"That's frustrating": Perceptions of ankle foot orthosis provision, use, and needs among people with cerebral palsy and caregivers.

BACKGROUND: Cerebral palsy (CP) affects roughly 3 per 1000 births in the United States and is the most common pediatric developmental motor disability. Ankle foot orthoses (AFOs) are commonly prescribed to provide support and improve function for individuals with CP. OBJECTIVES: The study objective was to evaluate the lived experiences of individuals with CP and their caregivers regarding AFO access, use, and priorities. We examined experiences around the perceived purpose of AFOs, provision process, current barriers to use, and ideas for future AFO design. STUDY DESIGN: Secondary qualitative data analysis. METHODS: Secondary data analysis was performed on semistructured focus groups that included 68 individuals with CP and 74 caregivers. Of the focus group participants, 66 mentioned AFOs (16 individuals with CP and 50 caregivers). Deidentified transcripts were analyzed using inductive coding, and the codes were consolidated into themes. RESULTS: Four themes emerged: 1) AFO provision is a confusing and lengthy process, 2) participants want more information during AFO provision, 3) AFOs are uncomfortable and difficult to use, and 4) AFOs can benefit mobility and independence. Caregivers and individuals with CP recommended ideas such as 3D printing orthoses and education for caregivers on design choices to improve AFO design and provision. CONCLUSIONS: Individuals with CP and their caregivers found the AFO provision process frustrating but highlight that AFOs support mobility and participation. Further opportunities exist to support function and participation of people with CP by streamlining AFO provision processes, creating educational materials, and improving AFO design for comfort and ease of use.

Diet quality in adults with cerebral palsy: a modifiable risk factor for cardiovascular disease prevention.

AIM: To assess diet quality and its relationship with cardiovascular health measures for adults with cerebral palsy (CP). METHOD: A convenience sample of 45 adults with CP (26 females, 19 males; mean age 35y 10mo [SD 14y 9mo]). were recruited for this cross-sectional study. Demographic, medical, and Gross Motor Function Classification System (GMFCS) information were obtained through in-person visits. Participants completed two 24-hour dietary recalls using the Automated Self-Administered 24-hour Dietary Assessment Tool. Specific macronutrient intake was compared to 2015 to 2020 US Department of Agriculture (USDA) guidelines. Other data included body mass index (BMI), waist-to-hip ratio (WHR), blood pressure, and hemoglobin A1c (HgA1c;n=43). RESULTS: Adults across GMFCS levels I to V were enrolled, 20 participants were in GMFCS levels IV or V. Mean calorie intake was 1777.91/day (SD 610.54), while sodium intake was 3261.75mg/day (SD 1484.92). Five participants met USDA vegetable and seven fruit guidelines. None met whole grain targets. Sixteen were overweight/obese by BMI. Sixteen participants without hypertension diagnoses had elevated blood pressure and nine had abnormal HgA1c without prediabetes/diabetes history. Percent calories from saturated fat was inversely associated with WHR in unadjusted and adjusted models (p=0.002 and p=0.003 respectively); all other dietary recommendations assessed (total calories, sodium, and sugar) were non-significant. Post hoc analyses were unchanged using 2020 to 2025 USDA guidelines. INTERPRETATION: Assessment of nutrient intake and diet quality is feasible and warrants further study in adults with CP, as USDA guidelines are largely unmet. What this paper adds Adults with cerebral palsy (CP) do not meet US Department of Agriculture dietary quality recommendations. Prediabetes and hypertension may be common, but unrecognized, in adults with CP. Screening for nutrient intake and diet quality should be performed to facilitate nutritional counseling.

Dance and rehabilitation in cerebral palsy: a systematic search and review.

AIM: To conduct a review of research literature on the use of dance and movement with music (rhythmic auditory stimulation [RAS]) in the neurorehabilitation of children and adults with cerebral palsy (CP). METHOD: We conducted a systematic search and quality appraisal of the research literature on dance and RAS in CP. Additionally, we linked the research outcomes to the International Classification of Functioning, Disability and Health (ICF) framework. RESULTS: Studies showed preliminary evidence of the benefits of dance and RAS on body functions, particularly balance, gait, walking, and cardiorespiratory fitness for individuals with CP. Research gaps are evident across all domains of the ICF, particularly in the participation and environment domains. INTERPRETATION: To facilitate translation of quantitative research outcomes to the clinical classification of the ICF, a table was constructed that links traditional areas of quantitative rehabilitation research with the ICF categories highlighting areas of research strengths and areas where increased rigor is desirable. The potential for dance and RAS to have positive impacts on body functions, emotional expression, social participation, and attitudinal change are indicated areas for consideration in future research. WHAT THIS PAPER ADDS: The potential for dance and movement to music help balance, gait, and walking in children and adults with cerebral palsy. Research gaps are evident across International Classification of Functioning, Disability and Health domains, particularly participation and environment domains.

LA DANZA Y LA REHABILITACIÓN EN LA PARÁLISIS CEREBRAL: UNA BÚSQUEDA SISTEMÁTICA Y REVISIÓN: OBJETIVO: Realizar una revisión de la literatura de investigación sobre el uso de la danza y el movimiento con la música (estimulación auditiva rítmica [RAS]) en la neurorrehabilitación de niños y adultos con parálisis cerebral (PC). MÉTODO: Llevamos a cabo una búsqueda sistemática y una evaluación de calidad de la literatura de investigación sobre danza y RAS en PC. Además, vinculamos los resultados de la investigación al marco teórico de la Clasificación Internacional del Funcionamiento, de la Discapacidad y de la Salud (CIF), RESULTADOS: Los estudios mostraron evidencia preliminar de los beneficios de la danza y el RAS en las funciones corporales, particularmente el equilibrio, la marcha, la marcha y la capacidad cardiorrespiratoria para las personas con PC. Las brechas de investigación son evidentes en todos los dominios de la CIF, particularmente en los ámbitos de participación y medio ambiente. INTERPRETACIÓN: Para facilitar la traducción de los resultados de la investigación cuantitativa a la clasificación clínica de la CIF, se construyó una tabla que vincula las áreas tradicionales de investigación de rehabilitación cuantitativa con las categorías CIF. destacando áreas de fortalezas de investigación y áreas donde es deseable un mayor rigor. El potencial de la danza y el RAS para tener un impacto positivo en las funciones corporales, la expresión emocional, la participación social y el cambio de actitud son áreas identificadas para tener en consideración en investigaciones futuras.

DANÇA E REABILITAÇÃO EM PARALISIA CEREBRAL: UMA PESQUISA E REVISÃO SISTEMÁTICA: OBJETIVO: Conduzir uma revisão da literaturs sobre o uso da dança e movimento com música (estimulação auditiva rítmica [EAR]) na neuroreabilitação de crianças e adolescentes com paralisia cerebral (PC). MÉTODO: Conduzimos uma busca sistemática e avaliação de qualidade da literatura sobre dança e EAR em PC. Adicionalmente, relacionamos os resultados da pesquisa com a estrutura da Classificação Internacional de Funcionalidade, Incapacidade e Saúde (CIF). RESULTADOS: Os estudos mostraram evidência preliminar dos benefícios e EAR nas funções do corpo, particularmente equilíbrio, marcha, caminhar e aptidão cárdio-respiratória em indivíduos com PC. Lacunas nas pesquisas são evidentes em todos os domínios da Classificação Internacional de Funcionalidade, Incapacidade e Saúde , particularmente nos domínios de participação e ambiente. INTERPRETAÇÃO: Para facilitar a transição de resultados de pesquisas quantitativas para a classificação clínica da CIF, uma tabela foi elaborada para relacionar áreas tradicionais de pesquisas quantitativas em reabilitação com as categorias da CIF. Foram realçadas áreas de em que pesquisas estão fortes e áreas onde maior rigor é necessário. O potencial da dança e EAR para proporcionar impactos positivos nas funções do corpo, expressão emocional, participação social, e mudança atitudinal são indicados como áreas para consideração em futuras pesquisas.

Gradual increase of perturbation load induces a longer retention of locomotor adaptation in children with cerebral palsy.

The goal of this study is to determine whether the size and the variability of error have an impact on the retention of locomotor adaptation in children with cerebral palsy (CP). Eleven children with CP, aged 7-16 years old, were recruited to participate in this study. Three types of force perturbations (i.e., abrupt, gradual and noisy loads) were applied to the right leg above the ankle starting from late stance to mid-swing in three test sessions while the subject walked on a treadmill. Spatial-temporal gait parameters were recorded using a custom designed 3D position sensor during treadmill walking. We observed that children with CP adapted to the resistance force perturbation and showed an aftereffect consisting of increased step length after load release. Further, we observed a longer retention of the aftereffect for the condition with a gradual load than that with an abrupt load. Results from this study suggested that the size of error might have an impact on the retention of motor adaptation in children with CP with a longer retention of motor adaptation for the condition with a small size of error than that with a large error. In addition, enhanced variability of error seems facilitate motor learning during treadmill training. Results from this study may be used for the development of force perturbation based training paradigms for improving walking function in children with CP.

Robotic Resistance Treadmill Training Improves Locomotor Function in Children With Cerebral Palsy: A Randomized Controlled Pilot Study.

OBJECTIVE: To determine whether applying controlled resistance forces to the legs during the swing phase of gait may improve the efficacy of treadmill training as compared with applying controlled assistance forces in children with cerebral palsy (CP). DESIGN: Randomized controlled study. SETTING: Research unit of a rehabilitation hospital. PARTICIPANTS: Children with spastic CP (N=23; mean age, 10.6y; range, 6-14y; Gross Motor Function Classification System levels, I-IV). INTERVENTIONS: Participants were randomly assigned to receive controlled assistance (n=11) or resistance (n=12) loads applied to the legs at the ankle. Participants underwent robotic treadmill training 3 times a week for 6 weeks (18 sessions). A controlled swing assistance/resistance load was applied to both legs starting from the toe-off to mid-swing phase of gait during training. MAIN OUTCOME MEASURES: Outcome measures consisted of overground walking speed, 6-minute walk distance, and Gross Motor Function Measure scores and were assessed pre and post 6 weeks of training and 8 weeks after the end of training. RESULTS: After 6 weeks of treadmill training in participants from the resistance training group, fast walking speed and 6-minute walk distance significantly improved (18% and 30% increases, respectively), and 6-minute walk distance was still significantly greater than that at baseline (35% increase) 8 weeks after the end of training. In contrast, overground gait speed and 6-minute walk distance had no significant changes after robotic assistance training. CONCLUSIONS: The results of the present study indicated that robotic resistance treadmill training is more effective than assistance training in improving locomotor function in children with CP.

Effects of an Off-Axis Pivoting Elliptical Training Program on Gait Function in Persons With Spastic Cerebral Palsy: A Preliminary Study.

This preliminary study examined the effects of off-axis elliptical training on reducing transverse-plane gait deviations and improving gait function in 8 individuals with cerebral palsy (CP) (15.5 ± 4.1 years) who completed an training program using a custom-made elliptical trainer that allows transverse-plane pivoting of the footplates during exercise. Lower-extremity off-axis control during elliptical exercise was evaluated by quantifying the root-mean-square and maximal angular displacement of the footplate pivoting angle. Lower-extremity pivoting strength was assessed. Gait function and balance were evaluated using 10-m walk test, 6-minute-walk test, and Pediatric Balance Scale. Toe-in angles during gait were quantified. Participants with CP demonstrated a significant decrease in the pivoting angle (root mean square and maximal angular displacement; effect size, 1.00-2.00) and increase in the lower-extremity pivoting strength (effect size = 0.91-1.09) after training. Reduced 10-m walk test time (11.9 ± 3.7 seconds vs. 10.8 ± 3.0 seconds; P = 0.004; effect size = 1.46), increased Pediatric Balance Scale score (43.6 ± 12.9 vs. 45.6 ± 10.8; P = 0.042; effect size = 0.79), and decreased toe-in angle (3.7 ± 10.5 degrees vs. 0.7 ± 11.7 degrees; P = 0.011; effect size = 1.22) were observed after training. We present an intervention to challenge lower-extremity off-axis control during a weight-bearing and functional activity for individuals with CP. Our preliminary findings suggest that this intervention was effective in enhancing off-axis control, gait function, and balance and reducing in-toeing gait in persons with CP.

Effects of the Integration of Dynamic Weight Shifting Training Into Treadmill Training on Walking Function of Children with Cerebral Palsy: A Randomized Controlled Study.

OBJECTIVE: The aim of the study was to determine whether applying an assistance force to the pelvis and legs during treadmill training can improve walking function in children with cerebral palsy. DESIGN: Twenty-three children with cerebral palsy were randomly assigned to the robotic or treadmill only group. For participants who were assigned to the robotic group, a controlled force was applied to the pelvis and legs during treadmill walking. For participants who were assigned to the treadmill only group, manual assistance was provided as needed. Each participant trained 3 times/wk for 6 wks. Outcome measures included walking speed, 6-min walking distance, and clinical assessment of motor function, which were evaluated before, after training, and 8 wks after the end of training, and were compared between two groups. RESULTS: Significant increases in walking speed and 6-min walking distance were observed after robotic training (P = 0.03), but no significant change was observed after treadmill training only. A greater increase in 6-min walking distance was observed after robotic training than that after treadmill only training (P = 0.01). CONCLUSIONS: Applying a controlled force to the pelvis and legs, for facilitating weight-shift and leg swing, respectively, during treadmill training may improve walking speed and endurance in children with cerebral palsy. 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 GMFCS level I, II and III following 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 0.5 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Pilot study of a targeted dance class for physical rehabilitation in children with cerebral palsy.

INTRODUCTION: This pilot study evaluates the effects of a targeted dance class utilizing classical ballet principles for rehabilitation of children with cerebral palsy on balance and upper extremity control. METHODS: Twelve children with cerebral palsy (ages 7-15 years) with Gross Motor Function Classification scores II-IV participated in this study and were assigned to either a control group or targeted dance class group. Targeted dance class group participated in 1-h classes three times per week in a 4-week period. The Pediatric Balance Scale and the Quality of Upper Extremity Skills Test were administered before, after, and 1 month after the targeted dance class. RESULTS: Improvements in the Pediatric Balance Scale were present in the targeted dance class group in before versus after and before versus 1 month follow-up comparisons (p-value = 0.0088 and p-value = 0.019, respectively). The Pediatric Balance Scale changes were not significant in the control group. The Quality of Upper Extremity Skills Test did not reach statistical differences in either group. CONCLUSION: Classical ballet as an art form involves physical training, musical accompaniment, social interactions, and emotional expression that could serve as adjunct to traditional physical therapy. This pilot study demonstrated improvements in balance control. A larger study with a more homogeneous sample is warranted.

Kinematic and EMG Responses to Pelvis and Leg Assistance Force during Treadmill Walking in Children with Cerebral Palsy.

Treadmill training has been used for improving locomotor function in children with cerebral palsy (CP), but the functional gains are relatively small, suggesting a need to improve current paradigms. The understanding of the kinematic and EMG responses to forces applied to the body of subjects during treadmill walking is crucial for improving current paradigms. The objective of this study was to determine the kinematics and EMG responses to the pelvis and/or leg assistance force. Ten children with spastic CP were recruited to participate in this study. A controlled assistance force was applied to the pelvis and/or legs during stance and swing phase of gait through a custom designed robotic system during walking. Muscle activities and spatial-temporal gait parameters were measured at different loading conditions during walking. In addition, the spatial-temporal gait parameters during overground walking before and after treadmill training were also collected. Applying pelvis assistance improved step height and applying leg assistance improved step length during walking, but applying leg assistance also reduced muscle activation of ankle flexor during the swing phase of gait. In addition, step length and self-selected walking speed significantly improved after one session of treadmill training with combined pelvis and leg assistance.

Motor impairment factors related to brain injury timing in early hemiparesis. Part I: expression of upper-extremity weakness.

BACKGROUND: Extensive neuromotor development occurs early in human life, but the time that a brain injury occurs during development has not been rigorously studied when quantifying motor impairments. OBJECTIVE: This study investigated the impact of timing of brain injury on the magnitude and distribution of weakness in the paretic arm of individuals with childhood-onset hemiparesis. METHODS: A total of 24 individuals with hemiparesis were divided into time periods of injury before birth (PRE-natal, n = 8), around the time of birth (PERI-natal, n = 8), or after 6 months of age (POST-natal, n = 8). They, along with 8 typically developing peers, participated in maximal isometric shoulder, elbow, wrist, and finger torque generation tasks using a multiple-degree-of-freedom load cell to quantify torques in 10 directions. A mixed-model ANOVA was used to determine the effect of group and task on a calculated relative weakness ratio between arms. RESULTS: There was a significant effect of both time of injury group (P < .001) and joint torque direction (P < .001) on the relative weakness of the paretic arm. Distal joints were more affected compared with proximal joints, especially in the POST-natal group. CONCLUSIONS: The distribution of weakness provides evidence for the relative preservation of ipsilateral corticospinal motor pathways to the paretic limb in those individuals injured earlier, whereas those who sustained later injury may rely more on indirect ipsilateral corticobulbospinal projections during the generation of torques with the paretic arm.

Motor impairments related to brain injury timing in early hemiparesis. Part II: abnormal upper extremity joint torque synergies.

BACKGROUND: Extensive neuromotor development occurs early in human life, and the timing of brain injury may affect the resulting motor impairment. In Part I of this series, it was demonstrated that the distribution of weakness in the upper extremity depended on the timing of brain injury in individuals with childhood-onset hemiparesis. OBJECTIVE: The goal of this study was to characterize how timing of brain injury affects joint torque synergies, or losses of independent joint control. METHOD: Twenty-four individuals with hemiparesis were divided into 3 groups based on the timing of their injury: before birth (PRE-natal, n = 8), around the time of birth (PERI-natal, n = 8), and after 6 months of age (POST-natal, n = 8). Individuals with hemiparesis and 8 typically developing peers participated in maximal isometric shoulder, elbow, wrist, and finger torque generation tasks while their efforts were recorded by a multiple degree-of-freedom load cell. Motor output in 4 joints of the upper extremity was concurrently measured during 8 primary torque generation tasks to quantify joint torque synergies. RESULTS: There were a number of significant coupling patterns identified in individuals with hemiparesis that differed from the typically developing group. POST-natal differences were most noted in the coupling of shoulder abductors with elbow, wrist, and finger flexors, while the PRE-natal group demonstrated significant distal joint coupling with elbow flexion. CONCLUSION: The torque synergies measured provide indirect evidence for the use of bulbospinal pathways in the POST-natal group, while those with earlier injury may use relatively preserved ipsilateral corticospinal motor pathways.

Locomotor training through a 3D cable-driven robotic system for walking function in children with cerebral palsy: a pilot study.

Locomotor training using treadmill has been shown to elicit significant improvements in locomotor ability for some children with cerebral palsy (CP), the functional gains are relatively small and it requires greater involvement from a physical therapist. Current robotic gait training systems are effective in reducing the strenuous work of a physical therapist during locomotor training, but are less effective in improving locomotor function in some children with CP due to the limitations of the systems. Thus, a 3D cable-driven robotic gait training system was developed and tested in five children with CP through a 6 week of long-term gait training. Results indicated that both overground walking speed and 6 minute walking distance improved after robot assisted treadmill training through the cable-driven robotic system, and partially retained at 8 weeks after the end of training. Results from this pilot study indicated that it seems feasible to conduct locomotor training in children with CP through the 3D cable-driven robotic system.

Pallidal deep-brain stimulation associated with complete remission of self-injurious behaviors in a patient with Lesch-Nyhan syndrome: a case report.

The purpose of this case report is to review the management of a boy with Lesch-Nyhan syndrome with deep-brain stimulation who had remission of self-injurious behaviors as a result. This patient was treated with intrathecal baclofen and, later, with deep-brain stimulation to reduce hypertonia. Goals were to improve wheelchair positioning for school attendance and to reduce the use of restraints for comfort. Intrathecal baclofen was implanted twice and decreased the hypertonia, but both were explanted because of infection. Deep-brain stimulation was initiated 2.5 years ago, and since that time, comfort and function have improved and caregiver burden has decreased. Improvements in dystonia with deep-brain stimulation have also occurred, and self-injurious behaviors have resolved.

Measuring care and comfort in children with cerebral palsy: the care and comfort caregiver questionnaire.

OBJECTIVE: To evaluate the psychometric properties of the Care and Comfort Caregiver Questionnaire (CareQ), which was developed to measure the perceived effort of caregivers in providing care for children with moderate to severe cerebral palsy (CP). DESIGN: Cross-sectional data collection from a representative sample of a large racially/ethnically diverse geographic region. SETTING: Outpatient CP clinics at a metropolitan rehabilitation institution. PARTICIPANTS: A total of 100 primary caregivers of children with CP whose Gross Motor Function Classification System (GMFCS) levels were III-V. METHODS: The CareQ was administered to primary caregivers of children with CP. Internal consistency of the CareQ and its 3 domains (Personal Care, Positioning/Transfers, and Comfort) were evaluated with the Cronbach α. Construct validity of the CareQ was evaluated by its correlation with the Pediatric Functional Independence Measure (WeeFIM). Associations between CareQ scores and child and caregiver characteristics were assessed. RESULTS: Mean CareQ scores for children with GMFCS levels III, IV, and V were 30.6, 42.8, and 45.1, respectively (P < .01). The Cronbach α was 0.90 for total CareQ and 0.93, 0.80, and 0.82 for its Personal Care, Positioning/Transfers, and Comfort domains, respectively. Total CareQ and WeeFIM scores were negatively correlated (r = -.22; P = .03). Total CareQ scores were positively correlated with the child's age (r = .38; P < .01) and with body weight (r =.37; P < .01); however, no caregiver characteristics were associated with CareQ scores. CONCLUSIONS: The CareQ is a concise and internally consistent measure of difficulty of care as perceived by caregivers of children whose GMFCS levels were III-V. Further investigation should include assessment of responsiveness of the CareQ to changes in the child's functional status over time and/or with rehabilitation interventions.

Quantitative evaluations of ankle spasticity and stiffness in neurological disorders using manual spasticity evaluator.

Spasticity and contracture are major sources of disability in people with neurological impairments that have been evaluated using various instruments: the Modified Ashworth Scale, tendon reflex scale, pendulum test, mechanical perturbations, and passive joint range of motion (ROM). These measures generally are either convenient to use in clinics but not quantitative or they are quantitative but difficult to use conveniently in clinics. We have developed a manual spasticity evaluator (MSE) to evaluate spasticity/contracture quantitatively and conveniently, with ankle ROM and stiffness measured at a controlled low velocity and joint resistance and Tardieu catch angle measured at several higher velocities. We found that the Tardieu catch angle was linearly related to the velocity, indicating that increased resistance at higher velocities was felt at further stiffer positions and, thus, that the velocity dependence of spasticity may also be position-dependent. This finding indicates the need to control velocity in spasticity evaluation, which is achieved with the MSE. Quantitative measurements of spasticity, stiffness, and ROM can lead to more accurate characterizations of pathological conditions and outcome evaluations of interventions, potentially contributing to better healthcare services for patients with neurological disorders such as cerebral palsy, spinal cord injury, traumatic brain injury, and stroke.

Efficacy of robotic rehabilitation of ankle impairments in children with cerebral palsy.

The current study introduces a novel rehabilitation robot for treatment of impaired ankle in children with cerebral palsy (CP). The treatment consisted of passive stretching under intelligent control and active movement training with motivating game-playing using the portable robot. After 18 sessions of training (3 sessions/week for 6 weeks), we found significant improvement in 12 children with CP in terms of improved passive and active ranges of motion, selective motor control and mobility functions. The positive outcomes of this study along with the improvements in motor control and functional activities suggest that robotic rehabilitation provides a useful and convenient option of treatment in clinic or patient home for more accessible and frequent rehabilitation.

Changes of calf muscle-tendon properties due to stretching and active movement of children with cerebral palsy--a pilot study.

A portable ankle rehabilitation robot with intelligent stretching and game-based active movement training was used to treat the spastic impaired ankle of children with cerebral palsy over six weeks. The subject's calf muscles and Achilles tendon properties were evaluated before and after treatment using ultrasonography and biomechanical measures. It was found that there were decreased Achilles tendon resting length (2.5%), increased cross-sectional area (5.5%), increased stiffness (22.9%), increased Young's modulus (13.8%), decreased soleus muscle fascicular stiffness (53.7%), and decreased medial gastrocnemius fascicular stiffness (46.1%).