Contribution of Different Impairments to Restricted Knee Flexion during Gait in Individuals with Cerebral Palsy.

The coexistence of overlapping impairments modulates the knee pattern in the swing phase of walking in children with cerebral palsy (CP). The impact and contribution of each impairment to the reduction of knee range-of-motion is unknown. The aim of the study was to establish the gradation of the impact of individual coexisting impairments on the knee flexion range-of-motion. Passive range-of-motion, selective motor control, strength, and spasticity from 132 patients (Male = 76, Female = 56, age:11 ± 4 years) with spastic CP were tested with clinical tools. Knee flexion range-of-motion at terminal stance, pre-swing, and initial swing phases were assessed by gait analysis. Hypertonia (ß = −5.75) and weakness (ß = 2.76) of knee extensors were associated with lower range of knee flexion (R2 = 0.0801, F = 11.0963, p < 0.0001). The predictive factors (R2 = 0.0744, F = 7.2135, p < 0.0001) were strength (ß = 4.04) and spasticity (ß = −2.74) of knee extensors and strength of hip flexors (ß = −2.01); in swing those were knee extensors hypertonia (ß = −2.55) and passive range of flexion (ß = 0.16) (R2 = 0.0398, F = 3.4010, p = 0.01). Hypertonia of knee extensors has the strongest impact on knee flexion range-of-motion; secondary is the strength of knee extensors. The knee extensors strength with knee extensors hypertonia and strength of hip flexors contributes in stance. Knee extensors hypertonia with passive knee flexion range-of-motion contributes in swing.

Baseline Gross Motor Function Affects the Outcome of Robot-Assisted Therapy in Ambulatory Individuals with Spastic Cerebral Palsy.

Robotic-assisted therapy (RAT) is a task-specific approach for treating gait disorders in individuals with neurological impairments. However, the effectiveness of RAT is not clear for different severities of involvement, pathologies, and ages. This study aimed to assess the functional and clinical status outcomes after RAT in individuals with cerebral palsy (CP). Twenty-eight individuals with bilateral spastic CP were enrolled (female = 10; male = 18; age = 15.2 ± 2.0 years). The RAT program consisted of 30 sessions: five sessions weekly for six weeks. Gross Motor Function Measure (GMFM) and clinical physical examinations were evaluated before and after RAT. Our results suggested that the RAT program with the described protocol can improve the general gross motor functions of individuals with CP in Gross Motor Function Classification System (GMFCS) levels I and II, and primarily improves performance on less complex GMFM items for those in GMFCS levels III and IV. The lower baseline functional level was related to a greater functional improvement. Older individuals were noticed to improve more in GMFM dimension D. Regarding impairments evaluated by clinical examinations, no change was found after RAT intervention. It is worth mentioning that the strength of knee muscles was not affected either.

Effects of Robot-Assisted Therapy on Gait Parameters in Pediatric Patients With Spastic Cerebral Palsy.

Background: Gait dysfunction is a crucial factor that restricts independence and quality of life in children with cerebral palsy (CP). Gait training based on robotic-assisted therapy (RAT) is widely used, but information about effectiveness and ideal patient profile is not sufficient. Aim of this study was to assess the effect of RAT on gait parameters in spastic children with CP, and to determine whether changes in gait parameters are different among patients on different ambulatory levels. Method: A total of 26 children with bilateral spastic CP were divided into two groups based on their functional ability: non-assisted ambulator (NAS) or assisted ambulator (AS); and underwent a RAT program (30 training sessions of RAT during 10 weeks). Gait analysis was performed: before the therapy (t1), right after (t2), and 6 weeks later (t3). Results: No significant changes in spatiotemporal parameters or gait deviation index at t2 or t3. Double support symmetry significantly improved (t1 vs. t3, p = 0.03) for the whole group (NAS + AS). Walking speed symmetry significantly improved (t2 vs. t3, p = 0.02) for group AS. Conclusion: RAT based on our protocol did not change spatiotemporal parameters and kinematics of walking except limited improvement in some aspects of gait symmetry. We did not find differences in changes in selected objective gait parameters among children with CP in different ambulatory levels.

The weight of an external breast prosthesis as a factor for body balance in women who have undergone mastectomy.

It has been shown that women who have undergone mastectomy (BG) demonstrated greater postural changes than women after breast reconstruction. In this study we wanted to verify if unilateral mastectomy affected body weight distribution and balance in a standing position and if the weight of an external breast prosthesis (EBP) influenced those variables and might provide some insight into the current post-mastectomy care. In our study BG completed the data acquisition protocol in 4 variants: 3 trials without EBP (group A), and the next 9 trials with 3 different weights of EBP. Group B - wearing a prosthesis weighing 10 grams; Group C - wearing a prosthesis weighing 50% of the total breast mass; Group D - wearing a prosthesis of equal weight to the operated breast. Each control group subject (CG) completed 3 consecutive trials. Instrumental assessment of body balance was conducted using FDM pressure distribution measurement platforms. This is a quantitative baropedometric tool which allowed for measuring forces exerted on the support surface in a standing position. Ellipse width, length, area and the center of feet pressure (CoP) path did not differ significantly between the measurements performed in different groups. Group D was closest to CG in terms of the width and length of the ellipse. Group C, on the other hand, was most similar to CG with respect to the other study variables. The study results suggest that women after mastectomy do not differ from the healthy subjects neither with regard to CoP features nor in terms of weight distribution on the supporting surface.

The popliteal angle tests in patients with cerebral palsy.

The aims were to determine during the popliteal angle (PA) tests whether particular knee muscles are activated and whether the position of pelvis affects the level of muscles activation. Twenty-two patients with cerebral palsy were recruited (age: 14±4.94 years). Knee muscle activities and range of motion were measured during PA. Knee flexors were active during tests, with fivefold increase of activation of ipsilateral hamstring. Higher and more frequent activation of muscles only in the contralateral limb was seen. Muscles activation should be considered as a confounding factor during tests. PA should not be relied upon as a major criterion for the treatment selection in cerebral palsy.

Validation of Manual Muscle Testing (MMT) in children and adolescents with cerebral palsy.

BACKGROUND: Weakness is a major impairment in many movement disorders, including cerebral palsy (CP), which presents as a decrease in muscle strength. Manual muscle testing (MMT) is very popular in clinical practice, however it has many limitations. OBJECTIVE: (1) Whether maximum voluntary contraction (MVC) measures differ across clinical MMT groups; (2) Whether an association exists between clinical MMT score groups and instrumental MVC measures. METHODS: Twenty-one participants with spastic CP were recruited (11 females and 10 males; age = 13.46±3.62 years). To achieve the aims of the study, we investigated the relationship between qualitative (MMT) and instrumental (MVC) measures of knee flexor muscles' strength in patients with CP. RESULTS: MVC values increased somewhat proportionally with increasing MMT score group (p = 0.032, MS = 207.54, F = 3.75). The differences in MVC values was only statistically significant between score groups 3 and 5. A weak correlation (R = 0.4, MVC = -2.54 + 4.50 MMT, p < 0.01) was found between measured MVCs and the MMT score groups. CONCLUSIONS: In pediatric research studies, instrumental MVC should be preferred over MMT scoring. Also, MMT score groups higher than 3 should be modified in clinical testing of children and adolescents with cerebral palsy.

Can the Weight of an External Breast Prosthesis Influence Trunk Biomechanics during Functional Movement in Postmastectomy Women?

INTRODUCTION: Recent papers indicate that one-side mastectomy can produce deleterious effects on the posture and musculoskeletal system. This study was conducted to better understand the underlying mechanisms involved in trunk motion in external prosthesis users. OBJECTIVE: The aim was to evaluate the changes in surface electromyographic (SEMG) activity of the erector spinae muscles (ES) in postmastectomy women with and without breast prostheses during functional body movement tests. METHODS: In 51 one-side postmastectomy women the SEMG muscle activity of bilateral ES was measured during symmetrical and asymmetrical dynamic activities in a counterbalanced manner with different weights of the breast prosthesis. Range-of-motion measurements were taken for forward bending, backward bending, lateral bending, and rotation. RESULTS: The mean level of the ES activity in the lumbar region was not affected by the weight of the external breast prosthesis during most of the functional body tests (P > 0.05). The activity of ES during functional body tests with and without different external breast prostheses did not differ between the two sides of the trunk (mastectomy and nonmastectomy) for most of the movement tests (P > 0.05). CONCLUSION: The lumbar ES activity during functional tests is not associated with the weight of the external breast prosthesis in postmastectomy women.

Assessment of selective motor control in clinical Gillette's test using electromyography.

BACKGROUND: Selective motor control (SMC), the ability to isolate selected muscle activation during a functional task, is often impaired. Gillette's SMC scale is commonly used to classify the impairment level; however it may not be sensitive to muscle coactivation. AIM: To characterize differences in muscle activation levels and coactivation incidence in Gillette's SMC grade levels. DESIGN: Non-randomized observational study. SETTING: Participants were recruited and examined in the motion analysis laboratory of a university hospital. POPULATION: Forty-two participants were enrolled: 23 patients with CP (13 females, 10 males; 15±5.59 years, range: 7-28 years; bilateral involvement; GMFCS levels I to III) and 19 able-bodied volunteers (14 females, 5 males; 22±1.54 years, range: 20-24 years). METHODS: Participants flexed each knee three times at self-paced velocity. Each limb was classified into one of three types using Gillette's SMC scale: Type 0 (CP limbs with no ability to isolate movement), Type 2 (CP limbs with complete isolation of movement) and Type C (Control limbs of able-bodied volunteers). Surface electromyography recorded muscle activation levels of hamstring, rectus femoris, hip adductor, gastrocnemius and tibialis anterior muscles. We applied the Friedman ANOVA χ2 Test to analyze muscle co-activation incidence and Kruskal-Wallis ANOVA and Median Tests to analyze muscle activation levels. We used the Wilcoxon Matched-Pairs Test to compare results between SMC Types. RESULTS: Comparing mean activation levels of the majority of muscles, we found: CP limbs (Type 0+2) > Control limbs (P<0.001); Type 0 > Type 2 (P<0.05); and Type 2 > Type C (P<0.01). The incidence of muscle co-activation was affected by CP (P=0.008) and differed by SMC type (P<0.001). CONCLUSIONS: Our quantitative study confirmed that SMC is worse in Gillette's Type 0 limbs than in Type 2 limbs. We also found that the SMC of Type 2 limbs of CP patients in CP patents is not equivalent to that of Type 2 limbs in able-bodied volunteers. CLINICAL REHABILITATION IMPACT: A better characterization of this clinical test will help gauge its usefulness in evaluating the effectiveness of rehabilitation treatments.

The influence of an external breast prosthesis on the posture of women after mastectomy.

BACKGROUND: Previous literatures showed no evidence that wearing an external breast prosthesis may prevent changes in body posture in women who underwent mastectomy. OBJECTIVE: To determine whether the weight of an external breast prosthesis can contribute to posture changes in women post mastectomy. METHODS: Fifty-one women with unilateral mastectomy (age 58 ± 11.39 years) were divided into 2 subgroups by their operation side. Asymmetry of body posture was evaluated by using the electromyography activity of erector spinae muscles with four different weights of breast prosthesis. RESULTS: Despite the operation side, the erector spinae muscle activities on the operation side and non-operation side were significantly different. Overall, for patients who had operation on the left side, their erector spinae muscle activity imbalance will be smaller, compared to the imbalance among patients with right operation side. The weight of the external breast prosthesis did not influence the differences of erector spinae muscle activities on the operation side and non-operation side. CONCLUSIONS: The weight of an external breast prosthesis for women after mastectomy may not be crucial when choosing a proper prosthesis.

The role of exaggerated patellar tendon reflex in knee joint position sense in patients with cerebral palsy.

The aim of this pilot study was to determine if exaggerated patellar tendon jerk affects knee joint position sense (JPS) in cerebral palsy (CP) patients, by comparing JPS of the knee between participants with normal and exaggerated reflexes. The thresholds for reflex classification were based upon the data from able-bodied volunteers. JPS was measured as the ability of a subject (with eyes closed) to replicate a knee joint position demonstrated by an examiner. Tendon jerk was measured as the moment of force in response to patellar tendon taps. Data was collected from 27 limbs of CP patients (N=14) and 36 limbs of able-bodied volunteers (N=18). JPS was less accurate (p=0.014) in limbs with non-exaggerated reflexes (50.28±43.63%) than in control limbs (11.84±10.85%). There was no significant difference (p=0.08) in JPS accuracy between limbs with exaggerated reflexes (18.66±15.50%) and control limbs. Our data suggests that one component of sensorimotor impairment, JPS, is not as commonly affected in CP patients as previously reported. JPS of the knee is reduced in limbs with non-exaggerated reflexes; however in limbs with exaggerated reflexes which is seen in the majority of CP patients, JPS is not affected.

The impact of an external breast prosthesis on the gait parameters of women after mastectomy.

BACKGROUND: An integral part of the recovery process after mastectomy involves the consideration of restorative options, including external prosthesis use; however, only few studies regarding the influence of breast prostheses on functional status have been done. OBJECTIVE: This study aimed to determine whether wearing an external breast prosthesis affects gait in women after a mastectomy. METHODS: Spatiotemporal gait parameters were collected in 40 women, postmastectomy, aged 37 to 70 years, divided into age subgroups of 37 to 54 years and 55 to 70 years, and in 38 healthy controls, women aged 38 to 69 years. Gait parameters were assessed with and without the breast prosthesis, including walking velocity, cadence, step length, step time, and left-right step time asymmetry. RESULTS: Significant differences were found in the gait parameters of the younger age group with and without a prosthesis. No significant differences were found in the women of the older group with and without the prosthesis. CONCLUSION: Gait parameters of the younger age group were closer to those of the healthy control group when they were wearing an external prosthesis, as compared with when they were not. This suggests a positive influence of breast prosthesis use on the functional status of women after mastectomy. IMPLICATIONS FOR PRACTICE: Clinical practitioners should be aware of the study results suggesting a positive influence of breast prosthesis use on gait parameters after mastectomy surgery, which could improve the patient's functional status after surgery; however, further research is still needed on factors affecting changes in gait with a larger study population.

The effect of a hippotherapy session on spatiotemporal parameters of gait in children with cerebral palsy - pilot study.

BACKGROUND: Hippotherapy has been shown to produce beneficial effects by improving the most difficult motor functions, such as sitting, running, jumping, coordination, as well as balance and muscle strength in children with motor developmental delays. The aim of this study was to analyze the effect of hippotherapy on spatiotemporal parameters of gait in cerebrally palsied children. MATERIAL AND METHODS: 16 ambulatory cerebrally palsied children (GMFCS Level I-III; Female: 10, Male: 6; Age: 5.7-17.5 years old) qualified for hippotherapy were investigated. Basic spatiotemporal parameters of gait, including walking speed, cadence, step length, stride length and the left-right symmetry, were collected using a three-dimensional accelerometer device (DynaPort MiniMod) before and immediately after a hippotherapy session. The Wilcoxon test was used to verify the differences between pre- and post-session results. RESULTS: Changes of walking speed were statistically significant. With the exception of step length, all spatiotemporal parameters improved, i.e. were closer to the respective reference ranges after the session. However, these changes were not statistically significant. CONCLUSION: One session of hippotherapy may have a significant effect on the spatiotemporal parameters of gait in cerebrally palsied children.

The gait pattern in post-menopausal women. Pilot study.

BACKGROUND: Aging brings about a number of degenerative changes in the body. The aging process in-creases its pace after the menopause. Women notice functional limitations in their daily lives, including mobility problems, as early as in their forties. Gait is one of the most reliable parameters reflecting the body's overall function and condition. The aim of this study was to determine the effect of menopause on gait patterns in healthy women. MATERIAL AND METHODS: The study involved a group of 48 healthy women (divided into Group A of pre-menopausal women and Group B of post-menopausal women). Gait parameters were acquired by a DynaPort MiniMod accelerometer. The pre- and post-menopausal women's gait data, including spatio-temporal parameters, gait cycle phases and the variability, were analysed. RESULTS: There were no significant differences between Group A and B in walking speed, step length, cadence, and gait phase duration. Significant differences were only noted in gait cycle phases with regard to the onset of single-support of the right limb, the 1st double-support of the right limb and the 2nd double-support of the left limb. Gait variability did not show any significant differences between the groups. CONCLUSIONS: 1. A prolonged stance phase during the gait cycle observed in the post-menopausal women in this study is a typical finding in aged people. 2. However, stride-to-stride variability of gait was not affected in the study.

[Assessment of absolute knee joint linear and angular velocity in patients with spastic cerebral palsy after operative treatment of lever arm disfunction deformities--prospective study]. / Ocena calkowitej predkosci liniowej i katowej stawu kolanowego u chorych z postacia spastyczna mózgowego porazenia po operacyjnym leczeniu tzw. "deformacji dzwigniowozaleznych" konczyn dolnych--badanie prospektywne.

INTRODUCTION: Lever arm dysfunction (LAD) deformities in patients with CP are based on imbalanced forces acting in lower limbs during gait. Muscle imbalance results in bone axial deformities, simultaneously magnifying biomechanical disturbances. Goal. Analysis of knee joint velocity in patients with spastic dipegia treated with use of single event multi level surgery (SEMLS). MATERIAL: 15 patients (21 limbs), mean age--15 years (12-23) at operation, with spastic CP treated with use of SEMLS were included. In all ceases the distal derotational femoral osteotomy, combined with various additional operative correction were performed. Patients were divided into two groups depending on distal RF transfer as a single criteria. METHOD: Patients were examined with use of VICON 460 motion analysis system: before and 12 months after operative treatment. Lower limb joints ROM, with changed parameters of coronal and sagittal plane moments, was subjected to detailed analysis, with assessment of influence of mentioned moments on knee joint absolute LV and AV during terminal stance (TS), toe off (TO) and initial swing (IS). RESULTS: The statistically significant increase in knee joint LV in TS, TO, IS, p < 0,001, before (mean: TS--536.3 mm/s; TO--668.7 mm/s; 826.1 mm/s) and after (mean: TS--828 mm/s; TO--1007.5 mm/s; 174.5 mm/s) treatment was observed and compared to normal healthy adults. The difference in knee joint AV was statistically significant in TS p = 0.018 (mean: before: 82.2 deg/s; after: 81.2 deg/s) and IS p = 0.023 (mean: before: 53 deg/s; after: 20.2 deg/s). CONCLUSIONS: Joints moments improvement, as an outcome of operative treatment, resulted in increase of absolute LV and AV of knee joint towards values of healthy adults, consequently improving CP patients gait.

[Idiopathic toe walking (ITW)--normal or pathological?]. / Idiopatyczne chodzenie na palcach--norma czy patologia?

UNLABELLED: Idiopathic toe walking ITW appears to be a clinical problem in otherwise healthy children after 3 years of age. The definitions includes patients walking on toes permanently and temporally. Goal. definition of kinematical and kinetic determinants of ITW and the use of gait analysis determinants of ITW according to Alvarez. Material and methods. 8 patients, mean age 7 (4-11), were assessed in Motion Analysis Laboratory with clinical examination use of Vicon 460 (Vicon U.K.) and force plates AMTI (Newton USA). Presence of 1st rocker, early 3rd rocker, and predominance of first ankle dorsal flexion moment was assessed. RESULTS: 1st rocker was observed in 2 patients--group I, early 3rd rocker in 2 patients group II, and predominance of ankle flexion moment in 3 patients--group III, 1 patient was not classified due to presence of 1st rocker combined with predominance of dorsal flexion moment. CONCLUSION: thanks to motion analysis we have a tool to differentiate between behavioral and fixed deformities and adjust treatment--physiotherapy, BTX, serial casting or surgical orthopaedic treatment.