Toe walking in children with cerebral palsy: a possible functional role for the plantar flexors

Low multiscale entropy of ankle joint position during toe gait in children with cerebral palsy is related to contracture development

BACKGROUND

Toe walking in children with cerebral palsy is typically less stable and less energy-efficient than plantigrade walking in typically developing children. We hypothesized that children with cerebral palsy may, nevertheless, show more stable toe walking due to the development of contractures compared to age-matched typically developing children.

METHODS

Multiscale entropy of the vertical position of the ankle joint was used to measure ankle joint stability during the stance phase of walking. Kinematic data were obtained from 37 children with spastic cerebral palsy and habitual toe walking, who walked on a treadmill at their preferred speed (1.3 ± 0.5 km/h for cerebral palsy children and 1.5 ± 0.4 km/h for typically developing children). Recordings from 21 age-matched typically developing children were used for comparison. Typically developing children walked both normally (plantigrade) and on toes.

FINDINGS

Multiscale entropy was significantly higher during toe walking than plantigrade walking in typically developing children (P < 0.001). For children under 6 years, multiscale entropy was higher in cerebral palsy children than in typically developing children. For children over 6 years, the opposite was observed. In children with cerebral palsy, multiscale entropy decreased with reduced passive range of motion in the ankle joint (P < 0.001).

INTERPRETATION

These findings suggest that contractures in children with cerebral palsy stabilize the ankle during toe walking. Younger children may show greater stability due to early contracture development, while advanced contractures in older children may reduce stability.

Barefoot walking improves cognitive ability in adolescents

Walking can have a positive impact on cognitive function in adolescents. This study aimed to compare the effects of walking with sneakers and barefoot on cognitive ability in adolescents. Fifty-nine adolescent male students were included in the study and assigned to the control (n = 20), sneaker (n = 19), and barefoot (n = 20) groups. The barefoot and sneakers group performed a 40-min walking exercise four times a week for 12 weeks during the morning physical activity time, while the control group performed self-study. Electroencephalogram (EEG) and brain activity variables were measured before and after the exercise program. The results showed that after 12 weeks, the barefoot group had a significant decrease in Gamma and H-beta waves and a significant increase in sensorimotor rhythm (SMR) and Alpha waves. Conversely, the control group showed a significant decrease in SMR waves and increase in Theta waves. The sneaker group showed a significant decrease in SMR waves alone. In an eyes-open resting state, the barefoot group showed a significant increase in H-beta, M-beta, SMR, and Alpha waves. The barefoot group also had a significant increase in cognitive speed and concentration and a significant decrease in brain stress. Taken together, barefoot walking can effectively enhance cognitive ability in adolescents, as demonstrated by the significant variation in EEG activity. This research highlights the potential benefits of barefoot walking as a simple and effective form of exercise for enhancing cognitive function in adolescents.

Catatonia and Neuroleptic Malignant Syndrome in Patients With Cerebral Palsy: Two Case Reports and a Systematic Review of the Literature

BACKGROUND

Patients with cerebral palsy, a group of movement disorders with motor, communication, and behavioral features that can mimic catatonic signs, could benefit from efforts to improve the detection and treatment of comorbid catatonia. Given that cerebral palsy frequently co-occurs with conditions associated with catatonia, such as autism spectrum disorder, epilepsy, intellectual disability, and mood and psychotic disorders, lifetime prevalence of catatonia in this population may be high.

OBJECTIVE

This study aimed to systematically review the literature on catatonia and the related condition of neuroleptic malignant syndrome (NMS) in patients with cerebral palsy while presenting 2 additional cases of catatonia.

METHODS

We used the terms "cerebral palsy" in combination with "catatoni∗," related terms for catatonia, and "neuroleptic malignant syndrome" to query Ovid MEDLINE (1948 to November 28, 2022), PsycINFO, Cumulative Index to Nursing, and Allied Health Literature, and Embase for applicable case reports. The Neuroleptic Malignant Syndrome Information Service database was also manually searched.

RESULTS

In addition to our 2 catatonia reports, we identified 10 reports of catatonia in patients with cerebral palsy, as well as 8 reports of NMS. Patients with both conditions responded well, and sometimes rapidly, to treatment. Notably, of the 5 patients with catatonia and cerebral palsy who received electroconvulsive therapy, 2 developed recurrent self-limited hyperthermia posttreatment. We also identified several cases of baclofen withdrawal, which can be life threatening because of seizure risk, presenting with NMS-like features in patients with cerebral palsy who had malfunctioning intrathecal baclofen pumps for spasticity management.

CONCLUSIONS

Given frequent comorbidity of conditions associated with catatonia in patients with cerebral palsy, as well as routine treatment with medications that can induce NMS, such as metoclopramide and anticholinergics, catatonia and NMS may be underreported in the cerebral palsy patient population, despite being highly treatable. Possible underdiagnosis of catatonia in patients with cerebral palsy may be because of misattribution of overlapping features between the 2 conditions to cerebral palsy. Clinicians should be aware of possible recurrent self-limited fever when using electroconvulsive therapy to treat patients with catatonia and cerebral palsy while also being vigilant for intrathecal baclofen withdrawal when encountering NMS-like features in patients with cerebral palsy.