Energy Efficiency in Children With Myelomeningocele During Acute Use of Assistive Devices: A Pilot Study.

Due to increased metabolic demands during walking, ∼50% of children with myelomeningocele transition to wheelchair use during adolescence/early adulthood. The purpose of our pilot study involving children with myelomeningocele was to determine: (a) energy expenditure needs during acute use of common assistive devices and (b) if walking poles are a feasible assistive device. Oxygen uptake was recorded for eight (5-12 years old) children in four conditions: independent, walker, crutches, and poles. Acute pole use did not significantly differ from independent walking net energy consumption or cost. Participants consumed more energy while walking with the walker than independently. Our pilot results suggest that (a) acute use of common assistive devices while walking increases energy consumption and cost versus independent and (b) poles are feasible assistive devices, resulting in slightly increased energy requirements. Poles may have provided "just enough" support with minimal change in energy requirements for our participants and, with practice, may enable children with myelomeningocele to remain community ambulators.

Developmental changes in motor cortex activity as infants develop functional motor skills.

Despite extensive research examining overt behavioral changes of motor skills in infants, the neural basis underlying the emergence of functional motor control has yet to be determined. We used functional near-infrared spectroscopy (fNIRS) to record hemodynamic activity of the primary motor cortex (M1) from 22 infants (11 six month-olds, 11 twelve month-olds) as they reached for an object, and stepped while supported over a treadmill. Based on the developmental systems framework, we hypothesized that as infants increased goal-directed experience, neural activity shifts from a diffused to focal pattern. Results showed that for reaching, younger infants showed diffuse areas of M1 activity that became focused by 12 months. For elicited stepping, younger infants produced much less M1 activity which shifted to diffuse activity by 12 months. Thus, the data suggest that as infants gain goal-directed experience, M1 activity emerges, initially showing a diffuse area of activity, becoming refined as the behavior stabilizes. Our data begin to document the cortical activity underlying early functional skill acquisition.

Bone Mineral Content in Infants With Myelomeningocele, With and Without Treadmill Stepping Practice.

PURPOSE: To study development of bone mineral content (BMC) in infants with myelomeningocele (MMC) who did or did not receive upright supported stepping practice (USSP) and in infants with typical development (TD). METHODS: We tested 36 infants across the ages of 1 to 18 months. Dual-energy x-ray absorptiometry was used to collect raw BMC data for the whole body, legs, and arms, which were normalized using anthropometrics. RESULTS: Whole-body BMC generally increased with age; values for infants with MMC were slightly lower than those for infants with TD. Bone mineral content for legs and arms was lower for infants with MMC than for infants with TD. Between MMC groups, the group receiving USSP showed increases in BMC with age. CONCLUSION: Bone mineralization in infants with MMC begins to lag compared with infants with TD across infancy, and daily USSP can improve BMC as early as the first year of life.

Early gait development in human infants: Plasticity and clinical applications.

In this paper we focus on how a developmental perspective on plasticity in the control of human movement can promote early therapy and improve gait acquisition in infants with developmental disabilities. Current knowledge about stepping development in healthy infants across the first year of life highlights strong plasticity, both in behavioral outcome and in underlying neuro-muscular activation. These data show that stepping, like other motor skills, emerges from the interaction between infant's maturation and the environment. This view is reinforced by showing that infants with different internal resources (like genetic disorder or neural tube defect) show unique developmental trajectories when supported on a treadmill, yet do respond. Moreover, we will show that their behavior can be improved by context manipulations (mostly sensory stimulation) or practice. Overall, plasticity in the neural, skeletal, and muscle tissues create new opportunities for optimizing early intervention by creatively tapping into the same developmental processes experienced by healthy infants.

Muscle activation patterns in infants with myelomeningocele stepping on a treadmill.

PURPOSE: To characterize how infants with myelomeningocele (MMC) activate lower limb muscles over the first year of life, without practice, while stepping on a motorized treadmill. METHODS: Twelve infants with MMC were tested longitudinally at 1, 6, and 12 months. Electromyography was used to collect data from the tibialis anterior, lateral gastrocnemius, rectus femoris, biceps femoris. RESULTS: Across the first year, infants showed no electromyographic activity for approximately 50% of the stride cycle with poor rhythmicity and timing of muscles, when activated. Single muscle activation predominated; agonist-antagonist coactivation was low. Probability of individual muscle activity across the stride decreased with age. CONCLUSIONS: Infants with MMC show high variability in timing and duration of muscle activity, few complex combinations, and very little change over time.

Longitudinal changes in muscle activity during infants' treadmill stepping.

Previous research has described kinetic characteristics of treadmill steps in very stable steppers, in cross-sectional designs. In this study we examined, longitudinally, muscle activation patterns during treadmill stepping, without practice, in 12 healthy infants at 1, 6, and 12 mo of age. We assessed lateral gastrocnemius, tibialis anterior, rectus femoris, and biceps femoris as infants stepped on a treadmill during twelve 20-s trials. Infants showed clear changes in kinematics, such as increased step frequency, increased heel contact at touch down, and more flat-footed contact at midstance. Electromyographic data showed high variability in muscle states (combinations), with high prevalence of all muscles active initially, reducing with age. Agonist-antagonist muscle coactivation also decreased as age increased. Probability analyses showed that across step cycles, the likelihood a muscle was on at any point tended to be <50%; lateral gastrocnemius was the exception, showing an adultlike pattern of probability across ages. In summary, over time, healthy infants produce a wide variety of muscle activation combinations and timings when generating stepping patterns on a treadmill, even if some levels of muscle control arose with time. However, the kinematic stability improved much more clearly than the underlying kinetic strategies. We conclude that although innate control of limb movement improves as infants grow, explore, and acquire functional movement, stepping on a treadmill is a novel and unpracticed one. Hence, developing stable underlying neural activations will only arise as functional practice ensues, similarly to that observed for other functional movements in infancy.

Functioning of peripheral Ia pathways in infants with typical development: responses in antagonist muscle pairs.

In muscle responses of proprioceptive origin, including the stretch/tendon reflex (T-reflex), the corresponding reciprocal excitation and irradiation to distant muscles have been described from newborn infants to older adults. However, the functioning of other responses mediated primarily by Ia-afferents has not been investigated in infants. Understanding the typical development of these multiple pathways is critical to determining potential problems in their development in populations affected by neurological disease, such as spina bifida or cerebral palsy. Hence, the goal of the present study was to quantify the excitability of Ia-mediated responses in lower limb muscles of infants with typical development. These responses were elicited by mechanical stimulation applied to the distal tendons of the gastrocnemius-soleus (GS), tibialis anterior (TA) and quadriceps (QAD) muscles of both legs in twelve 2- to 10-month-old infants and recorded simultaneously in antagonist muscle pairs by surface EMG. Tendon taps alone elicited responses in either, both or neither muscle. The homonymous response (T-reflex) was less frequent in the TA than the GS or QAD muscle. An 80 Hz vibration superimposed on tendon taps induced primarily an inhibition of monosynaptic responses; however, facilitation also occurred in either muscle of the recorded pair. These responses were not influenced significantly by age or gender. Vibration alone produced a tonic reflex response in the vibrated muscle (TVR) and/or the antagonist muscle (AVR). However, for the TA muscle the TVR was more frequently elicited in older than younger infants. High variability was common to all responses. Overall, the random distribution and inconsistency of muscle responses suggests that the gain of Ia-mediated feedback is unstable. We propose that during infancy the central nervous system needs to learn to set stable feedback gain, or destination of proprioceptive assistance, based on their use during functional movements. This will tailor the neuromuscular connectivity to support adaptive motor behaviors.

Patterns of gait variability across the lifespan in persons with and without down syndrome.

BACKGROUND AND PURPOSE: Greater gait variability has been observed in persons with Down syndrome (DS). An understanding of baseline patterns of variability, how these patterns relate to adaptive control of gait, and whether increasing or decreasing variability is better is necessary for physical therapists to determine whether and when to intervene. Our aim was to describe patterns of gait variability across the lifespan in persons with DS. METHODS: We examined differences in patterns of gait variability in new walkers, preadolescents, and adults with DS and typical development (TD). We collected kinematic data, while participants walked on a treadmill, and analyzed the data using the nonlinear measures of Lyapunov Exponent (LyE) and Approximate Entropy (ApEn). RESULTS: Beyond the greater gait variability demonstrated across the lifespan in persons with DS compared with their peers with TD, we report herein significant differences in nonlinear measures of patterns of variability. Preadolescents demonstrated higher LyE and ApEn values than new walkers and adults, suggesting that they are more adaptive in their use of variability during gait. CONCLUSION: From a clinical perspective, our results suggest that it may be of value to focus interventions on increasing adaptive use of variability during gait in new walkers and adults with DS. Experience with increased variability through practice under variable conditions or with perturbations may improve adaptive use of variability during gait.

Approximate entropy values demonstrate impaired neuromotor control of spontaneous leg activity in infants with myelomeningocele.

PURPOSE: One obstacle to providing early intervention to infants with myelomeningocele (MMC) is the challenge of quantifying impaired neuromotor control of movements early in life. METHODS: We used the nonlinear analysis tool Approximate Entropy (ApEn) to analyze periodicity and complexity of supine spontaneous lower extremity movements of infants with MMC and typical development (TD) at 1, 3, 6, and 9 months of age. RESULTS: Movements of infants with MMC were more regular and repeatable (lower ApEn values) than movements of infants with TD, indicating less adaptive and flexible movement patterns. For both groups ApEn values decreased with age, and the movements of infants with MMC were less complex than movements of infants with TD. Further, for infants with MMC, lesion level and age of walking onset correlated negatively with ApEn values. CONCLUSIONS: Our study begins to demonstrate the feasibility of ApEn to identify impaired neuromotor control in infants with MMC.

Impact of enhanced sensory input on treadmill step frequency: infants born with myelomeningocele.

PURPOSE: To determine the effect of enhanced sensory input on the step frequency of infants with myelomeningocele (MMC) when supported on a motorized treadmill. METHODS: Twenty-seven infants aged 2 to 10 months with MMC lesions at, or caudal to, L1 participated. We supported infants upright on the treadmill for 2 sets of 6 trials, each 30 seconds long. Enhanced sensory inputs within each set were presented in random order and included baseline, visual flow, unloading, weights, Velcro, and friction. RESULTS: Overall friction and visual flow significantly increased step rate, particularly for the older subjects. Friction and Velcro increased stance-phase duration. Enhanced sensory input had minimal effect on leg activity when infants were not stepping. CONCLUSIONS: : Increased friction via Dycem and enhancing visual flow via a checkerboard pattern on the treadmill belt appear to be more effective than the traditional smooth black belt surface for eliciting stepping patterns in infants with MMC.

Lateral stabilization improves walking in people with myelomeningocele.

Muscle weakness and sensory deficits in people with myelomeningocele (MMC) make their walking control a greater challenge. We know little about how people with MMC optimize their walking balance. Recently, researchers have argued that medial-lateral control of gait requires more active neural input than the anterior-posterior direction, which is more passive. Our goal was to investigate the effect of providing external lateral stabilization (ELS) on walking patterns in people with MMC. We examined 12 people with MMC who could perform at least 4-6 independent steps. We found that the normalized step width (SW) was decreased 20% from without stabilizer to with stabilizer, where as the normalized step length (SL) was increased 4.17% from without stabilizer to with stabilizer. The ELS resulted in 25.10% reduction in centre of mass (COM) ranges of motions in the medial-lateral direction and 13.43% reduction in pelvic range of motions in the frontal plane. Our results suggested that by decreasing the medial-lateral control demands in people with MMC, we could improve gait with smaller SW, longer SL as well as reduced COM and pelvic ranges of motion in the frontal plane. In addition, ELS decreased energy cost and muscle co-activation of soleus and vastus lateralis that may help in diminishing the chances of pain and fatigue in people with MMC. Exploring the effect of the ELS provided us information that might be used to increase mobility safety and to develop a superior rehabilitation intervention for people with MMC.

Early onset of stabilizing strategies for gait and obstacles: older adults with Down syndrome.

Our goal was to examine the gait patterns of older adults with Down syndrome (DS) for precocious stabilizing adaptations during comfortable over-ground walking and in more challenging conditions. Twelve participants with DS and 12 with typical development (TD) were matched for height, weight and age (range 35-62 years). We used a six-camera motion capture system to assess foot trajectories over obstacles. Participants first walked at their preferred speed over a 5.3 m instrumented gait mat (unperturbed condition). Subsequent walking trials included perturbations mid-walkway: (a) minimal obstacle to step over (12 cm high), (b) moderate obstacle to step onto with both feet and then off (standard step), and (c) maximum obstacle to step onto with only one foot and over with the other (standard step). Adults with DS walked slower with shorter, wider strides while spending more time in both stance and double support. These adaptations increased during the moderate and maximal perturbations. They stepped with the minimal perturbation obstacle further forward in their crossing step and produced a lower, flatter trajectory of the lead foot, with less dorsiflexion at crossing. This strategy decreased trailing toe clearance but did not alter leading heel clearance. The combined effects of ligamentous laxity, low tone, obesity, inactivity and physiological decrements associated with aging lead to these stability-enhancing adaptations at a younger chronological age in adults with DS. We believe intervention to increase overall stability will be beneficial in helping adults with DS maintain optimal functional mobility and health.

Early spontaneous leg movements in infants born with and without myelomeningocele.

PURPOSE: To compare quantity and quality of spontaneous leg movements during early infancy in babies with myelomeningocele (MMC) and babies with typical development (TD). METHODS: Nine infants with MMC and 12 with TD moved spontaneously while supine for 5 minutes at ages 1, 3, and 6 months. We used a 6-camera system to monitor leg movements. Resultant leg displacement and velocity were used to determine movement frequency and, for each movement, duration, distance, peak velocity, jerk, and number of acceleration peaks. RESULTS: Movements of infants with MMC were shorter in duration with fewer acceleration peaks than their peers. Asymmetrical interlimb frequencies in infants with TD resulted in one leg moving more than the other, which was similar to the lower symmetrical interlimb frequencies of infants with MMC. CONCLUSIONS: Infants with MMC show depressed movement activity. Further research is needed to determine if therapy can facilitate spontaneous activity and leg control.

Uncontrolled manifold analysis of segmental angle variability during walking: preadolescents with and without Down syndrome.

The uncontrolled manifold (UCM) approach allows us to address issues concerning the nature of variability. In this study we applied the UCM analysis to gait and to a population known for exhibiting high levels of performance variability, Down syndrome (DS). We wanted to determine if preadolescents (ages between 8 and 10) with DS partition goal-equivalent variability (UCM( ||)) and non-goal equivalent variability differently than peers with typical development (TD) and whether treadmill practice would result in utilizing greater amounts of functional, task-specific variability to accomplish the task goal. We also wanted to determine how variance is structured with respect to two important performance variables: center of mass (COM) and head trajectory at one specific event (i.e., heel contact) for both groups during gait. Preadolescents with and without DS walked on a treadmill below, at, and above their preferred overground speed. We tested both groups before and after four visits of treadmill practice. We found that children with DS partition more UCM( ||) variance than children with TD across all speeds and both pre and post practice. The results also suggest that more segmental configuration variance was structured such that less motion of COM than head position was exhibited at heel contact. Overall, we believe children with DS are employing a different control strategy to compensate for their inherent limitations by exploiting that variability that corresponds to successfully performing the task.

Scaling of dynamics in the earliest stages of walking.

BACKGROUND AND PURPOSE: Although the description of mature walking is fairly well established, less is known about what is being learned in the process. Such knowledge is critical to the physical therapist who wants to teach children with developmental delays. The purpose of this experiment was to test the notion that learning to walk efficiently involves fine-tuning the body's controllable stiffness (by co-contraction and isometric muscle contractions against gravity) to match (at a 1:1 scaling) the gravitational (pendular) stiffness of the swing leg. SUBJECTS: The study participants were 7 children with typical development and the newly emerged ability to walk 6 steps without falling (ages 11 months to 1 year 5 months at the onset of walking). METHODS: Pendular stiffness and spring stiffness were estimated from the equations of motion for a hybrid model with kinematic data as children walked over ground. Testing occurred once per month for the first 7 months of walking. RESULTS: After the first month of walking, children walked with greater spring stiffness than would be predicted by the model. The ratio began to approach the predicted value (1:1) as the months progressed. DISCUSSION AND CONCLUSION: The results of this and a previous study of the pendular dynamics of gait suggest that learning to walk is a 2-stage process. The first stage involves the child's discovery of how to conserve energy by inputting a particular muscular force at the correct moment in the cycle. The second stage involves the fine-tuning of the soft-tissue stiffness that takes advantage of the resonance characteristics of tissues. In order to address developmental delays, investigators must discover the dynamic resources used for the activity and attempt to foster their development. A number of interventions that probe this approach are discussed.

Effect of practice on a novel task--walking on a treadmill: preadolescents with and without Down syndrome.

BACKGROUND AND PURPOSE: The authors propose that preadolescents with Down syndrome (DS) initially adapt to contexts that challenge their stability by increasing stiffness and impulse but, with practice, they will continue to adapt, but in the opposite direction, by decreasing stiffness and impulse. The purpose of this study was to explore changes in stiffness and impulse values of participants with DS after sufficient, task-specific practice distributed over time in a motivating environment. SUBJECTS: Eight preadolescents with DS and 8 preadolescents with typical development (TD) participated. METHODS: At pretest and posttest visits, participants walked over ground at their preferred speed and on a treadmill at 40%, 75%, and 110% of their over-ground speed. Practice included 4 sessions of treadmill walking at 75% of over-ground speed for 12 minutes, with approximately 800 strides per leg per session. RESULTS: The preadolescents with DS had reduced stiffness and impulse values following walking practice while still producing kinematic patterns uniquely different from those of their peers with TD. DISCUSSION AND CONCLUSION: Preadolescents with DS can adjust their dynamic resources, both upward and downward. With practice, they can maintain stability while improving efficiency, producing stiffness and impulse values more like those of their peers with TD.

Early stage of walking: development of control in mediolateral and anteroposterior directions.

The authors examined the changes in bipedal gait of toddlers in the anteroposterior (AP) and mediolateral (ML) directions, as a set, at the onset of independent gait and 1 month after onset. Two groups with distinctly different dynamic resources were studied: 8 toddlers with typical development (TD) and 8 toddlers with Down syndrome (DS). Three-dimensional kinematic data were collected, and gait parameters, such as walking speed, stride length, and stride frequency, as well as the ratio of exchange between potential energy and kinetic energy of the center of mass (COM), were calculated. Displacement of the COM in the AP and ML directions were also analyzed. For some gait variables, toddlers with DS seemed to show more mature values at walking onset than their peers with TD. Those group differences reversed and increased by Visit 2. When the authors considered the motion of the COM of the system, it became clear that the qualitative differences between those groups were characterized primarily by constraints in the ML direction. The authors propose that establishment of coupling between AP and ML oscillations is a key component for the emergence of independent bipedal walking for both populations.

Changes in step variability of new walkers with typical development and with Down syndrome.

Models of human gait are based on adult locomotion. C. E. Bauby and A. D. Kuo (2000) proposed that adults rely on passive mechanisms at the spinal level to control motion in the anteroposterior direction and rely on direct monitoring of postural control in the lateral direction. The authors' purpose in this study was to determine if that model applies to control at the onset of walking in typically developing toddlers (n = 9) and in toddlers with Down syndrome (n = 6). Their longitudinal data suggested that toddlers control gait in a distinctly different manner than adults do. An adult pattern of control emerges with experience. In addition, the effect of experience on the emergence of that pattern is magnified by task-specific early intervention. The present data support the emergence and discovery of efficient patterns of control in this fundamental human behavior.

Discovery of the pendulum and spring dynamics in the early stages of walking.

The authors investigated the self-selected, overground walking patterns of 7 children (aged 11 months to 1 year, 5 months) at the initiation of walking (brand-new walkers [BNWs]) and for the next 6 months at 1-month intervals. Walking speed, stride length, and stride frequency increased significantly between the first 2 visits without significant changes in height and weight. The authors calculated sagittal plane angular accelerations of the center of mass over the foot for each step as an indicator of the escapement pulse. Results for the acceleration profiles changed after the 1st visit to positive, single-peaked accelerations that occurred < 0.20 s after initial foot contact. Increases in sagittal plane hip angular displacement and decreases in frontal plane pelvic angular displacement were observed. The pattern changes suggest that children quickly discover appropriately timed and directed escapements that initiate and support the conservative sagittal plane pendulum and spring dynamics observed in older children.

Functioning of peripheral Ia pathways in leg muscles of newly walking toddlers.

Monosynaptic and polysynaptic spinal level reflexes in the leg muscles of infants show significant dispersion across muscles, high variability, and no change in response patterns over the first 10 months. Here we tested the hypothesized relation between early walking experience and the tuning of these responses in three primary gait muscles of participants in four subgroups: cruisers (n=7) and toddlers with one (n=5), two (n=5), or three (n=5) months of walking experience. Reflex responses in multiple Ia pathways - tendon reflex (T-reflex), vibration-induced inhibition of the T-reflex (VIM-T-reflex), and tonic vibration-induced reflex (VIR), were elicited by mechanical stimuli applied to the distal tendons of the quadriceps, gastrocnemius-soleus, and tibialis anterior of both legs. Walking skill was assessed via a GAITRite mat. Generally, walking experience seemed to be related to slowly emerging improvements and, depending on muscle tested and pathway, progress was quite varied. Amplitude and latency of reflex responses were more clearly impacted by age or leg length while the ratio or distribution pattern of reflex response among antagonist pairs of muscles was impacted by walking experience and skill. As walking experience increased, the ratio of reflex responses tended to increase for the stimulated and decrease for the antagonist reflex loops with distribution of the pattern shifting gradually toward a single type of reflex response in all tested muscles. The very slow tuning of these reflexes may underlie the many missteps and falls reported to occur during early walking and suggest that subsequent studies should continue to follow the developmental trajectory through the first year of walking experience.