The lumbar spine in spastic diplegia. A radiographic study

Sagittal spinopelvic alignment in ambulatory persons with cerebral palsy

PURPOSE

This study aimed to describe the spinopelvic alignment of a cohort of young ambulatory individuals with cerebral palsy (CP) and compare it to published spinopelvic alignment data for the typically developing adolescents.

METHODS

Thirty-seven adolescents (18 females) with CP at GMFCS I-III were included in this retrospective case series. Lumbar lordosis and pelvic incidence were measured, and their mismatch was calculated. A model that calculates predicted lumbar lordosis based on pelvic incidence in normative data was utilized to calculate a predicted lumbar lordosis in this cohort with cerebral palsy.

RESULTS

At imaging, ages were mean and standard deviation 13.5 ± 3.0 years. Pelvic incidence was 46.2° ± 12.9°, pelvic tilt was 2.8° ± 9.4°, sacral slope was 43.6° ± 10.8°, and measured lumbar lordosis was 59.4° ± 11.6°. There were no differences in pelvic incidence or lumbar lordosis among the GMFCS levels; however, pelvic incidence was higher in females. Pelvic incidence-lumbar lordosis mismatch greater than 10° was found in 67% of the cohort. Mean predicted lumbar lordosis based on the model was 54.7° ± 8.5°, averaging 8° less than measured lordosis.

CONCLUSION

PI-LL mismatch was identified in 67% of this cohort of ambulatory adolescents with CP, in part due to greater lordosis than predicted by a model based on data from adolescents without CP. The implications of this finding, such as the correlation between sagittal spinopelvic alignment and quality of life in this population, should be assessed further in ambulatory patients with cerebral palsy.

LEVEL OF EVIDENCE

Level IV-retrospective cohort study and literature comparison.

Does patella lowering as part of multilevel surgery improve knee kinematics in children with cerebral palsy and crouch gait? A meta-analysis of comparative studies

Purpose

To evaluate differences in knee kinematic outcomes of patellar-lowering surgery, specifically patellar tendon advancement or patellar tendon shortening, compared with no-patellar-lowering surgery in multilevel surgery for children with cerebral palsy and crouch gait.

Methods

Four databases were searched to retrieve studies published from inception until 2023. Three reviewers independently screened for studies with observational or randomized control designs, comparing two groups of patients with cerebral palsy and crouch gait who underwent multilevel surgery (with patellar-lowering surgery versus no-patellar-lowering surgery), where various gait analysis outcomes were reported (CRD42023450692). The risk of bias was assessed with the Risk Of Bias In Non-randomised Studies - of Interventions (ROBINS-I) tool.

Results

Seven studies (249 patients and 368 limbs) met the eligibility criteria. Patients undergoing patellar-lowering surgery demonstrated statistically significant improvements in knee flexion at initial contact (mean difference = -6.39; 95% confidence interval = [-10.4, -2.75]; p = 0.0006; I2 = 84%), minimum knee flexion in stance (mean difference = -14.27; 95% confidence interval = [-18.31, -10.23]; p < 0.00001; I2 = 89%), and clinical knee flexion contracture (mean difference = -5.6; 95% confidence interval = [-9.59, -1.6]; p = 0.006; I2 = 95%), with a significant increase in anterior pelvic tilt (mean difference = 2.97; 95% confidence interval = [0.58, 5.36]; p = 0.01; I2 = 15%). However, improvements in gait deviation index and decrease in peak knee flexion in swing did not reach statistical significance. Subgroup analysis reduced heterogeneity and revealed (1) greater improvement using patellar tendon shortening versus patellar tendon advancement techniques; (2) lack of knee flexion contracture improvement in high-quality or longer-term studies; (3) longer-term improvement only in minimum knee flexion in stance, with a decrease in peak knee flexion in swing; and (4) an inability to assess the potential benefit of rectus femoris procedure and hamstring preservation.

Conclusions

Overall, the combination of patellar-lowering surgery with multilevel surgery demonstrated superior improvements in stance-phase knee kinematics compared with multilevel surgery alone, despite an increase in anterior pelvic tilt and a longer-term knee flexion reduction during the swing phase.

Level of evidence

Level III, Systematic review of level III studies.

A systematic review of complications following selective dorsal rhizotomy in cerebral palsy

PURPOSE

The literature lacks a concise overview of complications secondary to selective dorsal rhizotomy (SDR). The aim of this study was to systematically review the literature regarding post-SDR complications, and to present them concisely.

METHODS

The protocol of the review was registered on Open Science Framework. Studies on SDR in cerebral palsy were included. The studies to be included used SDR for management of spasticity in patients with cerebral palsy. The long-term complications of SDR mentioned in the articles were inventoried.

RESULTS

Thirty studies were included for qualitative review. Twenty-one types of complication were identified. Structural complications were the commonest: scoliosis (214/1,043, 20.5%), hyperlordosis (101/552, 18.2%), spondylolysis (55/574, 9.5%) and kyphosis (67/797, 8.4%). Neurological complications comprised constipation (70/485, 14.4%), hip subluxation (3/29, 10.3%), spastic syndrome (4/47, 8.5%), sensory changes (106/1290, 8.2%) and urinary incontinence (61/1013, 6%).

CONCLUSION

This review should help surgeons and parents alike to know about the potential complications of SDR. Complications may affect quality of life and should be weighed. Although the majority of these complications were managed conservatively, there would still be a physical, psychological and financial burden which should be taken into account. Screening should be continued vigorously throughout skeletal growth and at reduced frequency thereafter, for timely intervention in case of structural complications.

The relationship of trunk kinematics and kinetics with lower limb pathology during gait in children with spastic cerebral palsy

BACKGROUND

Trunk control during gait in children with cerebral palsy (CP) is known to be impaired. While differentiation of trunk movement between CP subtypes (unilateral/bilateral) has been examined, differentiation of lower lumbar spinal loading has not been considered. Furthermore, the relationship between lower lumbar loading and lower limb pathology has not been reported.

RESEARCH QUESTION

How do lower lumbar spinal kinetics differ during unilateral and bilateral CP gait and what is the relationship between trunk kinematics and L5/S1 kinetics with lower limb pathology?

METHODS

Three-dimensional thorax kinematics and L5/S1 kinetics were measured during gait with children divided into 3 groups (unilateral CP (n = 21), bilateral CP (n = 31) and typical development (TD) (n = 26)). Differences in thorax kinematics and reactive forces and moments at L5/S1 between groups were analysed using Statistical Parametric Mapping. Correlation coefficients were calculated between Gait Profile Score (GPS) and kinematic measures of the thorax and kinetics at L5/S1.

RESULTS

An increased ipsilateral bending moment was present for unilateral CP in the coronal plane (55-70% Gait Cycle (GC), p < 0.001), while children with bilateral CP demonstrated two distinct increased peaks during mid-stance (10-30 % GC, p < 0.001) and mid-swing (60-80% GC, p = 0.004) compared to TD. RMS and RoM thorax flexion, side flexion and L5/S1 lateral bend moment demonstrated significant moderate correlations with GPS.

SIGNIFICANCE

This study confirmed an increased involvement at the trunk and of lower lumbar spinal loading for children with bilateral CP compared to unilateral CP. It has been suggested that altered trunk movement in CP gait may be a combination of both a compensation for lower limb pathology and an underlying deficit. Our result of positive yet moderate correlations between GPS and trunk movement and lower spinal loading support this theory.

A long-term follow-up study of spinal abnormalities and pain in adults with cerebral palsy and spastic diplegia more than 25 years after selective dorsal rhizotomy

OBJECTIVE

The main purpose of selective dorsal rhizotomy (SDR) is to reduce spasticity in the lower extremities of children diagnosed with cerebral palsy (CP) and spastic diplegia. The potential for developing spinal abnormalities and pain is a concern, especially in the aging CP population. Therefore, the aim of this study was to evaluate spinal abnormalities, level of pain, and disability (due to back or leg pain) in adults with CP, and associations with participant characteristics, more than 25 years after SDR.

METHODS

This is a 9-year follow-up study with data collection conducted in 2008 and 2017. Radiographs were assessed for the degree of scoliosis, thoracic kyphosis and lumbar lordosis curvatures, and prevalence of spondylolysis and spondylolisthesis, while level of pain and disability was determined with a self-developed questionnaire and the Oswestry Disability Index (ODI) questionnaire, respectively.

RESULTS

Twenty-five participants were included (15 males; median age 35.9 years, IQR 34.3-41.5 years), with a follow-up time after SDR ranging from 25 to 35 years. No clinically relevant changes were found for spinal curvatures, spondylolysis and spondylolisthesis, perceived pain frequency, and ODI scores between 2008 and 2017. While the prevalence of spondylolysis was 44%, spondylolisthesis was found in 20% (of whom 15% were grade I and 5% grade II), lumbar hyperlordosis was found in 32%, thoracic hyperkyphosis in 4%, and scoliosis in 20%. The Cobb angle was < 25°, and no patient required surgery for scoliosis. In addition, the low back was reported as the most common site of pain, with 28% of the adults with CP having daily pain. This resulted in 80% of the cohort indicating none or minimal disability due to pain based on the ODI. The only correlation found was between hyperkyphosis and female gender.

CONCLUSIONS

At follow-up more than 25 years after SDR, no progression in spinal abnormalities, level of pain, and disability was found when compared with findings 15 years after SDR. The prevalence of scoliosis, thoracic hyperkyphosis, and lumbar hyperlordosis was within the range reported for adults with CP, while spondylolysis and spondylolisthesis occurred more often than would be expected. It is difficult, however, to establish the role of SDR in this finding, given the limited data on the natural history of CP. Despite the encouraging outcome of this long-term follow-up study after SDR, it is important to continue monitoring adults with CP during the aging process.

The progress in the treatment of spastic cerebral palsy with selective dorsal rhizotomy (SDR)

Spasticity is the main disabling clinical manifestation of children with cerebral palsy (CP). Selective dorsal rhizotomy (SDR) has been performed for the treatment of spastic CP in Asia for quite some time from 1990. The purpose of this review is to discuss the historical origin and development of SDR. Our goal here is to identify the current patient selection criteria for SDR and to point out indications and contraindications based on the patients with CP, age from 2 to 18 years-old, over 6000 cases, who received SDR surgery with spasticity of muscle tension more than 3 degrees in our center. We also discuss evidence-based approaches on how to evaluate postoperative patient outcomes of SDR and how complications can be avoided. Finally, we mention progress made in terms of SDR technical advances and how improvements can be made in the future. In conclusion, SDR surgery is a reliable way to improve outcomes of patients with spastic CP and can be done carefully in patients as long as stringent selection criteria are used. However, more research and technological advancements are needed to help address associated complications.

Cerebral palsy - beyond hip deformities

Cerebral palsy is a neurologic condition with myriad musculoskeletal and articular manifestations. While every patient is unique with innumerable variations in presentation, symptoms and treatments, there are broad themes and recognizable patterns of development. Many of these findings spill over to other neurodevelopmental disorders, and lessons learned from children with cerebral palsy translate well to multiple neurologic conditions. This review focuses on the more common manifestations involving the spine, knee, foot and ankle, with an emphasis on collecting and describing imaging features, along with clinical and radiologic pearls and pitfalls.

Association of back pain and pelvic tilt during gait in individuals with cerebral palsy

BACKGROUND

Back pain prevalence may increase with lumbar lordosis during standing in individuals with cerebral palsy (CP). Multiple interventions undertaken in individuals with CP have been shown to increase anterior pelvic tilt.

RESEARCH QUESTION

Are pelvic tilt and trunk tilt (proxy measurements for lumbar lordosis) during gait associated with back pain prevalence in ambulatory individuals with CP?

METHODS

A retrospective investigation was performed among all patients with cerebral palsy visiting a single clinical motion analysis laboratory over a 3.5 year period (January 2015 - May 2018) who also had complete pain questionnaire data. Back pain prevalence and its association with sagittal plane kinematic parameters (pelvic tilt and trunk tilt) were analyzed.

RESULTS

Among the 700 patients that met the inclusion criteria, 594 were children and 106 were adults. Back pain prevalence was 11.1% in children and 36.8% in adults. As pelvic tilt and age increased, back pain increased (odds ratio 95% confidence interval: 1.002-1.061 and 1.052-1.109, respectively). Walking with an assistive device was not associated with back pain, nor was trunk tilt.

SIGNIFICANCE

Back pain was more common with increasing age in ambulatory individuals with CP. After controlling for assistive device use and age, there was a weak relationship between pelvic tilt and back pain. Future studies are needed to determine if this is this a causal relationship.

The increase of anterior pelvic tilt after crouch gait treatment in patients with cerebral palsy

BACKGROUND

The increase of anterior pelvic tilt (APT) has been described after the treatment of crouch gait in cerebral palsy (CP). The ideal treatment option for flexed knee gait in CP should provide knee extension improvement in the stance phase without generating the increase of APT.

RESEARCH QUESTION

The purpose of this study was to compare three different approaches used for the treatment of crouch gait in CP [distal femur extension osteotomy (DFEO), patellar tendon shortening (PTS) and the combination of DFEO +PTS] regarding the increase of APT after the interventions.

METHODS

The inclusion criteria were: (1) diagnosis of spastic diplegic CP, (2) GMFCS levels I-III, (3) patients who underwent DFEO and/or PTS and (4) with complete documentation in the gait laboratory before and after the intervention. The included patients were divided into 3 groups, according to the procedures performed for crouch gait treatment: PTS (19 patients), DFEO (54 patients) and PTS + DFEO (22 patients).

RESULTS

During stance phase, knee flexion decreased from 41.6⁰ to 13.6⁰ in the PTS group (p < 0.001), from 46.0⁰ to 30.7⁰ in the DFEO group (p < 0.001) and from 52.3⁰ to 29.5⁰ in the PTS + DFEO group (p < 0.001). APT increased 14⁰ (p < 0.001) in the PTS group, 7.1° (p < 0.001) in the DFEO group and 6.6⁰ (p < 0.001) in the PTS + DFEO group after surgical intervention. The PTS group presented a more significant deterioration of pelvic tilt than the DFEO (p = 0.002) and PTS + DFEO (p = 0.001) groups. The increase of APT was higher when HSL was also performed in the PTS + DFEO group (p = 0.016).

SIGNIFICANCE

The increase of APT was observed in all studied groups, but it was more significant for those who underwent a PTS. The inclusion of HSL in the surgical plan was related a higher increase of APT in the PTS + DFEO group.

Pathological Movements of the Pelvis and Trunk During Gait in Children With Cerebral Palsy: A Cross-Sectional Study With 3-Dimensional Kinematics and Lower Lumbar Spinal Loading

BACKGROUND

Increased loading at the lumbar spine, particularly in the coronal plane, has been reported in children with cerebral palsy (CP). As pelvic and trunk movements associated with Trendelenburg and Duchenne type gait are most significant in the coronal plane, the potential exists for lower lumbar spinal loading to be negatively affected in children with CP and these types of movement patterns.

OBJECTIVE

The objective of this study was to assess trunk and pelvic kinematics and lower lumbar spinal loading patterns in children with CP and Trendelenburg and Duchenne type gait.

DESIGN

This was a cross-sectional study.

METHODS

Three-dimensional kinematic (lower limb and thorax) and L5-S1 kinetic data were recorded. Children were divided according to clinical presentation of Trendelenburg or Duchenne type gait. Several discrete kinematic and kinetic parameters were assessed between groups.

RESULTS

Three distinct pelvic and trunk movement patterns were identified for children with CP: Trendelenburg, Duchenne, and complex Trendelenburg-Duchenne. Peak L5-S1 lateral bending moments were increased by 62% in children with CP and Duchenne type gait. Children with CP and complex Trendelenburg-Duchenne gait demonstrated the largest deviations from normal, with increased peak ipsilateral and contralateral directed moments of 69% and 54%, respectively, compared with children with typical development.

LIMITATIONS

A test-retest reliability analysis or measure of minimal detectable change was not conducted as part of this study. Results suggest that measures of minimal detectable change may be high for some of the reported variables. In addition, the inverse dynamic approach determines only the net intersegmental reactive forces that reflect the effect of external loads. Previous studies have shown that spinal loads may be larger than the net intersegmental force.

CONCLUSIONS

Trendelenburg and Duchenne type movements were not always distinct, and a third type of movement, a combination of the two, was the most common in this study. Clinicians should be aware that children with CP and the Duchenne type or the complex Trendelenburg-Duchenne type of gait pattern experience abnormal loading that may have significant implications for the lower spine in the long term.

Predictors for anterior pelvic tilt following surgical correction of flexed knee gait including patellar tendon shortening in children with cerebral palsy

INTRODUCTION

Patellar tendon shortening procedure within single event multilevel surgeries was shown to improve crouch gait in Cerebral Palsy (CP) patients. However, one of the drawbacks associated to the correction of flexed knee gait may be increased pelvic anterior tilt with compensatory lumbar lordosis.

RESEARCH QUESTION

Which CP patients are at risk for excessive anterior pelvic tilt following correction of flexed knee gait including patellar tendon shortening?

METHODS

32 patients with CP between 8 and 18 years GMFCS I&II were included. They received patellar tendon shortenings within multilevel surgery. Patients with concomitant knee flexor lengthening were excluded. Gait analysis and clinical testing was performed pre- and 24.1 (SD=1.9) months postoperatively. Patients were subdivided into more/less than 5° increase in anterior pelvic tilt. Preoperative measures indicating m. rectus and m. psoas shortness, knee flexor over-length, hip extensor and abdominal muscle weakness and equinus gait were compared between groups. Stepwise multilinear regression of the response value increase in pelvic tilt during stance phase was performed from parameters that were significantly different between groups.

RESULTS

34% of patients showed more than 5° increased pelvic anterior tilt postoperatively. Best predictors for anterior pelvic tilt from preoperative measures were increased m. rectus tone and reduced hip extension during walking that explained together 39% of the variance in increase of anterior pelvic tilt.

DISCUSSION

Every third patient showed considerable increased pelvic tilt following surgery of flexed knee gait. In particular patients with preoperative higher muscle tone in m. rectus and lower hip extension during walking were at risk and both features need to be addressed in the therapy.

Position Between Trunk and Pelvis During Gait Depending on the Gross Motor Function Classification System

PURPOSE

To understand whether there is a trunk postural control threshold in the sagittal plane for the transition between the Gross Motor Function Classification System (GMFCS) levels measured with 3-dimensional gait analysis.

METHOD

Kinematics from 97 children with spastic bilateral cerebral palsy from spine angles according to Plug-In Gait model (Vicon) were plotted relative to their GMFCS level.

RESULTS

Only average and minimum values of the lumbar spine segment correlated with GMFCS levels. Maximal values at loading response correlated independently with age at all functional levels. Average and minimum values were significant when analyzing age in combination with GMFCS level.

CONCLUSION

There are specific postural control patterns in the average and minimum values for the position between trunk and pelvis in the sagittal plane during gait, for the transition among GMFCS I-III levels. Higher classifications of gross motor skills correlate with more extended spine angles.

Three-dimensional lumbar segment movement characteristics during paediatric cerebral palsy gait

Kinematic analysis of the trunk during cerebral palsy (CP) gait has been well described. In contrast, movement of the lumbar spine is generally ignored. This is most likely due to the complex nature of the spine. As an alternative to using complex sensor protocols, this study modelled the lumbar region as a single segment and investigated characteristic patterns of movement during CP gait. In addition, the impact of functional level of impairment and the relationship with lower lumbar spinal loading were examined. Fifty-two children with CP (26 GMFCS I and 26 GMFCS II) and 26 controls were recruited. A full barefoot 3-dimensional kinematic and kinetic analysis were conducted. Lumbar segment movement demonstrated increased forward flexion for CP children. This movement became more pronounced according to GMFCS level with GMFCS II children demonstrating increases of up to 8°. In addition, a moderate correlation was present between lumbar flexion/extension and L5/S1 sagittal moments (r=0.427 in the global frame and r=0.448 with respect to the pelvis, p<0.01). Children with CP demonstrated increased movement of the lumbar region compared to TD, with movement becoming more excessive as GMFCS level increased. Excessive forward flexion and loading at the lumbar spine were linked. However, the moderate correlation suggests other contributors to increased loading were present. In conclusion, this study is a first step at identifying how lumbar segment movement is altered during CP gait.

"Children with cerebral palsy experience greater levels of loading at the low back during gait compared to healthy controls"

Excessive trunk motion has been shown to be characteristic of cerebral palsy (CP) gait. However, the associated demands on the lower spine are unknown. This study investigated 3-dimensional reactive forces and moments at the low back in CP children compared to healthy controls. In addition, the impact of functional level of impairment was investigated (GMFCS levels). Fifty-two children with CP (26 GMFCS I and 26 GMFCS II) and 26 controls were recruited to the study. Three-dimensional thorax kinematics and reactive forces and moments at the low back (L5/S1 spine) were examined. Discrete kinematic and kinetic parameters were assessed between groups. Thorax movement demonstrated increased range for CP children in all 3 planes while L5/S1 reactive forces and moments increased with increasing level of functional impairment. Peak reactive force data were increased by up to 57% for GMFCS I and 63% for GMFCS II children compared to controls. Peak moment data were increased by up to 21% for GMFCS II children compared to GMFCS I and up to 90% for GMFCS II compared to control. In addition, a strong correlation was demonstrated between thorax side flexion and L5/S1 lateral bend moment (r=0.519, p<0.01) and medial/lateral force (r=0.352, p<0.01). Children with CP demonstrated increased lower spinal loading compared to TD. Furthermore, GMFCS II children demonstrated significantly more involvement. Intervention should be aimed at reducing excessive thorax movement, especially in the coronal plane, in order to reduce abnormal loading on the spine in this population.

Three-dimensional head and trunk movement characteristics during gait in children with spastic diplegia

This study uses a recently developed trunk model to determine which head and trunk kinematic parameters differentiate children with spastic diplegia from typically developing (TD) children while walking. Differences in head and trunk parameters in relation to the severity of the motor involvement (GMFCS levels) were additionally examined. The trunk model consisted of five segments (pelvis, thorax, head, shoulder line, spine). Discrete kinematic parameters (ROM, mean position) and angular waveforms were compared between 20 children with spastic diplegia (age 9.8 years±2.9 years; GMFCS I: n=10, GMFCS II: n=10) and 20 individually age-matched TD children (9.7 years±3 years). A new measure for overall trunk pathology, the trunk profile score (TPS), was proposed and included in the comparative analysis. Compared to TD children, children with GMFCS II showed a significantly higher TPS and increased ROM for pelvis tilt, for thorax and head in nearly all planes, and the angle of kyphosis. In children with GMFCS I, only ROM of thorax lateral bending was significantly increased. Sagittal ROM differentiated best between GMFCS levels, with higher ROM found in children with GMFCS II. Current results provide new insights into head and trunk kinematics during gait in children with spastic diplegia.

Reliability and validity of the AutoCAD software method in lumbar lordosis measurement

OBJECTIVE

The aim of this study was to determine the reliability and validity of the AutoCAD software method in lumbar lordosis measurement.

METHODS

Fifty healthy volunteers with a mean age of 23 ± 1.80 years were enrolled. A lumbar lateral radiograph was taken on all participants, and the lordosis was measured according to the Cobb method. Afterward, the lumbar lordosis degree was measured via AutoCAD software and flexible ruler methods. The current study is accomplished in 2 parts: intratester and intertester evaluations of reliability as well as the validity of the flexible ruler and software methods.

RESULTS

Based on the intraclass correlation coefficient, AutoCAD's reliability and validity in measuring lumbar lordosis were 0.984 and 0.962, respectively.

CONCLUSIONS

AutoCAD showed to be a reliable and valid method to measure lordosis. It is suggested that this method may replace those that are costly and involve health risks, such as radiography, in evaluating lumbar lordosis.

Reliability of head and trunk kinematics during gait in children with spastic diplegia

This study describes the reliability of a clinically oriented model for three-dimensional movement analysis of head and trunk movements in children with spastic diplegia. The model consists of five rigid segments (head, thorax, pelvis, shoulder line, spine) and includes a detailed analysis of spinal segmental movements. Within and between session reliability during gait was tested in 10 children with spastic diplegia (6-14yrs). Reliability of discrete parameters was assessed with the intraclass correlation coefficient (ICC) and similarity of thorax and pelvis waveforms with the coefficient of multiple correlation (CMC). Measurement errors were calculated for all parameters (SEM, σ). Results indicated acceptable within and between session reliability of discrete parameters for thorax, pelvis, shoulder line, angle of kyphosis and the majority of the spinal segmental angles, reflected by low SEMs (<4°) and most ICCs>0.60. Within and between session waveform errors were below 4°. CMCs ranged from poor to very good, with highest values for movements in the frontal and transversal planes. The angle of lordosis showed lower between session reliability for several discrete parameters, although waveform errors were still below 5°. Head parameters showed lower overall reliability. The results of this study support the reliability of the proposed model. Head kinematic parameters should be interpreted with caution, due to difficulties in standardization. Accurate palpation of the spinal markers, especially the lumbar spine, is critical and demands thorough training of the assessor.

Walking deterioration and gait analysis in adults with spastic bilateral cerebral palsy

Walking deterioration occurs frequently in adults with spastic bilateral cerebral palsy (CP), but their gait characteristics are largely unknown. The study aims were (1) to compare selected gait analysis variables between those reporting and those not reporting walking deterioration, and (2) to characterise the overall gait deviations and classify the gait patterns. Participants (N=16) were recruited from a follow-up study, had spastic bilateral CP, <40 years in 2006, GMFCS levels I-III, and could walk at least 10 m without support. Eight reported walking deterioration (cases) and eight did not (controls). A theoretical framework linking work of walking, fatigue and deterioration in walking was developed. It was hypothesised that higher energy requirements during gait and larger gait deviations would be associated with deterioration in walking. Three-dimensional gait analysis was used to obtain centre of mass work, mechanical joint work, lower limb kinematics, movement analysis profile (MAP), and gait profile scores (GPS). There were no differences between the cases and controls in centre of mass work, joint work, or in the GPS. The largest MAP deviations were seen in sagittal pelvis, hip, and knee angles and foot progression. Crouch and asymmetric gait were common patterns. Walking deterioration could not be explained by these work and kinematic variables. An individual's perception of deterioration in walking is subjective, and may be experienced and interpreted differently across people. Larger, longitudinal studies on the natural history of walking in spastic CP are needed. Qualitative studies on the subjective experiences of walking deterioration are also warranted.

Kinematic and electromyographic studies on unaided, unilateral and bilateral crutch walking in adolescents with spastic diplegia

BACKGROUND

Back pain and ambulation deterioration among ambulatory individuals with cerebral palsy (CP) are common as they grow older and walking aids are often prescribed to improve stability and promote maximal weight-bear on lower limbs during gait.

OBJECTIVE

To investigate the effects of walking aids on back muscle activity and whole body kinematics among adolescents with spastic diplegia.

STUDY DESIGN

A repeated-measures design was adopted with participants tested under different walking conditions.

METHODS

Ten participants were recruited and Lofstrand forearm crutches were selected. Both the activity of lumbar erector spinae and the kinematics of head, trunk, pelvis and lower limbs during walking were monitored using telemetric electromyography and motion analysis system respectively.

RESULTS

Comparisons between walking unaided and walking with unilateral and bilateral crutch(es) were made. Significant decreases in speed, cadence, erector spinae activity and lower trunk extension were observed during crutch walking together with significantly increased stride time and anterior pelvic tilt.

CONCLUSIONS

These findings suggested that Lofstrand crutch(es) reduced muscular demands and lumbar lordosis with increased lower back mobility. The results shed light on the prescription of walking aid in the management and prevention of chronic back pain for ambulatory individuals with CP from a life span perspective.

Effect of load carriage on chronic low back pain in adults with cerebral palsy

BACKGROUND

Chronic low back pain (LBP) is a common secondary musculoskeletal problem among adults with cerebral palsy (CP). This study investigated the feasibility of incorporating backpack carriage with daily production activities for relieving chronic LBP among adults with CP.

OBJECTIVES

The effects of backpack carriage in relieving chronic LBP for adults with CP.

STUDY DESIGN

A multiple bivariate approach with convenience sampling.

METHODS

Nine adults with CP suffering from chronic LBP were scheduled to carry a 4 lb backpack at work for 60 minutes on weekdays for four consecutive weeks. The pain level was rated by the participants on an 11-point scale. Muscle activity of erector spinae was measured by surface electromyography.

RESULTS

Significant improvement in back pain was found immediately after the backpack carriage with no adverse effect reported. It was accompanied with significantly reduced erector spinae activity. Although the overall change in pain ratings across the study period was not significant, a decreasing trend with time was observed.

CONCLUSIONS

The loaded backpack has the potential to serve as an 'orthosis' for immediate back pain relief among adults with CP. Its underlying mechanism can be attributed to a reduction in back muscle tension during the load carriage.

Validity of gait parameters for hip flexor contracture in patients with cerebral palsy

BACKGROUND

Psoas contracture is known to cause abnormal hip motion in patients with cerebral palsy. The authors investigated the clinical relevance of hip kinematic and kinetic parameters, and 3D modeled psoas length in terms of discriminant validity, convergent validity, and responsiveness.

METHODS

Twenty-four patients with cerebral palsy (mean age 6.9 years) and 28 normal children (mean age 7.6 years) were included. Kinematic and kinetic data were obtained by three dimensional gait analysis, and psoas lengths were determined using a musculoskeletal modeling technique. Validity of the hip parameters were evaluated.

RESULTS

In discriminant validity, maximum psoas length (effect size r = 0.740), maximum pelvic tilt (0.710), maximum hip flexion in late swing (0.728), maximum hip extension in stance (0.743), and hip flexor index (0.792) showed favorable discriminant ability between the normal controls and the patients. In convergent validity, maximum psoas length was not significantly correlated with maximum hip extension in stance in control group whereas it was correlated with maximum hip extension in stance (r = -0.933, p < 0.001) in the patients group. In responsiveness, maximum pelvic tilt (p = 0.008), maximum hip extension in stance (p = 0.001), maximum psoas length (p < 0.001), and hip flexor index (p < 0.001) showed significant improvement post-operatively.

CONCLUSIONS

Maximum pelvic tilt, maximum psoas length, hip flexor index, and maximum hip extension in stance were found to be clinically relevant parameters in evaluating hip flexor contracture.

The adult with cerebral palsy

Advances in medical and surgical care over the past 20 years have resulted in children who formerly would have died at birth or infancy now surviving well into adulthood, many with permanent physical disabilities, including those caused by cerebral palsy. Inadequate medical and surgical diagnoses and intervention are prevalent in the adult cerebral palsy population. Decreased physical activity and participation in physical therapy and fitness programs, along with loss of strength, contractures, and pain are common factors in the loss of functional weight bearing, self-care, and daily performance over time. Increased awareness of these problems is needed by adult health care providers who provide care to these individuals and also by pediatric providers who may be able to intervene and prevent some of the long-term problems. Early identification and intervention in the child and younger adult remain the ideal in the pursuit of optimal musculoskeletal function and lifestyle throughout the adult years.

Incidence and etiology of lumbar spondylolysis: review of the literature

BACKGROUND

Lumbar spondylolysis is a defect of the pars interarticularis known to occur as a stress fracture. Its incidence varies considerably depending on ethnicity, sex, and sports activity. However, there are few literature reviews describing its incidence in different ethnic groups or in people who engage in different sports.

METHODS

We reviewed the most relevant articles on spondylolysis published in scientific journals. First, we focused on its incidence in various ethnic groups distributed by sex, the familial occurrence, and in patients with relevant diseases. Second, we focused on the incidence of spondylolysis in relation to the sports practiced by the patients. Although placing special emphasis on the incidence of lumbar spondylolysis in the general population in Japan, we also reviewed the Japanese and English literature to investigate its incidence among those who engage in different sports.

RESULTS

The incidence of lumbar spondylolysis in the general Japanese population was 5.9%. Most studies report that the incidence in higher in male subjects than in female subjects. We found that Japanese rugby and judo players were prone to suffer lumbar spondylolysis, at an incidence of about 20%. However, the incidence for Japanese professional soccer and baseball players was much higher, at 30%, which was more than five times the incidence in the general Japanese population.

CONCLUSIONS

The incidence of lumbar spondylolysis varies depending on ethnicity, sex, family history, relevant disease, and sports activity.

Incidence of spinal abnormalities in patients with spastic diplegia 17 to 26 years after selective dorsal rhizotomy

INTRODUCTION

The aim of this study was to evaluate the mechanical status of the spine in patients with spastic diplegia 17-26 years after selective dorsal rhizotomy (SDR).

METHODS

We compared original radiographic reports from our earlier short-term follow-up study with current X-rays. In addition, we obtained magnetic resonance images (MRI) of the spine and additional information regarding back pain and clinical assessments.

RESULTS

Thirty patients (17 males and 13 females; median age 26.8 years) participated in the current study, with median follow-up times of 4.0 and 21.4 years. Comparison of the X-ray results showed respectively: scoliosis 0% and 57%; kyphosis 0% and 7%; lordosis 21% and 40%; spondylolysis 18% and 37%; and spondylolisthesis grade I occurred in one patient. The only statistically significant difference was found for scoliosis (p < 0.01). The majority had Cobb angles <30 degrees with only two patients with curves of 35 degrees. MRI scans showed spinal stenosis in 27%, black discs in 10%, and disc protrusion in 3%. Daily back pain was reported in 17%, while 23% reported "moderate disability" as a result of back and leg pain. No patient to date has required any surgical intervention on the spine.

CONCLUSIONS

Except for spondylolisthesis, spinal deformities did appear to progress with time. However, this increase was not marked, and the development of relatively mild scoliosis was the only statistically significant increase. This group of patients requires continued follow-up. Further studies are required to ascertain the natural history of spinal deformity in adults with spastic diplegia who have not had SDR.

Cerebral palsy lifetime care - four musculoskeletal conditions

Cerebral palsy (CP) has always been considered a static condition in the neurological sense. Secondary and associated conditions that occur in the patient with CPcan progress over time and cause unwanted sequelae. This paper discusses four musculoskeletal conditions that present across the lifetime and can lead to progressive loss of function in the patient with CP. Patella alta can be particularly painful in the early adult years, limiting mobility particularly when associated with crouch gait. Adults with lower-extremity weight-bearing status having hip dysplasia, progressive over time, often develop pain and severe degenerative arthritis, with or without arthrodesis. Spondylolysis, particularly at the L5 S1 level, is fairly common in the ambulatory adult with diplegia and may, if not diagnosed early, progress to spondylolisthesis. Cervical stenosis appears to be more prevalent in adults with spastic quadriparesis and dystonia and is often associated with myelomalacia and/or radiculopathy. All four of these conditions may be lessened, or even prevented, with intervention and diagnosis in the younger years. Possible interventions and outcomes over time are discussed in the context of multidisciplinary team management of the individual with CP.

La douleur chez le sujet adulte infirme moteur cérébral

INTRODUCTION

Pain is the main problem in patients with cerebral palsy. To improve the quality of life of people with cerebral palsy, a good knowledge of the clinical syndrome is necessary.

METHOD

We reviewed the published data of the APIB study. We analysed data about pain, especially its correlation with age, motor handicap, and depressive syndrome. We also reviewed the literature to survey the pain syndrome in such a situation.

RESULTS

A total of 562 patients responded to the APIB survey (mean age 36+/-14 years). Of these, 75% complained about physical pain. Pain was significantly associated with age, motor handicap, depressive syndrome, and sleep disorders.

DISCUSSION

A study of the literature confirms our results on pain in cerebral palsy from the APIB survey. The main localisations of pain are the spine, and scapular and pelvic girdles. Pain syndromes of the upper and lower limbs are also frequent, with much due to overuse. Some rare causes include heterotopic ossifications.

CONCLUSION

A good knowledge of the characteristics of the pain syndromes in people with cerebral palsy is important because of the great prevalence of this problem in this population. Better knowledge will help prevent the pain and improve quality of life.

Selective dorsal rhizotomy for spastic cerebral palsy: a review

OBJECTIVE

The purpose of this report is to review the historical development, current operative techniques, selection criteria, outcomes, and complications of selective dorsal rhizotomy (SDR) for treatment of spastic cerebral palsy (CP).

MATERIALS AND METHODS

This review is based on a review of literature and personal observations.

RESULTS

SDR has evolved from the 1960s onwards into a standard neurosurgical procedure for spastic CP. There is much variation in the operative technique among surgeons with respect to the level of exposure, electrophysiological guidance, and extent of rhizotomies. Appropriate selection of patients for SDR requires determination that spasticity, not dystonia, is the major disabling hypertonia and that the lower limbs are maximally involved. Positive outcomes have been well demonstrated in the impairment, functional limitations, and disability dimensions, as per the National Center for Medical Rehabilitation Research Model of Dimensions of the Disabling Process. Complications have been relatively few.

CONCLUSIONS

SDR is the procedure of choice for treatment of spasticity in spastic diplegic CP and in selected children with spastic quadriplegic CP. Optimal selection and outcomes are achieved using a multidisciplinary approach.

Spinal deformities following selective dorsal rhizotomy

OBJECT

Selective dorsal rhizotomy (SDR) has been shown to provide considerable benefit to children with spastic cerebral palsy (CP). The authors sought to evaluate the risks of postoperative spinal deformities in patients following SDR.

METHODS

All patients who underwent SDR at McGill University between 1991 and 2001 were identified. Hospital charts and radiographic spinal studies (both preoperative and the latest postoperative) were systematically reviewed. Univariate and multivariate regression analyses were conducted to test all independent variables of potential interest to determine risk factors more likely to be associated with spinal deformity. There were 98 patients whose mean age at surgery was 5.1 years; the mean radiographic follow-up duration was 5.8 years. Thirty-nine (44.8%) of 87 patients in whom postoperative weight-bearing radiographs were obtained had mild scoliosis, and 17 in whom standing radiographs were acquired had hyperlordosis. In all, 18 of 94 patients (19.1%) who had postoperative radiographs on which the lumbosacral junction was visible were found to have spondylolisthesis. Regression analysis identified the severity of preoperative CP as an important predictor, and less ambulatory patients were more likely to have scoliotic curves. Younger age at surgery and male sex were factors associated with a lower rate of hyperlordosis. Spondylolisthesis developed only in ambulatory children. None of the patients experienced clinically significant deficits.

CONCLUSIONS

There was a high rate of radiologically documented deformities in patients with CP who underwent SDR. Ambulatory function, CP severity, age at surgery, and sex may be contributing factors.

Evaluating upper body movements during gait in healthy children and children with diplegic cerebral palsy

Movements of the lower limbs during gait have been analysed extensively whereas data on upper body movements are scarce. The aim of this study was to evaluate upper body movements during gait in nine healthy children and 10 children with diplegic cerebral palsy. Children were investigated using a full-body marker set to calculate the upper body kinematics of trunk and arms. When the healthy children were compared with the children with cerebral palsy, the latter compensated more for their gait deviations and were less stable. This was expressed by their greater variability in arm movements and increased movements at the thorax. The thorax showed an increased forward tilt with greater range of motion over the gait cycle. The shoulders were more abducted with increased elbow flexion. Gait analysis with the full-body marker set has offered prospects for a better understanding of compensatory mechanisms for the pathological gait pattern in children with diplegic cerebral palsy.

Obstetric brachial plexus palsy: increasing disability and exacerbation of symptoms with age

BACKGROUND

People with congenital conditions such as obstetric brachial plexus palsy (OBPP), sometimes known as Erb's palsy, may experience adverse effects as a result of compensatory strategies adopted to achieve improved function. Anecdotal evidence suggests that problems do occur in adult life but little is known about the type and extent of problems experienced, nor whether they are similar to those with other conditions involving movement dysfunction.

METHOD

A survey of adults with OBPP to determine problems currently experienced. Subjects were members of the Erb s Palsy Group UK.

RESULTS

Forms were sent to all adult members of the group (n = 61), and replies were received from 36 (59%). The majority of the sample reported many problems, including pain, impaired sensation, arthritis and limitation of function, which interfered with activities of daily living.

CONCLUSION

In the present small sample, most adults with OBPP reported experiencing many difficulties, some similar to those experienced by others with movement dysfunction. The topic warrants further investigation, both in terms of avoiding these problems where possible and, when complications occur, considering how they can best be managed.

Spinal deformity after selective dorsal rhizotomy in ambulatory patients with cerebral palsy

Thirty-four patients with ambulatory spastic diplegia (ages 10-19.8 years) who were part of a prospective study of selective dorsal rhizotomy (SDR) had standardized radiographs before and after SDR. Follow-up ranged from 5 to 11.6 years after surgery. Two different surgical approaches were used: laminectomy (14 patients) and laminoplasty (20 patients). Radiographs were measured for coronal and sagittal balance. Thirty patients had a spinal deformity at long-term follow-up compared with 10 patients before surgery. Seventeen patients (50%) developed lumbar hyperlordosis greater than 60 degrees. Six patients (18%) developed grade 1 spondylolisthesis, Scoliosis occurred de novo in eight patients (24%) and progressed by greater than 5 degrees in two patients with preoperative scoliosis. No significant differences were found between laminoplasty and laminectomy patients. None of the patients have undergone any surgical intervention for spinal deformity. There was a higher incidence of spinal deformity after SDR than in normals and an historical control population, which warrants clinical and radiographic long-term follow-up.

Spinal deformity following selective dorsal rhizotomy

The authors performed a review of 79 patients treated by selective dorsal rhizotomy with laminoplasty, 78 of whom were ambulatory, to determine the prevalence of spinal deformities. The mean radiographic follow-up was 4.2 years, the mean clinical follow-up 5.8 years. Scoliosis (11 degrees -24 degrees ) was identified in 13 children, none of whom had a preexisting deformity. There were no significant differences between preoperative and follow-up thoracic kyphosis or lumbar lordosis, although there was a significant difference in lumbar lordosis between sitting and standing radiographs. No progressive or rigid hyperlordotic deformities were observed in the lumbar spine. Spondylolisthesis was identified in nine children (12%) (8/9 grade I), and one patient required an arthrodesis for pain. Spondylolisthesis was correlated with greater lumbar lordosis, stronger hip abductors, and increased popliteal femoral angles preoperatively, and with stronger hip flexors postoperatively. Back pain was identified in 4 of the 79 patients at last follow-up, 2 of whom had spondylolisthesis. As some cases of spondylolisthesis will remain asymptomatic, periodic radiographic follow-up is recommended.

Role for botulinum toxin in back pain treatment in adults with cerebral palsy: report of a case

OBJECTIVE

To report a case illustrating the usefulness of botulinum toxin A in the treatment of spinal dystonia responsible for low back pain and postural disorders.

METHODS

Critical appraisal of a case report.

CASE REPORT

A young woman with cerebral palsy had lumbar paraspinal muscle dystonia responsible for pain and hyperlordosis unresponsive to oral medications for muscle spasm. Botulinum toxin A (Botox(R), 200 U) was injected into the paraspinal muscles at six sites, to good effect.

DISCUSSION

The few reported cases consistently show a favorable effect of local botulinum toxin A injections in patients with painful paraspinal muscle dystonia related to neurological disease or chronic low back pain.

CONCLUSION

Botulinum toxin A may be a useful treatment for incapacitating painful dystonia of the paraspinal muscles. This treatment improves posture in the sitting position and facilitates the fitting of orthotic devices. Furthermore, botulinum toxin A treatment may help to determine whether an intrathecal baclofen test is in order.

Progressive bone and joint abnormalities of the spine and lower extremities in cerebral palsy

Bone and joint changes in cerebral palsy result from muscle spasticity and contracture. The spine and the joints of the lower extremity are most commonly affected. Scoliosis may progress rapidly and may continue after skeletal maturity. Increased thoracic kyphosis and lumbar lordosis, spondylolisthesis, spondylolysis, and pelvic obliquity may accompany the scoliosis. Progressive hip flexion and adduction lead to windswept deformity, increased femoral anteversion, apparent coxa valga, subluxation, deformity of the femoral head, hip dislocation, and formation of a pseudoacetabulum. In the knee, flexion contracture, patella alta, and patellar fragmentation are the most commonly seen abnormalities. Recurvatum deformity can also develop in the knee secondary to contracture of the rectus femoris muscle. Progressive equinovalgus and equinovarus of the foot and ankle are associated with rocker-bottom deformity and subluxation of the talonavicular joint. Early recognition of progressive deformity in patients with cerebral palsy allows timely treatment and prevention of irreversible change.

Profiles of the cervical, thoracic, and lumbosacral spine in children and adolescents with lumbosacral spondylolisthesis

The sagittal and frontal profiles of the entire spine are poorly studied in lumbosacral spondylolisthesis. It was the purpose of this study to further investigate these profiles. Standing posterior-anterior and lateral radiographs in 24 children with lumbosacral spondylolisthesis were reviewed (18 isthmic, 6 congenital). Cervical lordosis, lumbar lordosis, thoracic kyphosis, sagittal vertebral axis, sacral inclination, slip magnitude, slip angle, and sagittal rotation were measured. Cobb magnitude, Risser sign, curve location, and direction were noted for those with scoliosis. Relationships between sagittal variables were explored (Pearson correlation). The average age of patients was 14.7 +/- 2.5 years, slip magnitude was 38 +/- 38%, slip angle was 5 +/- 31 degrees, sagittal rotation was -6 +/- 31 degrees, thoracic kyphosis was 29 +/- 16 degrees, cervical lordosis was -1 +/- 12 degrees, and lumbar lordosis was 62 +/- 22 degrees. Correlations were noted between thoracic kyphosis and sacral inclination, percent slip, slip angle, and sagittal rotation. Sacral inclination decreased as the slip increased. Scoliosis was present in 10 children, with an average curve of 19 +/- 6 degrees. Thoracic kyphosis was less in those with scoliosis (21 +/- 25 degrees versus 33 +/- 25 degrees, p = 0.033). In children with lumbosacral spondylolisthesis, the sacrum becomes more vertical as the slip worsens. As the sacrum becomes more vertical, the thoracic spine becomes more lordotic, which is likely an adaptive mechanism used by the body to maintain forward visual gaze.