Kinematic analysis of upper limb during walking in diplegic children with Cerebral Palsy

The effects of improvement in upper extremity function on gait and balance in children with upper extremity affected

BACKGROUND

This study aimed to investigate the effects of functional improvement in the upper extremity on gait and balance in children with upper extremity affected.

RESEARCH QUESTION

What are the effects of functional improvement in the upper extremity on gait and balance in children with upper extremity affected?

METHODS

Eighteen children with a diagnosis of rheumatologic diseases and 15 healthy children were evaluated with Shriners Hospital Upper Extremity Assessment, Jebsen-Taylor Hand Function Test, Abilhand Rheumatoid Arthritis Scale, 10-meter walk test and Childhood Health Assessment Questionnaire. For static balance assessment, the Biodex Balance was used. Ground reaction forces (peak forces (heel strike and push-off) and minimum force (loading response), single-limb support duration, Center-of-Force displacement and walking speed were evaluated with the Sensor Medica. Arm swing was evaluated with the Kinovea 2D motion analysis.

RESULTS

Before treatment, single-limb support duration and push-off force was higher and center-of-force displacement was lower on affected side compared to unaffected side in rheumatologic group. After the 6-week rehabilitation program, upper extremity function, quality of life and functional gait score improved. Single-limb support duration decreased on affected side and increased on unaffected side. On affected side, push-off force decreased. The arm swing parameters were similar before and after treatment.

SIGNIFICANCE

Improving upper extremity function can help with gait balance by decreasing the difference in walking and balance parameters between the affected and unaffected sides and providing for more symmetrical weight transfer.

Motion-based technology to support motor skills screening in developing children: A scoping review

BACKGROUND

Acquiring motor skills is fundamental for children's development since it is linked to cognitive development. However, access to early detection of motor development delays is limited.

AIM

This review explores the use and potential of motion-based technology (MBT) as a complement to support and increase access to motor screening in developing children.

METHODS

Six databases were searched following the PRISMA guidelines to search, select, and assess relevant works where MBT recognised the execution of children's motor skills.

RESULTS

164 studies were analysed to understand the type of MBT used, the motor skills detected, the purpose of using MBT and the age group targeted.

CONCLUSIONS

There is a gap in the literature aiming to integrate MBT in motor skills development screening and assessment processes. Depth sensors are the prevailing technology offering the largest detection range for children from age 2. Nonetheless, the motor skills detected by MBT represent about half of the motor skills usually observed to screen and assess motor development. Overall, research in this field is underexplored. The use of multimodal approaches, combining various motion-based sensors, may support professionals in the health domain and increase access to early detection programmes.

Analysis of the movements of the upper extremities during gait: Their role for the dynamic balance

BACKGROUND

The movement of the upper extremities is important for balance control in human walking. However, it is still unknown which mode of arm swing ensures the most stable gait due to the lack of appropriate measures which can quantify the movement of the upper extremities. In this study, we formulate a new parameter to numerically describe the arm swing. We investigated the effect of walking speed, sports activities and the subject's BMI on the movement of the upper limbs.

METHODS

Data of healthy 50 subjects from an external database was used. We used a human gait database for this analysis. All experimental trials were performed in Centre National de Rééducation Fonctionnelle et de Réadaptation - Rehazenter in Laboratoire d'Analyse du Mouvement et de la Posture in Luxembourg. Participants were asked to walk on a straight level walkway at 5 different speeds: 0-0.4 m/s, 0.4-0.8 m/s, 0.8-1.2 m/s, self-selected spontaneous and fast speeds. The human motion was recorded by using a 10-camera optoelectronic system.

FINDINGS

The amplitude of arm swing was greater in gait with self-selected fast speed then in slow walking. Higher walking speeds entailed also the more structured and repetitive movement of the upper extremities. For self-selected fast speed, the mean value of Pearson's correlation coefficient between arm swing amplitude of the left and right side was 0.935 ± 0.102, 0.943 ± 0.073 and 0.973 ± 0.020 for the young, middle aged and elderly group respectively, while in slow walking it was in the range 0.393-0.633 (for the representatives of the three groups). Our results could suggest other factors which influence arm swing, such as obesity and doing asymmetric sports.

INTERPRETATIONS

Our results suggest that choosing the lowest possible walking speed is not the best strategy as the most symmetric arm swing occurs during gait with self-selected speed.

Upper Limb Movement Measurement Systems for Cerebral Palsy: A Systematic Literature Review

Quantifying the quality of upper limb movements is fundamental to the therapeutic process of patients with cerebral palsy (CP). Several clinical methods are currently available to assess the upper limb range of motion (ROM) in children with CP. This paper focuses on identifying and describing available techniques for the quantitative assessment of the upper limb active range of motion (AROM) and kinematics in children with CP. Following the screening and exclusion of articles that did not meet the selection criteria, we analyzed 14 studies involving objective upper extremity assessments of the AROM and kinematics using optoelectronic devices, wearable sensors, and low-cost Kinect sensors in children with CP aged 4–18 years. An increase in the motor function of the upper extremity and an improvement in most of the daily tasks reviewed were reported. In the population of this study, the potential of wearable sensors and the Kinect sensor natural user interface as complementary devices for the quantitative evaluation of the upper extremity was evident. The Kinect sensor is a clinical assessment tool with a unique markerless motion capture system. Few authors had described the kinematic models and algorithms used to estimate their kinematic analysis in detail. However, the kinematic models in these studies varied from 4 to 10 segments. In addition, few authors had followed the joint assessment recommendations proposed by the International Society of Biomechanics (ISB). This review showed that three-dimensional analysis systems were used primarily for monitoring and evaluating spatiotemporal variables and kinematic parameters of upper limb movements. The results indicated that optoelectronic devices were the most commonly used systems. The joint assessment recommendations proposed by the ISB should be used because they are approved standards for human kinematic assessments. This review was registered in the PROSPERO database (CRD42021257211).

A New Method for Postural Misalignment of a 6-Year-Old Girl With Cerebral Palsy: A Case Report

Objective

To demonstrate the effects of a newly designed postural alignment relearning system on postural control dysfunction in a typical patient with cerebral palsy (CP).

Design

Evaluation before and after 8 weeks of Constraint Standing Training 3-dimensional postural alignment relearning system.

Setting

Department of Rehabilitation Medicine.

Participant

A 6-year-old girl with CP and postural misalignment on Gross Motor Function Classification System level I.

Interventions

Constraint Standing Training for 8 weeks to correct postural misalignment.

Main Outcome Measures

Parameters of lateral plain radiographs in static standing, posturography measurements in standing and walking, motor ability (Gross Motor Function Measure-88 [GMFM-88] scores, manual muscle testing [MMT] scores, muscle architecture), and gait kinematic parameters (40 3-dimensional parameters of arms, trunk, waist, and lower limbs).

Results

Knee hyperextension angle in static standing; peaks of knee flexion angle (KFA) when walking, hip flexion angle and ankle flexion angle in dynamic standing; and the KFA at initial contact in gait cycle all decreased significantly (P<.01). Scores of GMFM-88 sections D and E and MMT of 5 core stability muscles improved (P<.01). The velocities and range of motion of the arms, the 3-dimensinoal range of motion of the trunk and waist, and most of the parameters of the lower limbs showed statistically significant change (P<.01). Bilateral muscle thickness did not change significantly after the treatment (P=.738 left, P=.978 right), but the gluteus maximus morphology was changed: the muscle fibers became rounder, the interfiber space decreased, and the border lines of the muscle fibers got clearer.

Conclusions

Postural alignment, motor ability, and gait may be homologous external manifestations of more fundamental core abilities, referring to correct standing posture cognition, muscle activation, and postural unconsciousness. Constraint Standing Training 3-dimensional postural alignment relearning system aimed to improve the static and dynamic standing control ability, may fix postural misalignment and improve motor ability and flexed-knee gait. Future work should use Constraint Standing Training with patients with different kinds of misalignment, choose sensitive indicators, observe the duration of each step, and reveal the mechanism causes postural misalignment.

Quantification of the effects of robotic-assisted gait training on upper and lower body strategy during gait in diplegic children with Cerebral Palsy using summary parameters

The effects of robotic-assisted gait training on upper and lower body strategy during gait in diplegic children with Cerebral Palsy (CP) were quantified using summary parameters (Upper Body Profile Score (UBPS) and Gait Profile Score (GPS)). Firstly, the upper body strategy during gait was assessed in 73 children with CP and 15 healthy children (Control Group: CG): patients with CP exhibited higher values of most of the summary parameters of the upper body position than the CG. Then, the effects of a robotic-assisted gait training in a sub-group of 35 children by means of UBPS were evaluated. After robotic-assisted gait training program, no significant differences as for the summary parameters (UBPS and GPS). However, considering the specific variables scores, significant improvements are displayed as for the upper body parameter on the sagittal plane (Upper Body Ant/Pst index) and the lower limbs, in particular pelvis (Pelvic Ant/Pst and Pelvic Int/Ext indices) and as for walking velocity. A sort of reorganization of full-body kinematics, especially at upper body and proximal level (pelvis) seems to appear, with a new gait approach, characterised by a better strategy of the upper body associated with a significant improvement of the pelvis movement.

Analysis of dynamic elbow flexion deformity in children with hemiplegic cerebral palsy

BACKGROUND

Cerebral palsy affects 1 per 1.000 children, and in 83% of the cases upper extremity is involved. Dynamic elbow flexion deformity is a movement disorder observed in individuals with hemiparesis secondary to cerebral palsy. We sought to determine whether children with hemiplegic cerebral palsy exhibit dynamic elbow flexion deformity during daily activities and its influence to reaching function.

METHODS

Sixteen children with upper limb hemiparesis and cerebral palsy (age 11y 7mo (SD 3y 2mo); 11 boys, 5 girls; Gross Motor Function Classification System level I or II) were included in this observational descriptive study. Manual Ability Classification System, Children's Hand-use Experience Questionnaire and Shriners Hospital for Children Upper Extremity Evaluation were used to evaluate affected upper extremity function. Spasticity was assessed with Modified Ashworth scale. Involuntary elbow flexion was recorded in eight daily activities. Elbow motion during reach function was measured.

FINDINGS

Fifteen out of 16 individuals showed dynamic elbow flexion deformity. There was a significative increase of involved median elbow flexion in all the activities studied, except for "high speed stairs climbing" evaluation. Children's Hand-use Experience Questionnaire showed that children were independent in most of the daily activities (21 out of 29). Correlation between dynamic elbow flexion deformity and Shriners Hospital for Children Upper Extremity Evaluation was observed only in sitting-standing activity (Spearman's ρ 0.549, P = 0.028).

INTERPRETATION

Dynamic elbow flexion deformity is very common in hemiplegic cerebral palsy and occurs proportionally to the degree of the effort demanded by the activities. Despite of presenting this movement disorder, it does not affect in children participation in daily activities.

The nature and extent of upper limb associated reactions during walking in people with acquired brain injury

BACKGROUND

Upper limb associated reactions (ARs) are common in people with acquired brain injury (ABI). Despite this, there is no gold-standard outcome measure and no kinematic description of this movement disorder. The aim of this study was to determine the upper limb kinematic variables most frequently affected by ARs in people with ABI compared with a healthy cohort at matched walking speed intention.

METHODS

A convenience sample of 36 healthy control adults (HCs) and 42 people with ABI who had upper limb ARs during walking were recruited and underwent assessment of their self-selected walking speed using the criterion-reference three dimensional motion analysis (3DMA) at Epworth Hospital, Melbourne. Shoulder flexion, abduction and rotation, elbow flexion, forearm rotation and wrist flexion were assessed. The mean angle, standard deviation (SD), peak joint angles and total joint angle range of motion (ROM) were calculated for each axis across the gait cycle. On a group level, ANCOVA was used to assess the between-group differences for each upper limb kinematic outcome variable. To quantify abnormality prevalence on an individual participant level, the percentage of ABI participants that were outside of the 95% confidence interval of the HC sample for each variable were calculated.

RESULTS

There were significant between-group differences for all elbow and shoulder abduction outcome variables (p < 0.01), most shoulder flexion variables (except for shoulder extension peak), forearm rotation SD and ROM and for wrist flexion ROM. Elbow flexion and shoulder abduction were the axes most frequently affected by ARs. Despite the elbow being the most prevalently affected (38/42, 90%), a large proportion of participants had abnormality, defined as ±1.96 SD of the HC mean, present at the shoulder (32/42, 76%), forearm (20/42, 48%) and wrist joints (10/42, 24%).

CONCLUSION

This study provides valuable information on ARs, and highlights the need for clinical assessment of ARs to include all of the major joints of the upper limb. This may inform the development of a criterion-reference outcome measure or classification system specific to ARs.

Excessive Lateral Trunk Lean in Patients With Cerebral Palsy: Is It Based on a Kinematic Compensatory Mechanism?

Introduction: Excessive lateral trunk lean is a commonly observed gait deviation in children with cerebral palsy (CP), with implications for energy expenditure and the development of back pain. While the trunk lean toward the stance leg is widely interpreted as a compensatory strategy to unload the hip, in CP the relation to hip abductor muscle strength is only weak. Therefore, other mechanisms may play a role in the prevalence of excessive trunk lean in CP, or it could be a primary motor function deficit.

Research Question: Is the excessive lateral trunk lean in patients with CP part of an underlying biomechanical mechanism?

Materials and Methods: Patients with bilateral CP (N = 255; age 13.6 ± 6.6 years) were retrospectively included and divided into a group with (n = 174) and without (n = 81) excessive lateral trunk lean. Ten lower-extremity joint angle waveforms were analyzed using a principal component analysis (PCA) to identify patterns of correlated deviations from average angle waveforms. Binary logistic regressions were performed to determine the discriminative capacity of the identified patterns.

Results: The PCA identified correlated kinematic patterns, with lower-order patterns showing more common gait pathologies, such as torsional malalignments and crouch gait pattern. Within five patterns, significant (p < 0.0025) group differences were identified. Interestingly, the trunk lean was not always distinctive in these patterns and despite the significant differences their effect sizes were small. The logistic regression was unable to reliably classify patients based on their trunk lean patterns.

Discussion: The current study identified multiple trunk lean-related patterns, however, excessive trunk lean was not attributable to a distinctive CP related gait pathology or to a specific compensatory strategy. Overall, the results do not support the hypothesis that excessive trunk lean is part of a biomechanical mechanism. Therefore, it seems more likely that excessive lateral trunk lean is based on other disease specific dysfunctions, influenced by the severity of the disease.

Age-related changes in arm motion during typical gait

BACKGROUND

When toddlers learn to walk, they do so with a typical high guard position of the arms. As gait matures, children develop a reciprocal arm swing. So far, there have been no attempts to describe age-related changes of arm movements during walking after this first rapid development.

RESEARCH QUESTION

The purpose of this study was to investigate age-related changes in arm movement during typical gait.

METHODS

All participants (n = 102) received gait analysis using a full-body marker set (Plug-in Gait). Participants were divided into five age-groups: young children (G1: n = 20; 3.0-5.9y), children (G2: n = 24; 6.0-9.9y), pubertal children (G3: n = 26; 10.0-13.9y), adolescents (G4: n = 16; 14.0-18.9y) and adults (G5: n = 16; 19.0-35.2y). Age-related changes in arm movements were investigated by comparing continuous joint angular waveforms (spm1d) between all groups, as well as by comparing the mean joint angle and range of motion of the different joints between age-groups.

RESULTS

The overall shape of movement patterns was comparable across all age groups. Nevertheless, with advancing age, consistency increased. At the shoulder, G1&2 showed a larger mean extension angle compared to older children and adults. The range of shoulder axial rotation was significantly larger in adults compared to all other age groups. In the youngest groups (G1-G2), an increased mean elbow flexion and mean wrist extension angle was found.

SIGNIFICANCE

Determining an exact age of maturation of arm swing remains difficult as parameter specific adult-like values were not reached at the same age but should not be set before the age of ten to fourteen years for any parameter.

The influence of the use of ankle-foot orthoses on thorax, spine, and pelvis kinematics during walking in children with cerebral palsy

BACKGROUND

To improve gait function in children with cerebral palsy, ankle-foot orthoses are often prescribed. However, until now, little attention has been devoted to the effect of ankle-foot orthoses on the postural control during walking in children with cerebral palsy.

OBJECTIVES

The aim was to compare the differences in thorax, spine, and pelvis movements in children with cerebral palsy during walking barefoot and walking with ankle-foot orthoses.

STUDY DESIGN

Clinical study with an intra subject design.

METHODS

A total of 15 children (12 boys and 3 girls; mean age, 8 ± 2 years) with bilateral spastic cerebral palsy (12 with Gross Motor Function Classification System I and 3 with Gross Motor Function Classification System II) performed a full-body three-dimensional gait analysis. Differences in the range of motion of the thorax, spine, and pelvis during walking barefoot and walking with bilateral ankle-foot orthoses were analyzed (SPSS v20, paired-samples t-test).

RESULTS

Children with cerebral palsy showed a significantly larger range of motion of the thorax (flexion/extension, lateral bending, and rotation) and the spine (lateral bending) during walking with ankle-foot orthoses compared to walking barefoot. No significant differences were found in the range of motion of the pelvis between these two conditions.

CONCLUSION

It can be concluded that wearing ankle-foot orthoses influences the postural control during walking in children with bilateral spastic cerebral palsy. Due to the increased range of motions, the movement pattern of the trunk diverges from the typically developing children. Clinical relevance Wearing ankle-foot orthoses not only gives more stability at the pelvis and ankle joint but also influences trunk motion. In order of the level of core stability of the child, compensations can be either seen in the lower back or the upper trunk. Clinicians should be aware of these compensations and should evaluate postural control in a more detailed evaluation.

Upper extremity motion during gait in adolescents with structural leg length discrepancy-An exploratory study

BACKGROUND AND PURPOSE

Depending on the extent of a structural leg length discrepancy (LLD), several compensatory mechanisms take place in order to maintain function and to optimize energy consumption during gait. However, studies describing the influence of a structural LLD on upper limb motion are lacking. The current study therefore aimed at the evaluation of upper limb motion during gait in LLD patients compared to healthy controls.

METHODS

Motion capture data from 14 patients with structural LLD and 15 healthy controls that were collected during barefoot walking at a self-selected speed were retrospectively analyzed. Specifically, kinematic parameters of the shoulder and elbow joints as well as the trunk segment were investigated and considered in relation to a minimal clinically important difference of 5°.

RESULTS

The shoulders in LLD patients were kept constantly in a more extended and at initial contact in a more adducted position as compared to healthy controls. In addition, the patients' elbow joints showed increased flexion motion and the trunk segment indicated a constant trunk lateral-flexion and axial rotation tendency towards the affected side.

CONCLUSIONS

Patients with structural LLD indicated clinically relevant secondary deviations in shoulder and elbow motion. While some of these deviations were most likely passive physical effects, others might have occurred as active strategies to maintain balance or to regulate total body angular momentum. These findings contribute to the understanding of secondary gait deviations induced by a structural LLD and might serve as a basis for further investigations using complex musculoskeletal models.

Restricted Arm Swing Affects Gait Stability and Increased Walking Speed Alters Trunk Movements in Children with Cerebral Palsy

Observational research suggests that in children with cerebral palsy, the altered arm swing is linked to instability during walking. Therefore, the current study investigates whether children with cerebral palsy use their arms more than typically developing children, to enhance gait stability. Evidence also suggests an influence of walking speed on gait stability. Moreover, previous research highlighted a link between walking speed and arm swing. Hence, the experiment aimed to explore differences between typically developing children and children with cerebral palsy taking into account the combined influence of restricting arm swing and increasing walking speed on gait stability. Spatiotemporal gait characteristics, trunk movement parameters and margins of stability were obtained using three dimensional gait analysis to assess gait stability of 26 children with cerebral palsy and 24 typically developing children. Four walking conditions were evaluated: (i) free arm swing and preferred walking speed; (ii) restricted arm swing and preferred walking speed; (iii) free arm swing and high walking speed; and (iv) restricted arm swing and high walking speed. Double support time and trunk acceleration variability increased more when arm swing was restricted in children with bilateral cerebral palsy compared to typically developing children and children with unilateral cerebral palsy. Trunk sway velocity increased more when walking speed was increased in children with unilateral cerebral palsy compared to children with bilateral cerebral palsy and typically developing children and in children with bilateral cerebral palsy compared to typically developing children. Trunk sway velocity increased more when both arm swing was restricted and walking speed was increased in children with bilateral cerebral palsy compared to typically developing children. It is proposed that facilitating arm swing during gait rehabilitation can improve gait stability and decrease trunk movements in children with cerebral palsy. The current results thereby partly support the suggestion that facilitating arm swing in specific situations possibly enhances safety and reduces the risk of falling in children with cerebral palsy.