluate the repeatability of the GDI (test–retest evaluation). Monte Carlo simulations were applied for all groups (TD and children with CP) in order to evaluate the propagation of errors stemming from kinematics. The repeatability coefficient (2SD of test–retest differences), obtained on the GDI for the 16 TD children (32 lower limbs) was ±10. Monte Carlo simulations showed an uncertainty ranging between 0.8 and 1.3 for TD children and all groups with CP. The Spearman Rank correlation showed a moderate correlation between the GDI and the GMFCS (r=−0.44, p<0.0001).
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footplant · Oct 8, 2013

Hi all,

The following document includes perspectives on medical, surgical, orthotic and therapy management of CP, from a consensus conference. The meeting included some prominent academics and clinicians working with CP. Link to a PDF is included below.

NeuroRehabilitation. 2011;28(1):37-46. doi: 10.3233/NRE-2011-0630.
Orthotic management of cerebral palsy: recommendations from a consensus conference.
Morris C, Bowers R, Ross K, Stevens P, Phillips D.
Source
Cerebra Research Unit and PenCLAHRC, Peninsula Medical School, University of Exeter, Exeter, UK. chris.morris@pms.ac.uk

http://www.ispoint.org/sites/default/files/archives/ispo_cp_report_oxford_2008.pdf

NewsBot · Nov 8, 2013

Crouch Gait Changes after Planovalgus Foot Deformity Correction in Ambulatory Children with Cerebral Palsy
Muayad Kadhim, Freeman Miller
Gait & Posture Available online 2 November 2013

Ambulatory children with cerebral palsy (CP) may present with several gait patterns due to muscular spasticity, commonly with crouch gait. Several factors may contribute to continuous knee flexion during gait, including hamstring and gastrocnemius contracture. In planovalgus foot deformity, the combination of heel equinus, talonavicular joint dislocation, midfoot break and external tibial torsion also contribute to crouch gait as part of lever arm dysfunction. In this retrospective cohort study, we assessed 21 children with CP (34 feet) who underwent planovalgus foot correction as a single level surgery. Fifteen feet underwent subtalar fusion and 19 feet had lateral calcaneal lengthening. Patients who underwent knee, hip or pelvis surgeries were excluded from the study. The aim was to examine the changes in gait pattern and the correlation between the changes of knee flexion at stance phase with the other kinematic and kinetic parameters after foot surgery. Post surgery change of Maximum knee extension at stance (MKE-dif) was the outcome of interest. The magnitude of change in MKE after surgery increased (less crouch after surgery) in patients who had milder preoperative planovalgus feet and higher preoperative ankle maximum dorsiflexion at stance and ankle power. The gain of knee extension after surgery correlated with correction of ankle hyperdorsiflexion and with increase of knee extension at initial contact and knee power. Patients with high preoperative ankle maximum dorsiflexion may benefit from surgical foot deformity correction to achieve decreased ankle dorsiflexion with no knee surgical intervention.
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Highlights
• Correcting mild pes planovalgus improves crouch gait without knee surgery.
• Gain of knee extension after foot surgery correlated with gain of knee power.
• Correcting ankle hyperdorsiflexion increases knee extension at stance.
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NewsBot · Dec 9, 2013

Crouch gait changes after planovalgus foot deformity correction in ambulatory children with cerebral palsy
Muayad Kadhim, Freeman Miller
Gait and Posture; online first

Ambulatory children with cerebral palsy (CP) may present with several gait patterns due to muscular spasticity, commonly with crouch gait. Several factors may contribute to continuous knee flexion during gait, including hamstring and gastrocnemius contracture. In planovalgus foot deformity, the combination of heel equinus, talonavicular joint dislocation, midfoot break and external tibial torsion also contribute to crouch gait as part of lever arm dysfunction. In this retrospective cohort study, we assessed 21 children with CP (34 feet) who underwent planovalgus foot correction as a single level surgery. Fifteen feet underwent subtalar fusion and 19 feet had lateral calcaneal lengthening. Patients who underwent knee, hip or pelvis surgeries were excluded from the study. The aim was to examine the changes in gait pattern and the correlation between the changes of knee flexion at stance phase with the other kinematic and kinetic parameters after foot surgery. Post surgery change of Maximum knee extension at stance (MKE-dif) was the outcome of interest. The magnitude of change in MKE after surgery increased (less crouch after surgery) in patients who had milder preoperative planovalgus feet and higher preoperative ankle maximum dorsiflexion at stance and ankle power. The gain of knee extension after surgery correlated with correction of ankle hyperdorsiflexion and with increase of knee extension at initial contact and knee power. Patients with high preoperative ankle maximum dorsiflexion may benefit from surgical foot deformity correction to achieve decreased ankle dorsiflexion with no knee surgical intervention.
Click to expand...

Highlights
•Correcting mild pes planovalgus improves crouch gait without knee surgery.
•Gain of knee extension after foot surgery correlated with gain of knee power.
•Correcting ankle hyperdorsiflexion increases knee extension at stance.
Click to expand...

NewsBot · Dec 17, 2013

Subtalar fusion for pes valgus in cerebral palsy: results of a modified technique in the setting of single event multilevel surgery.
Shore BJ, Smith KR, Riazi A, Symons SB, Khot A, Graham K.
J Pediatr Orthop. 2013 Jun;33(4):431-8. doi: 10.1097/BPO.0b013e31827d0afa.

BACKGROUND:
We studied the use of cortico-cancellous circular allograft combined with cannulated screw fixation for the correction of dorsolateral peritalar subluxation in a series of children with bilateral spastic cerebral palsy undergoing single event multilevel surgery.
METHODS:
Forty-six children who underwent bilateral subtalar fusion between January 1999 and December 2004 were retrospectively reviewed. Gait laboratory records, Gross Motor Function Classification System (GMFCS) levels, Functional Mobility Scale (FMS) scores, and radiographs were reviewed. The surgical technique used an Ollier type incision with a precut cortico-cancellous allograft press-fit into the prepared sinus tarsi. One or two 7.3 mm fully threaded cancellous screws were used to fix the subtalar joint. Radiographic analysis included preoperative and postoperative standing lateral radiographs measuring the lateral talocalcaneal angle, lateral talo-first metatarsal angle, and navicular cuboid overlap. Fusion rate was assessed with radiographs >12 months after surgery.
RESULTS:
The mean patient age was 12.9 years (range, 7.8 to 18.4 y) with an average follow-up of 55 months. Statistically significant improvement postoperatively was found for all 3 radiographic indices: lateral talocalcaneal angle, mean improvement 20 degrees (95% CI, 17.5-22.1; P<0.001); lateral talo-first metatarsal angle, mean improvement 21 degrees (95% CI, 19.2-23.4; P<0.001); and navicular cuboid overlap, mean improvement 29% (95% CI, 25.7%-32.6%; P<0.001). FMS improved across all patients, with Gross Motor Function Classification System III children experiencing a 70% improvement across all 3 FMS distances (5, 50, and 500 m). All 3 radiographic measures improved significantly (P<0.001). Fusion was achieved in 45 patients and there were no wound complications.
CONCLUSIONS:
With this study, we demonstrate significant improvement in radiographic segmental alignment and overall function outcome with this modified subtalar fusion technique. We conclude that this technique is an effective complement for children with dorsolateral peritalar subluxation undergoing single event multilevel surgery.
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NewsBot · Dec 27, 2013

Movement within foot and ankle joint in children with spastic cerebral palsy: a 3-dimensional ultrasound analysis of medial gastrocnemius length with correction for effects of foot deformation
Peter A Huijing, Menno R Bénard, Jaap Harlaar, Richard T Jaspers and Jules G Becher
BMC Musculoskeletal Disorders 2013, 14:365 doi:10.1186/1471-2474-14-365

Background
In spastic cerebral palsy (SCP), a limited range of motion of the foot (ROM), limits gait and other activities. Assessment of this limitation of ROM and knowledge of active mechanisms is of crucial importance for clinical treatment.

Methods
For a comparison between spastic cerebral palsy (SCP) children and typically developing children (TD), medial gastrocnemius muscle-tendon complex length was assessed using 3-D ultrasound imaging techniques, while exerting externally standardized moments via a hand-held dynamometer. Exemplary X-ray imaging of ankle and foot was used to confirm possible TD-SCP differences in foot deformation.

Results
SCP and TD did not differ in normalized level of excitation (EMG) of muscles studied. For given moments exerted in SCP, foot plate angles were all more towards plantar flexion than in TD. However, foot plate angle proved to be an invalid estimator of talocrural joint angle, since at equal foot plate angles, GM muscle-tendon complex was shorter in SCP (corresponding to an equivalent of 1 cm). A substantial difference remained even after normalizing for individual differences in tibia length. X-ray imaging of ankle and foot of one SCP child and two typically developed adults, confirmed that in SCP that of total footplate angle changes (0-4 Nm: 15[degree sign]), the contribution of foot deformation to changes in foot plate angle (8) were as big as the contribution of dorsal flexion at the talocrural joint (7[degree sign]). In typically developed individuals there were relatively smaller contributions (10 -11%) by foot deformation to changes in foot plate angle, indicating that the contribution of talocrural angle changes was most important.

Using a new estimate for position at the talocrural joint (the difference between GM muscle-tendon complex length and tibia length, GM relative length) removed this effect, thus allowing more fair comparison of SCP and TD data. On the basis of analysis of foot plate angle and GM relative length as a function externally applied moments, it is concluded that foot plate angle measurements underestimate angular changes at the talocrural joint when moving in dorsal flexion direction and overestimates them when moving in plantar flexion direction, with concomitant effects on triceps surae lengths.

Conclusions
In SCP children diagnosed with decreased dorsal ROM of the ankle joint, the commonly used measure (i.e. range of foot plate angle), is not a good estimate of rotation at the talocrural joint. since a sizable part of the movement of the foot (or foot plate) derives from internal deformation of the foot.
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NewsBot · Jan 18, 2014

Overview of foot deformity management in children with cerebral palsy.
Sees JP, Miller F.
J Child Orthop. 2013 Nov;7(5):373-377.

Foot deformities in children with cerebral palsy are common. The natural history of the deformities of the feet is very variable and very unpredictable in young children less then 5 years old. Treatment for the young children should be primarily with orthotics and manual therapy. Equinus is the most common deformity, with orthotics augmented with botulinum toxin being the primary management in young children. When fixed deformity develops lengthening only the muscle which is contracted is preferred. Varus deformity of the feet is often associated with equinus, and can almost always be managed with orthotics until 8 or 10 years of age. Planovalgus is the most common deformity in children with bilateral lower extremity spasticity. The primary management is orthotics until the child no longer tolerates the orthotic; then surgical management needs to consider all the deformities and all should be corrected. This requires correcting the subtalor subluxation with calcaneal lengthening or fusion, medial midfoot correction with osteotomy or fusion.
Click to expand...

NewsBot · Jan 18, 2014

Feedback system based on plantar pressure for monitoring toe-walking strides in children with cerebral palsy.
Pu F, Fan X, Yang Y, Chen W, Li S, Li D, Fan Y.
Am J Phys Med Rehabil. 2014 Feb;93(2):122-9.

OBJECTIVE:
The aim of this study was to develop a feedback system to assist gait rehabilitation of cerebral palsy (CP) toe walkers with dynamic equinus.
DESIGN:
Plantar pressure of the forefoot and the heel was collected by sensorized insoles embedded in custom-built shoes and transmitted to a smartphone via Bluetooth. Dynamic foot pressure index of each stride was calculated by purpose-designed software running in the smartphone to distinguish toe-walking strides from normal strides in real time. An auditory signal would be produced to alert the patient each time a toe-walking stride was detected.
RESULTS:
For CP toe walkers, the one-way analysis of variance indicated a significant difference (F1,14 = 19.492, P = 0.001) in dynamic foot pressure index between the affected side (31.4 ± 12.0) and the unaffected side (58.6 ± 2.5). In addition, the validation test showed that this system can distinguish toe-walking strides from normal strides of children with CP with an accuracy of 95.3%.
CONCLUSIONS:
This system was able to monitor the toe-walking strides of children with CP in real time and had the potential to enhance rehabilitation training efficiency and correct toe-walking gait in children with CP with dynamic equinus.
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NewsBot · Jan 21, 2014

Can we unmask features of spasticity during gait in children with cerebral palsy by increasing their walking velocity?
Anja Van Campenhout, Lynn Bar-On, Erwin Aertbeliën, Catherine Huenaerts, Guy Molenaers, Kaat Desloovere
Gait & Posture; Article in Press

Highlights
•Spasticity is commonly measured in a passive condition.
•Signs of spasticity may be highlighted when increasing walking velocity.
•We compare gait parameters at different walking velocities in CP and TD children.
•CP children used a different strategy than the TD children to increase their walking velocity.
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Background and aim
Spasticity is a velocity dependent feature present in most patients with cerebral palsy (CP). It is commonly measured in a passive condition. The aim of this study was to highlight markers of spasticity of gastrocnemius and hamstring muscles during gait by comparing the effect of increased walking velocity of CP and typical developing (TD) children.

Methods
53 children with spastic CP and 17 TD children were instructed to walk at self-selected speed, faster and as fast as possible without running. Kinematics, kinetics and electromyography (EMG) were collected and muscle length and muscle lengthening velocity (MLV) were calculated. To compare the data of both groups, a linear regression model was created which resulted in two non-dimensional gait velocities. A difference score (DS) was calculated between the high and low velocity values for both groups.

Results
103 gait parameters were analyzed of which 16 had a statistically significant DS between TD and CP groups. The spastic gastrocnemius muscle presented at high velocity with a higher ankle angular velocity, plantar flexion moment, power absorption and increased EMG signal during loading response. The spastic hamstrings demonstrated at high velocity a delayed maximum knee extension moment at mid-stance and increasing hip extension moment and hip power generation. The hamstrings also presented with a lower MLV during swing phase.

Conclusions
A limited number of gait parameters differ between CP and TD children when increasing walking velocity, giving indirect insight on the effect of spasticity on gait.
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NewsBot · Mar 21, 2014

Balance control in gait children with cerebral palsy
L. Wallard, G. Dietrich, Y. Kerlirzin, J. Bredin
Gait & Posture; Article in Press

Highlights
•We aimed to highlight the balance control process during gait in children with CP.
•We assessed gait as a dynamic imbalance which has to be accepted and controlled.
•An intercorrelation between the COM–COP trajectory and the forces was conducted.
•We highlighted the different strategies used during gait by children with CP.
•This research can be useful in understanding and the rehabilitation of these children.
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This study sought to highlight the balance control process during gait in children with cerebral palsy (CP) by analyzing the different strategies used in order to generate forward motion while maintaining balance. Data were collected using a motion analysis system in order to provide a clinical gait analysis for 16 children with CP and 16 children with typical development. Significant differences between the two groups are observed in terms of kinetic data of the propulsive forces of the center of mass (COM) and of the center of pressure (COP) dynamic trajectory and for locomotor parameters. The imbalance generated by divergent trajectories of COM and COP produce the propulsive forces responsible for human gait initiation. Moreover, we observe in children with CP an “en bloc” postural strategy resulting in increasing divergence between trajectories of COM–COP. This particular strategy of the children with CP is characterized by a greater time duration between the moment of COM–COP trajectory divergence and the moment where the forward propulsive forces became apparent.
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NewsBot · Mar 25, 2014

Forefoot mobility in ankle and foot orthoses: effect on gait of children with cerebral palsy.
Carmick J.
Pediatr Phys Ther. 2013 Fall;25(3):331-7.

BACKGROUND AND PURPOSE:
Typical gait requires flexibility in the ankle and foot. During gait, it is critical that the ankle dorsiflex and the toes extend. The purpose of this report is to demonstrate that when foot orthoses block critical movement undesirable compensations that may interfere with gait can appear.
CASE DESCRIPTION:
Three children with spastic cerebral palsy demonstrate the effect on gait when the blocks attributable to the orthoses were removed.
INTERVENTION:
All children received electrical stimulation and used foot orthoses.
OUTCOMES:
Internal hip rotation and toe walking occurred when orthoses blocked digit extension. A block may be small and unnoticed but can still influence gait and force the child to compensate for the loss of mobility.
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NewsBot · Jul 10, 2014

Gait Changes Following Myofascial Structural Integration (Rolfing) Observed in 2 Children With Cerebral Palsy
Alexis B. Hansen, MD; Karen S. Price, BA, CAR; Elizabeth C. Loi, BA; Christina A. Buysse, MD; Theresa M. Jaramillo, DPT; Elaine L. Pico, MD; Heidi M. Feldman, MD, PhD
Journal of Evidence-Based Complementary & Alternative Medicine July 2, 2014

Children with spastic cerebral palsy experience difficulty with ambulation. Structural changes in muscle and fascia may play a role in abnormal gait. Myofascial structural integration (Rolfing) is a manual therapy that manipulates muscle and soft tissues to loosen fascia layers, reposition muscles, and facilitate alignment. This study aimed to document (1) gait characteristics of 2 children with cerebral palsy and (2) effects of myofascial structural integration on their gait. Children received 3 months of weekly therapy sessions by an experienced practitioner. Gait parameters were recorded at baseline and after treatment using an electronic walkway. Children with cerebral palsy demonstrated abnormal velocity and cadence, decreased step length and single support times, and increased double support time. After treatment, both children demonstrated improvement for 3 months in cadence and double support time. The objective gait analyses demonstrated temporary improvements after myofascial structural integration in children with spastic cerebral palsy.
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NewsBot · Jul 10, 2014

Overground versus self-paced treadmill walking in a virtual environment in children with cerebral palsy
Marjolein M. van der Krogt, Lizeth H. Sloot, Jaap Harlaar
Gait & Posture; Articles in Press

Highlights
•We compared self-paced treadmill walking to walking in a conventional gait lab and in a courtyard
•Subjects with and without CP walked at similar speed in both labs, but faster in the courtyard
•Stride width was wider and stride length shorter on the treadmill than overground
•Kinematic curves were quite similar, but some increased deviation was found in CP on the treadmill
•Self-paced treadmill walking is a promising tool for kinematic gait analysis in patients with CP
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Treadmill walking offers several advantages for clinical gait analysis and gait training, but may affect gait parameters. We compared walking on a self-paced treadmill in a virtual environment (TM+) with overground walking in a conventional gait lab (CGL), and with natural walking (NW) outside a lab environment on a GaitRite measurement mat, for 11 typically developing (TD) children and 9 children with cerebral palsy (CP). Spatiotemporal parameters and subjective scores on similarity to normal walking were compared between all three conditions, while kinematic parameters and Gait and Motion Analysis Profile Scores (GPS and MAP) were compared between CGL and TM+. Subjects walked slower and with shorter strides in both lab conditions compared to NW. Stride width was 3 to 4 cm wider in TM+ than in CGL and NW. Mean kinematic curves showed a few differences between CGL and TM+: on the treadmill children with CP walked with on average 2° more pelvic tilt, 7° more knee flexion at initial contact, and more deviating knee and ankle kinematics as indicated by the MAP scores. These differences may in part be due to increased fatigue in TM+ as a result of longer continuous walking time. Our results indicate that differences between self-paced treadmill walking in a VR and walking in a conventional gait lab are generally small, but need to be taken into account when performing gait analysis on a treadmill.
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NewsBot · Jul 31, 2014

Recurrence of Equinus Foot Deformity After Tendo-Achilles Lengthening in Patients With Cerebral Palsy.
Chung CY, Sung KH, Lee KM, Lee SY, Choi IH, Cho TJ, Yoo WJ, Park MS.
J Pediatr Orthop. 2014 Jul 29

BACKGROUND::
Recurrence of equinus deformity after surgery is common in patients with cerebral palsy. This retrospective study was undertaken to estimate the recurrence rate of the equinus deformity after tendo-Achilles lengthening (TAL) in patients with cerebral palsy and to investigate the risk factors associated with the recurrence.
METHODS::
Two-hundred forty three ambulatory patients with cerebral palsy, who underwent TAL for equinus foot deformity since 1995, and had undergone a preoperative and postoperative 3-dimensional gait analysis, were included. Cox proportional hazards model was used to determine the significant contributing factor for the recurrence of equinus foot deformity.
RESULTS::
The mean patient age at surgery was 7.8±2.7 years and the mean follow-up duration was 8.1±3.4 years. Equinus deformity recurred in 22 of the 243 patients (9.1%) and the Kaplan-Meier survival estimate was shown to be 89.4% at 10 years not needing repeat surgery. According to the multivariate analysis using the Cox proportional hazard model, preoperative ankle dorsiflexion at initial contact (P=0.016) was the only significant factor for recurrence of equinus deformity after surgery. Age at surgery and the type of limb involvement were not associated with the recurrence (P=0.433 and 0.269). The cutoff values of preoperative gait kinematics between the nonrecurrence and recurrence groups were -19 degrees of ankle dorsiflexion at initial contact (P=0.018).
CONCLUSIONS::
This study showed that the severity of preoperative equinus deformity was a risk factor associated with recurrence after TAL in patients with cerebral palsy. Therefore, surgeons should consider the recurrence and later revision surgery for the patients with severe equinus foot deformity.
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NewsBot · Aug 16, 2014

Effect of Sensory Integration Therapy on Foot to Foot Distribution during Gait in Children with Spastic Diplegia
Nahla M.Ibrahium et al
JMSCR Volume||2||Issue||8||Page1961-1967||August-2014

Background: The ability to walk is a major concern of the parents of children with cerebral palsy, and
improving or maintaining this ability is often considered to be the primary focus of most therapeutic
interventions addressing the motor problems seen in children with spastic diplegia.
Purpose: to assess the effect of sensory integration therapy on foot to foot distribution during gait in
children with spastic diplegia.
Subjects: Twenty spastic diplegic cerebral palsy children were randomly divided into 2 groups 10 of each:
Group A (control) and Group B (study), patients of both groups had received the traditional physical
therapy program with sensory integration therapy was added to the gait training program for group B.
Methods: The Biodex gait trainer2 was used to assess foot to foot distribution for all patients pre and after
3 months of treatment.
Results: results revealed improvement in percent of foot to foot distribution for both groups but with
significant improvement for the group B.
Conclusion: sensory integration therapy is effective in improving foot to foot distribution during gait for
children with spastic diplegia.
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NewsBot · Oct 18, 2014

Gait training reduces ankle joint stiffness and facilitates heel strike in children with Cerebral Palsy.
Willerslev-Olsen M, Lorentzen J, Nielsen JB.
NeuroRehabilitation. 2014 Oct 15.

BACKGROUND:
Foot drop and toe walking are frequent concerns in children with cerebral palsy (CP). Increased stiffness of the ankle joint muscles may contribute to these problems.
OBJECTIVE:
Does four weeks of daily home based treadmill training with incline reduce ankle joint stiffness and facilitate heel strike in children with CP?
METHODS:
Seventeen children with CP (4-14 years) were recruited. Muscle stiffness and gait ability were measured twice before and twice after training with an interval of one month. Passive and reflex-mediated stiffness were measured by a dynamometer which applied stretches below and above reflex threshold. Gait kinematics were recorded by 3-D video-analysis during treadmill walking. Foot pressure was measured by force-sensitive foot soles during treadmill and over-ground walking.
RESULTS:
Children with increased passive stiffness showed a significant reduction in stiffness following training (P = 0.01). Toe lift in the swing phase (P = 0.014) and heel impact (P = 0.003) increased significantly following the training during both treadmill and over-ground walking.
CONCLUSIONS:
Daily intensive gait training may influence the elastic properties of ankle joint muscles and facilitate toe lift and heel strike in children with CP. Intensive gait training may be beneficial in preventing contractures and maintain gait ability in children with CP.
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NewsBot · Oct 18, 2014

Gait cycle and plantar pressure distribution in children with cerebral palsy: Clinically useful outcome measures for a management and rehabilitation.
Nsenga Leunkeu A, Lelard T, Shephard RJ, Doutrellot PL, Ahmaidi S.
NeuroRehabilitation. 2014 Oct 15.

BACKGROUND:
Information on altered foot pressures during ambulation would clarify how far limb deformities modify walking patterns in cerebral palsy (CP), and whether such data can inform prognosis and guide rehabilitation.
OBJECTIVE:
To compare the extent of plantar pressures during walking between children with CP and their able-bodied (AB) peers.
METHODS:
Twenty-five children/adolescents (10 with hemiplegia, 5 with diplegia, and 10 AB, respective ages 13.0 ± 1.9, 13.0 ± 0.6 and 14.0 ± 0.7 years) walked a 12 m line at a self-selected speed. Spatio-temporal parameters and peak in-shoe plantar pressures were recorded for both feet, using the Parotec analysis system.
RESULTS:
Walking speeds (m·-1) differed significantly between groups (0.65 ± 0.13, hemiplegia, 0.93 ± 0.22 diplegia and 1.26 ± 0.05 AB), with shorter stride lengths in CP. Contact time, double support time and step duration were also shorter in hemiplegia. Plantar pressures differed substantially and consistently between AB and CP, with increased medial heel pressures in hemiplegia, and reduced hallux and lateral heel pressures but increased lateral, medial mid-foot and first metatarsal pressures in diplegia.
CONCLUSIONS:
Substantial alterations in spatio-temporal parameters (greater in hemiplegia than in diplegia) and plantar pressure distribution reflect attempts to compensate for poor stability of posture in CP. Further study of these adaptive changes holds clinical promise in providing data relevant to the design of orthotics, determinations of prognosis and the planning of neurorehabilitation.
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NewsBot · Nov 11, 2014

Kinematic Foot Types in Youth with Equinovarus Secondary to Hemiplegia
Joseph J. Krzak, Daniel M. Corcos, Diane L. Damiano, Adam Graf, Donald Hedeker, Peter A. Smith, Gerald F. Harris
Gait & Posture; Articles in Press

Highlights
•Kinematics were collected on youth with equinovarus using the Milwaukee Foot Model.
•PCA reduced clinically relevant kinematic variables to 6 principal components.
•K-means cluster analysis was used to identify 5 distinct kinematic subgroups.
•Subgroups had either isolated or combined hindfoot and/or forefoot involvement.
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Background
Elevated kinematic variability of the foot and ankle segments exists during gait among individuals with equinovarus secondary to hemiplegic cerebral palsy (CP). Clinicians have previously addressed such variability by developing classification schemes to identify subgroups of individuals based on their kinematics.

Objective
To identify kinematic subgroups among youth with equinovarus secondary to CP using 3-dimensional multi-segment foot and ankle kinematics during locomotion as inputs for principal component analysis (PCA), and K-means cluster analysis.

Methods
In a single assessment session, multi-segment foot and ankle kinematics using the Milwaukee Foot Model (MFM) were collected in 24 children/adolescents with equinovarus and 20 typically developing children/adolescents.

Results
PCA was used as a data reduction technique on 40 variables. K-means cluster analysis was performed on the first 6 principal components (PCs) which accounted for 92% of the variance of the dataset. The PCs described the location and plane of involvement in the foot and ankle. Five distinct kinematic subgroups were identified using K-means clustering. Participants with equinovarus presented with variable involvement ranging from primary hindfoot or forefoot deviations to deformtiy that included both segments in multiple planes.

Conclusion
This study provides further evidence of the variability in foot characteristics associated with equinovarus secondary to hemiplegic CP. These findings would not have been detected using a single segment foot model. The identification of multiple kinematic subgroups with unique foot and ankle characteristics has the potential to improve treatment since similar patients within a subgroup are likely to benefit from the same intervention(s).
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NewsBot · Nov 14, 2014

Long-term Outcomes of Triple Arthrodesis in Cerebral Palsy Patients.
Trehan SK, Ihekweazu UN, Root L.
J Pediatr Orthop. 2014 Nov 12.

BACKGROUND::
Triple arthrodesis in the appropriately indicated cerebral palsy patient with a painful and/or rigid foot deformity can significantly alleviate pain and improve function. Limited data on long-term outcomes of triple arthrodesis in this patient population exist. In addition, there have been concerns about the long-term consequences of altered biomechanics in these patients on the tibiotalar (ankle) joint.
METHODS::
We retrospectively reviewed 21 cerebral palsy patients who had undergone triple arthrodesis for a painful and/or rigid foot deformity at our institution with at least 10 years of clinical or radiographic follow-up. Preoperative, and the most recent, clinical evaluations and radiographs were reviewed. In addition, all 21 patients and/or caretakers responded to a questionnaire at the time of this study by means of telephone to assess subjective pain, analgesia use, walking aid necessity, walking distance, and satisfaction with the procedure.
RESULTS::
In this series of 21 cerebral palsy patients, 5 patients had bilateral surgery, resulting in 26 operative feet. The mean age at the time of surgery was 19.4 years and most recent clinical or radiographic follow-up was 22.1 years postoperatively. Preoperative foot deformity was characterized by hindfoot valgus in 66.7% (14/21) and varus in 33.3% (7/21) of patients. Postoperatively, fusion was achieved in 96.2% (25/26) of feet. At final follow-up, 3 feet (11.5%) demonstrated tibiotalar joint arthritis, 1 (3.8%) had midfoot arthritis, and 10 (38.5%) had residual deformity. Of the total patients, 95.2% (20/21) were satisfied with the outcome and 61.9% (13/21) reported pain-free ambulation. There was no association between eventual functional outcome and preoperative diagnosis, preoperative foot deformity, postoperative tibiotalar joint arthritis, or postoperative residual deformity.
CONCLUSIONS::
Triple arthrodesis is a surgical option in cerebral palsy patients with painful and/or rigid foot deformities. From this series, successful outcomes can be expected as long as bony union is achieved. The incidence of tibiotalar arthritis is relatively low and not associated with long-term functional outcome. In addition, preoperative and residual postoperative foot deformity is not associated with long-term outcome.
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NewsBot · Nov 29, 2014

Trunk movements during gait in cerebral palsy
Michael Attias, Alice Bonnefoy-Mazure, Mathieu Lempereur, Pierre Lascombes, Geraldo De Coulon, Stéphane Armand
Clinical Biomechanics; Articles in Press

Highlights
•We examined trunk movements in a large database of cerebral palsy patients.
•We found an increase of trunk movement linked with the impairment level.
•Diplegia has more range of motion for trunk tilt and obliquity than hemiplegia.
•Diplegia has less range of motion for trunk rotation than hemiplegia.
•Clinicians should consider trunk motions during gait analysis.
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Background
Whereas lower limb deficits have been widely studied during gait in cerebral palsy, deficits in upper body have received little attention. The purpose of this research was to describe characteristics of trunk movement of cerebral palsy children in terms of type of deficits (diplegia/hemiplegia) and gross motor function classification system (1, 2 or 3).

Methods
Data from 92 cerebral palsy children, which corresponds to 141 clinical gait analysis, were retrospectively selected. Kinematic parameters of the trunk were extracted from thorax and spine angles in the sagittal, transverse and coronal planes. The range of motion and the mean positions over the gait cycle were analysed. Overall gait parameters were assessed in relation to normalised walking speed and gait profile score. Intra-group differences between the children with diplegia or hemiplegia, gross motor function classification system 1 to 3 and typically developing participants were analysed with Kruskal-Wallis tests and post hoc tests. Pearson correlation coefficients between the gait profile score normalised walking speed and kinematic parameters of the thorax were assessed.

Findings
The results revealed: 1) the range of motion of the thorax and spine exhibited more significant differences between groups than the mean positions; 2) greater levels of impairment were associated with higher thorax range of motion, and 3) the children with diplegia and gross motor function classification system 3 exhibited a greater range of motion for all planes with the exception of spine rotation.

Interpretation
This study confirmed that greater levels of impairment in cerebral palsy are associated with greater thorax range of motion during gait. The thorax plays an important role during gait in cerebral palsy.
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