Effects of Participation in Sports Programs on Walking Ability and Endurance Over Time in Children With Cerebral Palsy.

OBJECTIVE: Children with cerebral palsy may benefit from maintaining a high level of physical fitness similar to typically developing children especially in terms of long-term physical performance, although in practice this is often difficult. The purpose of this study was to determine the effect of participation in sports programs on walking ability and endurance over time. DESIGN: A retrospective cohort study included participants with cerebral palsy, aged 6 to 20 yrs, who attended a summer sports program from 2004 to 2012. There were 256 participant sessions with pre/post data recorded. The participants consisted of a total of 97 children (mean age [SD] = 11.4 [3.1] yrs), many of whom attended multiple programs throughout the years. Programs were held 6 hrs/d, 5 d/wk for up to 4 wks. Outcome measures included the Timed Up and Go, modified 6-min walk, and 25-ft walk/run. RESULTS: The results showed significant improvements in the Timed Up and Go, modified 6-min walk distance and 25-ft walk/run over time. Children in Gross Motor Classification System level III made the largest gains. CONCLUSIONS: Walking ability and endurance seem to improve after participation in an intensive summer sports programs. Higher frequency of program attendance resulted in significant improvements in the Timed Up and Go. TO CLAIM CME CREDITS: Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME CME OBJECTIVES: Upon completion of this article, the reader should be able to: (1) Discuss the importance of physical activity at the participation level (sports programs) for children with cerebral palsy; (2) Contrast the changes in walking ability and endurance for children in Gross Motor Function Classification System level I, II, and III after sports programs; and (3) Identify the impact of higher frequency of sports program attendance over time on walking ability. LEVEL: Advanced ACCREDITATION: The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 0.75 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

PREDICTING FOOT PROGRESSION ANGLE DURING GAIT USING TWO CLINICAL MEASURES IN HEALTHY ADULTS, A PRELIMINARY STUDY.

BACKGROUND: The foot progression angle (FPA) is related to the transverse plane rotation of the lower extremities and associated with many lower extremity conditions. PURPOSE: The purpose of this study was to examine how two commonly used clinical measures, tibio-fibular torsion (TF) and hip rotation, can be used to predict FPA during gait in healthy adults. STUDY DESIGN: Cross-sectional study design. METHODS: Passive hip internal and external rotation ranges of motion and TF torsion were measured with a 12-inch goniometer while the FPA (degree of toe-in/out) was measured with the GAITRite during midstance in sixty participants. The data was analyzed using a multiple regression model. RESULTS: Hip ER was not significant and was therefore excluded from the final model. The final model included passive hip IR and TF torsion (F = 19.64; p < .001; multiple R(2) = .41; adjusted R(2) = .39). Simple binary correlations showed that hip IR had a moderate negative correlation (r = -.40) with FPA (the greater the hip IR, the greater the in-toeing) while TF torsion had a positive correlation (r = .39) with FPA (the greater the external TF torsion. the greater the out-toeing). CONCLUSIONS: Greater amount of passive hip IR predicts in-toeing while greater TF torsion predicts out-toeing of the foot during midstance phase of gait. LEVEL OF EVIDENCE: Level 2.

Reliability of sagittal plane hip, knee, and ankle joint angles from a single frame of video data using the GAITRite camera system.

The purpose of this study was to establish intra-rater, intra-session, and inter-rater, reliability of sagittal plane hip, knee, and ankle angles with and without reflective markers using the GAITRite walkway and single video camera between student physical therapists and an experienced physical therapist. This study included thirty-two healthy participants age 20-59, stratified by age and gender. Participants performed three successful walks with and without markers applied to anatomical landmarks. GAITRite software was used to digitize sagittal hip, knee, and ankle angles at two phases of gait: (1) initial contact; and (2) mid-stance. Intra-rater reliability was more consistent for the experienced physical therapist, regardless of joint or phase of gait. Intra-session reliability was variable, the experienced physical therapist showed moderate to high reliability (intra-class correlation coefficient (ICC) = 0.50-0.89) and the student physical therapist showed very poor to high reliability (ICC = 0.07-0.85). Inter-rater reliability was highest during mid-stance at the knee with markers (ICC = 0.86) and lowest during mid-stance at the hip without markers (ICC = 0.25). Reliability of a single camera system, especially at the knee joint shows promise. Depending on the specific type of reliability, error can be attributed to the testers (e.g. lack of digitization practice and marker placement), participants (e.g. loose fitting clothing) and camera systems (e.g. frame rate and resolution). However, until the camera technology can be upgraded to a higher frame rate and resolution, and the software can be linked to the GAITRite walkway, the clinical utility for pre/post measures is limited.

Robotics and gaming to improve ankle strength, motor control, and function in children with cerebral palsy--a case study series.

The objective of this study was to investigate the feasibility of game-based robotic training of the ankle in children with cerebral palsy (CP). The design was a case study, 12 weeks intervention, with no follow-up. The setting was a university research laboratory. The participants were a referred sample of three children with cerebral palsy, age 7-12, all male. All completed the intervention. Participants trained on the Rutgers Ankle CP system for 36 rehabilitation sessions (12 weeks, three times/week), playing two custom virtual reality games. The games were played while participants were seated, and trained one ankle at-a-time for strength, motor control, and coordination. The primary study outcome measures were for impairment (DF/PF torques, DF initial contact angle and gait speed), function (GMFM), and quality of life (Peds QL). Secondary outcome measures relate to game performance (game scores as reflective of ankle motor control and endurance). Gait function improved substantially in ankle kinematics, speed and endurance. Overall function (GMFM) indicated improvements that were typical of other ankle strength training programs. Quality of life increased beyond what would be considered a minimal clinical important difference. Game performance improved in both games during the intervention. This feasibility study supports the assumption that game-based robotic training of the ankle benefits gait in children with CP. Game technology is appropriate for the age group and was well accepted by the participants. Additional studies are needed however, to quantify the level of benefit and compare the approach presented here to traditional methods of therapy.

A new manual muscle test for assessing the entire trapezius muscle.

UNLABELLED: Manual muscle testing (MMT), the trapezius muscle is an important part of the examination in patients with upper extremity dysfunction or pain. PURPOSE: The purpose of this study was to assess the reliability and validity of a new MMT that assesses the entire trapezius muscle instead of the usual method of separating it into three different parts. The new trapezius MMT is similar to the serratus anterior muscle test; however, the testing is performed in the frontal versus sagittal plane. METHODS: A convenience sample of 11 subjects was recruited with no known shoulder pathology. Surface electromyography electrodes were placed on the upper, middle, and lower trapezius fibers according to a previously validated method and MMTs for the three different trapezius muscle test positions were normalized against the new trapezius test position. RESULTS: The new trapezius MMT showed very high maximal voluntary isometric contraction (MVIC; 160.80%) for the upper trapezius muscle, high for the middle trapezius muscle (59.23%), and high for the lower trapezius muscle (47.54%) when normalized against the MVICs for each individual trapezius muscle tests. CONCLUSIONS: A new MMT that assesses the whole trapezius in its role as an upward scapular rotator was found to be reliable and valid.

Changes in muscle activation following ankle strength training in children with spastic cerebral palsy: an electromyography feasibility case report.

ABSTRACT Children with cerebral palsy (CP) are likely to experience decreased participation in activities and less competence in activities of daily living. Studies of children with spastic CP have shown that strengthening programs produce positive results in strength, gait, and functional outcomes (measured by the Gross Motor Function Measure). No investigations have analyzed electromyography (EMG) activity before and after strength training to determine whether any changes occur in the GMFM.  This feasibility case report quantified dorsiflexor and plantarflexor muscle activation changes during performance of 3-5 selected GMFM items following a plantarflexor strength training in two children with cerebral palsy. Increased plantarflexor strength and increased ability to selectively activate muscles were found. Little carryover to performance on GMFM items was observed. It is feasible to use EMG during performance on selected GMFM items to evaluate motor control changes following strength training in children with CP.

Therapy incorporating a dynamic wrist-hand orthosis versus manual assistance in chronic stroke: a pilot study.

BACKGROUND AND PURPOSE: The purpose of this study was to compare the effect of therapy using a wrist-hand orthosis (WHO) versus manual-assisted therapy (MAT) for individuals with chronic, moderate-to-severe hemiparesis. The relationship between the repetitions during therapy and functional change was also examined. METHODS: Nineteen participants were randomly assigned to either the WHO group (n = 10) or the MAT group (n = 9). The WHO group performed therapy while wearing a dynamic WHO (SaeboFlex), the MAT group performed therapy with manual assistance of a therapist. Both groups participated in 1 hour of therapy per week for 6 weeks and were prescribed exercises to perform at home 4 days per week. Pre- and posttraining assessments included grip strength, the Action Research Arm Test (ARAT), Box and Blocks (B&B) test, and Stroke Impact Scale (SIS). RESULTS: There were no significant between-group differences for any of the measures. Within-group differences showed that the WHO group had a significant improvement in the ARAT score (mean = 2.2; P = 0.04). The MAT group had a significant improvement on the percent recovery on the SIS (mean = 9.3%; P = 0.03) and approached a significant improvement on the ARAT (mean = 1.4; P = 0.08). When analyzing all participants together, the relationship between the number of exercise repetitions and functional improvement was moderate for the ARAT and the B&B test (r = 0.55, P = 0.02, and r = 0.30, P = 0.10, respectively). DISCUSSION AND CONCLUSIONS: Small improvements in function and perception of recovery were observed in both groups, with no definite advantage of the WHO. This study adds to the evidence that individuals with chronic stroke can improve arm use with therapy incorporating functional hand training, and that there is a relationship between amount of change and amount of practice.

Comparison of 3 different methods to analyze ankle plantarflexor stiffness in children with spastic diplegia cerebral palsy.

OBJECTIVE: To compare 3 different methods of measuring plantarflexor stiffness in children with spastic diplegia cerebral palsy (CP) and children without disability. DESIGN: Case-control study. SETTING: Human performance laboratory. PARTICIPANTS: A retrospective analysis was conducted with children with spastic diplegia (n=121; mean age, 8.4y) and children with typical development (TD) (n=48; mean age, 9.7y). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: An isokinetic dynamometer was used to measure ankle plantarflexor stiffness at 10°/s using 3 methods: (1) end-range method, which applied a linear slope to the end of the torque-angle curve; (2) set-range method, which applied a linear slope from 30° to 10° plantarflexion; and (3) a linear method, which applied a slope only to the linear portion of the curve. RESULTS: Two-way analysis of variance revealed significant main effects for group and stiffness method. The end-range method showed no significant difference between groups for plantarflexor stiffness (P=.62), the set-range method showed the CP group with 120% greater stiffness than the TD group (P<.046), and the linear method showed the CP group with 35% greater stiffness than the TD group (P<.001). CONCLUSIONS: The linear method appeared to resolve the issues with the previous methods; applying a linear slope to a nonlinear curve or applying a linear slope to the same range of motion for each child regardless of their range limitations. It is clear that children with CP have limited range of motion; therefore, stiffness occurs earlier in the range than would be expected for a typically developing child. Using the linear method, children with CP were 35% stiffer in the ankle plantarflexors than typically developing peers.

Effects of a supported speed treadmill training exercise program on impairment and function for children with cerebral palsy.

AIM: To compare the effects of a supported speed treadmill training exercise program (SSTTEP) with exercise on spasticity, strength, motor control, gait spatiotemporal parameters, gross motor skills, and physical function. METHOD: Twenty-six children (14 males, 12 females; mean age 9y 6mo, SD 2y 2mo) with spastic cerebral palsy (CP; diplegia, n=12; triplegia, n=2; quadriplegia n=12; Gross Motor Function Classification System levels II-IV) were randomly assigned to the SSTTEP or exercise (strengthening) group. After a twice daily, 2-week induction, children continued the intervention at home 5 days a week for 10 weeks. Data collected at baseline, after 12-weeks' intervention, and 4 weeks after the intervention stopped included spasticity, motor control, and strength; gait spatiotemporal parameters; Gross Motor Function Measure (GMFM); and Pediatric Outcomes Data Collection Instrument (PODCI). RESULTS: Gait speed, cadence, and PODCI global scores improved, with no difference between groups. No significant changes were seen in spasticity, strength, motor control, GMFM scores, or PODCI transfers and mobility. Post-hoc testing showed that gains in gait speed and PODCI global scores were maintained in the SSTTEP group after withdrawal of the intervention. INTERPRETATION: Although our hypothesis that the SSTTEP group would have better outcomes was not supported, results are encouraging as children in both groups showed changes in function and gait. Only the SSTTEP group maintained gains after withdrawal of intervention.

Observation of amounts of movement practice provided during stroke rehabilitation.

UNLABELLED: Lang CE, MacDonald JR, Reisman DS, Boyd L, Jacobson Kimberley T, Schindler-Ivens SM, Hornby TG, Ross SA, Scheets PL. Observation of amounts of movement practice provided during stroke rehabilitation. OBJECTIVE: To investigate how much movement practice occurred during stroke rehabilitation, and what factors might influence doses of practice provided. DESIGN: Observational survey of stroke therapy sessions. SETTING: Seven inpatient and outpatient rehabilitation sites. PARTICIPANTS: We observed a convenience sample of 312 physical and occupational therapy sessions for people with stroke. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: We recorded numbers of repetitions in specific movement categories and data on potential modifying factors (patient age, side affected, time since stroke, FIM item scores, years of therapist experience). Descriptive statistics were used to characterize amounts of practice. Correlation and regression analyses were used to determine whether potential factors were related to the amount of practice in the 2 important categories of upper extremity functional movements and gait steps. RESULTS: Practice of task-specific, functional upper extremity movements occurred in 51% of the sessions that addressed upper limb rehabilitation, and the average number of repetitions/session was 32 (95% confidence interval [CI]=20-44). Practice of gait occurred in 84% of sessions that addressed lower limb rehabilitation and the average number of gait steps/session was 357 (95% CI=296-418). None of the potential factors listed accounted for significant variance in the amount of practice in either of these 2 categories. CONCLUSIONS: The amount of practice provided during poststroke rehabilitation is small compared with animal models. It is possible that current doses of task-specific practice during rehabilitation are not adequate to drive the neural reorganization needed to promote function poststroke optimally.

Use of relative phase as a measure of motor control at the ankle in persons with cerebral palsy: a preliminary study.

This investigation developed a measure of motor control at the ankle for persons with CP using relative phase. Twenty-nine subjects, 14 with spastic diplegia cerebral palsy (CP group) and 15 without disability (WD group) were tested once. Video data were collected as a seated subject performed four full range of ankle plantar and dorsiflexion movement tasks (right ankle, left ankle, ankles in-phase with each other, and ankles antiphase to each other) at four different frequencies (self-paced, 0.5, 0.75, 1.0 Hz). The relative phase measure was able to discern the differences between the two groups of children. The CP group had poorer motor control than the WD group, based upon the measure. Both groups had more difficulty performing the antiphase than the in-phase movements. The investigation adds to the body of knowledge in that the concept of relative phase was used as a measure of motor control at the ankle in persons with CP. Results indicated that the measure was adequately sensitive to quantify differences between a group with CP and a group without disability. Clinically the measure could eventually be used as both an assessment and outcome tool.

Relationships between spasticity, strength, gait, and the GMFM-66 in persons with spastic diplegia cerebral palsy.

OBJECTIVE: To determine the relationships between spasticity, strength, and the functional measures of gait and gross motor function in persons with spastic diplegia cerebral palsy (CP). DESIGN: Retrospective, cross-sectional study. SETTING: Hospital clinic. PARTICIPANTS: Ninety-seven participants (49 boys, 48 girls; mean age+/-standard deviation, 9.11+/-4.8 y) with spastic diplegia CP were tested once. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: A KinCom dynamometer was used to objectively measure spasticity (ankle plantarflexors, knee flexors, hip adductors) and maximum strength (ankle dorsiflexors and plantarflexors, knee flexors and extensors, hip abductors and adductors). A gait analysis was conducted to evaluate linear variables (gait speed, stride length, cadence) and kinematic variables (ankle dorsiflexion, foot progression, knee and hip flexion, pelvic tilt at initial contact and ankle dorsiflexion, knee and hip flexion, pelvic tilt, trunk rotation range of motion) during gait. Gross motor function was measured using the Gross Motor Function Measure (GMFM-66) and separately, the GMFM walking, running & jumping dimension. Multiple linear regression analysis was used to determine the relationships between spasticity, strength, gait, and the GMFM (P<.05). RESULTS: Spasticity did not account for a substantial amount of explained variance in gait and gross motor function (up to 8% for the GMFM walking, running & jumping dimension). Moderate to high correlations existed between strength and gait linear data and function, accounting for up to 69% of the explained variance (strength and GMFM-66, r2=.69). CONCLUSIONS: For this cohort of participants with spastic diplegia CP who ambulated with or without an assistive device, strength was highly related to function and explained far more of the variance than spasticity. The results may not be generalized to those with more severe forms of CP.

Predicting functional change from preintervention measures in selective dorsal rhizotomy.

OBJECT: In this investigation the authors attempted to predict change in function following selective dorsal rhizotomy (SDR) and intensive physical therapy in patients with spastic diplegic cerebral palsy (CP) based on multidomain preintervention measures. METHODS: Data pertaining to 22 children with CP were collected before the SDR and again 20 months afterward. Although equations for predicting change in gait speed and function (such as the Gross Motor Function Measure) were derived, the 95% confidence interval (CI) widths were too broad to make accurate predictions that were clinically useful outside the study group. CONCLUSIONS: Future work should be focused on developing additional measures such as lower-extremity motor control and balance in an attempt to reduce the CIs to more clinically relevant values.

Increasing ankle strength to improve gait and function in children with cerebral palsy: a pilot study.

PURPOSE: This pilot study was designed to determine whether increases in ankle strength could improve gait and function in children with spastic diplegia. METHODS: Data were obtained from 12 children with spastic diplegia who were assigned randomly to a dorsiflexor group, a plantarflexor group, a dorsi- and plantarflexor group, or a control group. Training group subjects participated in a 12-week strength program using an isokinetic dynamometer. RESULTS: The majority of subjects increased their strength in the trained muscles; the strength of untrained muscles was unchanged. The Gross Motor Function Measure (GMFM) walk-run-jump dimension and a quality of life measure (ie, Peds QL) improved significantly for the entire training group. Gait speed was not significantly increased for the entire training group but varied among training groups. Gait kinematics significantly improved or showed trends for improvement for the entire training group. CONCLUSION: This pilot investigation indicates that ankle strength increases may lead to improved function, gait speed, and quality of life in children with spastic diplegia.

Effect of selective dorsal rhizotomy in the treatment of children with cerebral palsy.

OBJECT: In this investigation the authors compared impairment and functional outcomes between two groups of children with cerebral palsy (CP): one group underwent selective dorsal rhizotomy (SDR) followed by intensive physical therapy (PT), and the other group underwent the latter only (PT group). Data from an age-matched group of children without disability (nondisabled [ND] group) were also collected. METHODS: Data pertaining to the 68 children with CP were collected before any intervention and again 8 and 20 months afterwards. Data regarding the 40 children in the ND group were collected in a single session. CONCLUSIONS: Although patients in both groups with CP were weaker than those in the ND group, they did have strength gains. Gait speed in the SDR-PT group was slower than that in the ND group preoperatively but not at 20 months postoperatively. Gait speed in the PT group remained slower than that in the ND group. The pre- to postoperative change in the Gross Motor Abilities Estimate score was significantly greater in the SDR-PT group than in the PT-only group. An effective treatment for children with CP, SDR offers gains in strength, gait speed, and overall gross motor function.

Comparison of three heel cord surgeries in children with cerebral palsy.

This nonrandomized prospective descriptive study compared outcomes of three isolated heel cord surgeries in children with spastic diplegia cerebral palsy (CP): (1) heel cord advancement (HCA), (2) heel cord lengthening according to Vulpius (HCL-V), and (3) heel cord lengthening according to White (HCL-W). Thirty-two children were tested prior to and approximately 1 year after undergoing one of the three surgeries. Objective measures were collected for ankle passive and active range of motion, gross motor function measure (GMFM), and gait. All surgeries indicated significant improvements in end range passive and active ankle dorsiflexion, GMFM, and dorsiflexion during gait. Gait speed was significantly improved for the HCA group, but appeared to be the result of maturity. Gait speed for the HCL-V and HCL-W groups was unchanged. The study was the first to directly compare three heel-cord-lengthening surgeries.

Prospective comparison of gait and trunk range of motion in adolescents with idiopathic thoracic scoliosis undergoing anterior or posterior spinal fusion.

STUDY DESIGN: Prospective evaluation of gait and spinal range of motion (ROM) in adolescent idiopathic scoliosis (AIS) patients undergoing either an anterior or a posterior spinal fusion. OBJECTIVE: Compare changes in gait and spine ROM between AIS patients undergoing either an anterior or posterior spinal fusion. SUMMARY AND BACKGROUND DATA: Problems with AIS posterior spinal fusion and attempts to minimize the number of spinal segments fused have led to the promotion of anterior spinal fusion. Comparison of functional outcomes of the two surgeries has not been reported. MATERIALS AND METHODS: Thirty-one patients with single or double thoracic AIS undergoing an anterior (n = 16) or posterior (n = 15) instrumented spinal fusion underwent gait and triplanar ROM tests before surgery and 24 months postoperative. Videography with reflective surface markers on the scapula, spine, and pelvis were used to quantify changes in gait and trunk ROM. RESULTS: Surgical results indicated that an average of four fewer levels was fused and the lowest instrumented vertebrae were one level higher in the spine for the anterior group compared to the posterior group. Gait results showed no change in gait speed and no change in coronal and sagittal plane kinematics, regardless of group. Transverse plane motion during gait was reduced in both groups. Spinal ROM results indicated motion loss in all three planes, regardless of group, with the posterior group having less postoperative ROM than the anterior group. Unlinking surgical approach from number of fused levels and lowest instrumented vertebrae with a subset of subjects also indicated less postoperative ROM for the posterior group. CONCLUSIONS: The surgical and ROM results seem to favor the anterior approach over the posterior approach for the classification of patients in this investigation. However, it should be noted that both groups had decreased postoperative ROM.

Changes in hip spasticity and strength following selective dorsal rhizotomy and physical therapy for spastic cerebral palsy.

Hip adductor spasticity and strength in participants with cerebral palsy (CP) were quantified before and after selective dorsal rhizotomy (SDR) and intensive physical therapy. Twenty-four participants with cerebral palsy (CP group) and 35 non-disabled participants (ND controls) were tested with a dynamometer (OP group: mean age 8 years 5 months, 13 males, 11 females; ND group: mean age 8 years 6 months, 19 males, 16 females). According to the Gross Motor Function Classification System (GMFCS), of the 24 participants with CP, eight were at level I, six were at level II, and 10 participants were at level III. For the spasticity measure, the dynamometer quantified the resistive torque of the hip adductors during passive abduction at 4 speeds. The adductor strength test recorded a maximum concentric contraction. CP group spasticity was significantly reduced following SDR and adductor strength was significantly increased after surgery. Both pre- and postoperative values remained significantly less than the ND controls. Spasticity results agreed with previous studies indicating a reduction. Strength results conflicted with previous literature subjectively reporting a decrease following SDR. However, results agreed with previous objective investigations examining knee and ankle strength, suggesting strength did not decrease following SDR.

Relation between spasticity and strength in individuals with spastic diplegic cerebral palsy.

The relation between spasticity and strength in individuals with cerebral palsy (CP) has not been extensively researched. Knee and ankle spasticity and strength were quantified in a retrospective analysis of 60 individuals with spastic diplegic CP (mean age 12 years, range 3 to 38) and a group of 50 individuals without disabilities (WD group; mean age 12 years, range 4 to 36). Spasticity was measured using a KinCom dynamometer that stretched the passive knee flexors or ankle plantarflexors at different speeds and recorded the amount of resistive torques. For the strength tests, the participant performed a maximum contraction of the knee flexors/extensors and ankle plantarflexors/dorsiflexors throughout their range of motion at a speed of 10 degrees/s on the dynamometer. Pearson's correlation coefficient was used to determine if a relation existed between spasticity and strength within the same muscle group and in opposing muscle groups at the knee and ankle joints. A t-test was performed to determine if greater spasticity and less strength existed at the ankles compared with the knees in those with CP. Results show that there was no relation between spasticity and strength either within the same muscle group or at opposing muscle groups at the knee and ankle joints in persons with CP. Individuals with spastic diplegic CP were more involved (greater spasticity, less strength) distally at the ankles compared with the knees. The findings conflict with the literature, which contains several assumptions, one of which is that a spastic muscle is a strong muscle and that spasticity causes weakness in the opposing muscle group. We found no relation between spasticity and strength in individuals with CP. Our findings support the literature, which states that individuals with spastic diplegic CP are more involved distally compared with proximally in the lower extremities.