Anita Bagley

A method for determination of upper extremity kinematics

Kinematic analysis of the upper extremity has been conducted using a wide variety of techniques, philosophies, and analytic methods. We describe a simple, marker-based three-dimensional video analytic technique that borrows concepts from lower extremity kinematic analysis. A sequential rotation order about orthogonal axes is described, although alternate methods are examined as well. The method has been verified by application to a mechanical model. In certain positions, gimbal lock may occur, and a different sequence of rotational decomposition may be required. Agreement on standardization of technique would assist in the dissemination of upper extremity scientific data.

A Biomechanical Analysis of Gait During Pregnancy

Background: There are many anatomical changes during pregnancy that could potentially lead to substantial alterations in gait. Gait deviations may contribute to a variety of musculoskeletal overuse conditions associated with pregnancy, such as low-back, hip, and calf pain. Because we are aware of little research on this topic, the purpose of this study was to objectively analyze gait during pregnancy. Methods: Three-dimensional gait analysis was performed on fifteen women during the second half of the last trimester of pregnancy and again one year post partum. Selected kinematic and kinetic parameters for the pregnancy and one-year postpartum conditions were compared with use of paired t tests (95 percent significance level). Results: Overall, gait kinematics were remarkably unchanged during pregnancy. No evidence of a so-called waddling gait during pregnancy was found. Maximum anterior pelvic tilt during gait increased a mean of 4 degrees during pregnancy, although individual subject-to-subject variation (range, an increase of 13 degrees to a decrease of 10 degrees) was observed. Significant increases in hip and ankle kinetic gait parameters, however, were observed during pregnancy (p < 0.05). Conclusions: Significant increases in kinetic gait parameters during pregnancy (p < 0.05) explain how gait motion remained relatively unchanged despite increases in body mass and width as well as changes in mass distribution about the trunk. This finding indicates that during pregnancy there may be an increased demand placed on hip abductor, hip extensor, and ankle plantar flexor muscles during walking. Clinical Relevance: Many of the common musculoskeletal problems associated with pregnancy may be due, in part, to musculoskeletal overuse injuries incurred as a consequence of secondary gait deviations that compensate for changes in body mass and distribution. Physicians caring for pregnant women with musculoskeletal problems should emphasize the value of exercise and conditioning during pregnancy for both preventative and rehabilitative management.

Outcome tools used for ambulatory children with cerebral palsy: responsiveness and minimum clinically important differences

This prospective longitudinal multicenter study of ambulatory children with cerebral palsy (CP) examined changes in outcome tool score over time, tool responsiveness, and used a systematic method for defining minimum clinically important differences (MCIDs). Three hundred and eighty‐one participants with CP (Gross Motor Function Classification System [GMFCS] Levels I–III; age range 4–18y, mean age 11y [SD 4y 4mo]; 265 diplegia, 116 hemiplegia; 230 males, 151 females). At baseline and follow‐up at least 1 year later, Functional Assessment Questionnaire, Gross Motor Function Measure, Pediatric Quality of Life Inventory, Pediatric Outcomes Data Collection Instrument, Pediatric Functional Independence Measure, temporal–spatial gait parameters, and oxygen cost were collected. Adjusted standardized response means determined tool responsiveness for nonsurgical (n=292) and surgical (n=87) groups at GMFCS Levels I to III. Most scores reaching medium or large effect sizes were for GMFCS Level III. Nonsurgical group change scores were used to calculate MCID thresholds for ambulatory children with CP. These values were verified by examining participants who changed GMFCS levels. Tools measuring function were responsive when a change large enough to cause a change in GMFCS level occurred. MCID thresholds assess change in study populations over time, and serve as the basis for designing prospective intervention studies.

Gross motor function classification System and outcome tools for assessing ambulatory cerebral palsy: a multicenter study

The relationships between different levels of severity of ambulatory cerebral palsy, defined by the Gross Motor Function Classification System (GMFCS), and several pediatric outcome instruments were examined. Data from the Gross Motor Function Measure (GMFM), Pediatric Orthopaedic Data Collection Instrument (PODCI), temporal-spatial gait parameters, and oxygen cost were collected from six sites. The sample size for each assessment tool ranged from 226 to 1047 participants. There were significant differences among GMFCS levels I, II, and III for many of the outcome tools assessed in this study. Strong correlations were seen between GMFCS level and each of the GMFM sections D and E scores, the PODCI measures of Transfer and Mobility, and Sports and Physical Function, Gait Velocity, and Oxygen Cost. Correlations among tools demonstrated that the GMFM sections D and E scores correlated with the largest number of other tools. Logistic regression showed GMFM section E score to be a significant predictor of GMFCS level. GMFM section E score can be used to predict GMFCS level relatively accurately (76.6%). Study data indicate that the assessed outcome tools can distinguish between children with different GMFCS levels. This study establishes justification for using the GMFCS as a classification system in clinical studies.

Family needs of parents of children and youth with cerebral palsy

BACKGROUND Understanding the needs of families of children and youth with cerebral palsy (CP) is important for family-centred services. The aims of this study were to identify: (1) differences in the number and types of family needs expressed by parents based on the age and gross motor function level of their children with CP; (2) the most frequent family needs; and (3) needs that differ on gross motor function level. METHODS A total of 501 parents (77.6% mothers) of children and youth with CP completed a modified version of a Family Needs Survey and a demographic questionnaire. Childrens gross motor function level was classified using the Gross Motor Function Classification System. RESULTS Total number of family needs differed based on gross motor function level (P < 0.001) but not age. Parents of children/youth who use wheeled mobility expressed the highest number of family needs, while parents of children/youth who walk without restrictions expressed the fewest needs. Family needs for Information (P= 0.001), Support (P= 0.001), Community Services (P < 0.001) and Finances (P < 0.001) differed based on childrens gross motor function level. Over 50% of parents expressed family needs for information on current and future services, planning for the future, help in locating community activities and more personal time. Parents of children and youth who use wheeled mobility were more likely to express the need for help in paying for home modifications, equipment, services and locating sitters, respite care providers and community activities. CONCLUSIONS The gross motor function of children/youth with CP has implications for collaboration with families to identify needs and co-ordinate services. Health professionals have a role to assist families with information needs and locating community services and leisure activities. Family needs for future planning suggest that health professionals should assist families to prepare for key periods in the lives of their children with CP.

Outcome assessments in children with cerebral palsy, Part I: descriptive characteristics of GMFCS Levels I to III

This prospective cross‐sectional multicenter study assessed the relationships between Gross Motor Function Classification System (GMFCS) level and scores on outcome tools used in pediatric orthopedics. Five hundred and sixty‐two participants with cerebral palsy (CP; 339 males, 223 females; age range 4‐18y, mean age 11y 1mo [SD 3y 7mo]; 400 with diplegia, 162 with hemiplegia; GMFCS Levels I‐III;) completed the study. The Functional Assessment Questionnaire (FAQ), Gross Motor Function Measure (GMFM) Dimensions D and E, Pediatric Quality of Life Inventory (PedsQL), the Pediatric Outcomes Data Collection Instrument (PODCI), Pediatric Functional Independence Measure (WeeFIM), temporal‐spatial gait parameters, and O2 cost were collected during one session. Descriptive characteristics are reported by GMFCS level clinicians can use for comparison with individual children. Tools with a direct relationship between outcome scores and GMFCS levels were the PODCI Parent and Child Global Function, Transfers & Basic Mobility, and Sports and Physical Function; PODCI Parent Upper Extremity Function; WeeFIM Self‐care and Mobility; FAQ Question 1; GMFM Dimensions D and E; GMFM‐66; O2 cost; and temporal‐spatial gait parameters. Child report scores differed significantly higher than Parent scores for six of eight PODCI subscales and three of four PedsQL dimensions. Children classified into different GMFCS levels function differently.

Impact of Prostheses on Function and Quality of Life for Children with Unilateral Congenital Below-the-Elbow Deficiency

BACKGROUND Children with unilateral congenital below-the-elbow deficiency present a dilemma to clinicians. Parents want the child to have a prosthesis and, because it seems that the deficiency will cause functional problems, one is customarily prescribed for infants. Use of the prosthesis is then encouraged throughout childhood. However, these children frequently abandon the prosthesis. There are no evidence-based guidelines regarding prescription of prostheses or standard methods for assessing use and function. METHODS A multicenter outcomes study was done to assess the quality of life and function of 489 children with a unilateral congenital below-the-elbow deficiency; 321 wore a prosthesis, and 168 did not. The Unilateral Below-the-Elbow Test (UBET) was designed, validated, and administered to these children along with several outcomes measures, including the Pediatric Outcomes Data Collection Instrument (PODCI), the Pediatric Quality of Life Inventory (PedsQL), and the Prosthetic Upper Extremity Functional Index (PUFI). RESULTS Use of a prosthesis was not associated with any clinically relevant differences in PODCI or PedsQL scores. Non-wearers performed either the same as or better than wearers on the UBET. When queried (with use of the PUFI) about performance of various tasks, non-wearers scored themselves higher than wearers. Children with a unilateral congenital below-the-elbow deficiency scored the same as or higher than the general population on the PedsQL. They scored significantly lower than the general population on the PODCI Upper Extremity Physical Function Domain and higher on the Happiness Domain, but the differences were small. CONCLUSIONS Prostheses may help with social acceptance or may be useful as tools for specialized activities, but they do not appear to improve function or quality of life, which are nearly normal for children with unilateral congenital below-the-elbow deficiency regardless of whether they wear a prosthesis. These findings call into question the standard practices of fitting infants with prostheses and encouraging young children to wear the prosthesis.

Voluntary (normal) versus obligatory (cerebral palsy) toe-walking in children: a kinematic, kinetic, and electromyographic analysis.

Surgical management of toe-walking gait in children with cerebral palsy currently favors simultaneous, multilevel soft-tissue and bony interventions. Formulation of such a surgical plan is based on our ability to determine which of the gait deviations present are primary and which are secondary or compensatory. To evaluate this issue further, 32 normal children, walking normally and voluntarily toe-walking, were compared to 15 children with cerebral palsy walking in an obligatory toe-walking gait pattern. Computer-based analysis of gait was performed for each child, including time-distance, kinematic, kinetic, and electromyographic analyses. Significant deviations common to both normal and cerebral palsy toe-walking groups were determined to be due, at least in part, to the biomechanical constraints associated with a toe-walking gait pattern. Deviations unique to the cerebral palsy group were thought to represent primary gait deviations related to the underlying injury to the central nervous system. This study identifies the need to develop more sophisticated techniques of data collection and analysis and supports the inclusion of more varied and demanding functional activities for distinguishing between primary and secondary gait deviations in children with cerebral palsy.

Relationships among functional outcome measures used for assessing children with ambulatory CP

In ambulatory children with cerebral palsy (CP), practitioners often examine outcomes using measures related to functions necessary for daily life. The Gross Motor Function Measure (GMFM) Dimensions D and E, Pediatric Outcomes Data Collection Instrument (PODCI) Parent and Child versions, Gillette Functional Assessment Questionnaire (FAQ) Walking subscale, Functional Independence Measure for Children (WeeFIM), Pediatric Quality of Life Inventory (PedsQL), temporal‐spatial gait parameters, and O2 cost during ambulation were selected for study. Cross‐sectional data were collected in a prospective multicenter study of 562 participants with CP (339 males, 223 females), between 4 and 18 years of age (mean age 11y 1mo). There were 240 classified as Gross Motor Function Classification System Level I, 196 as Level II, and 126 as Level III. The tools that had the best interrelationships and underlying constructs predominately measured changes in physical function. These included portions of the FAQ, Parent PODCI, WeeFIM, and GMFM. GMFM Dimensions D and E exhibited a very strong relationship. Temporal‐spatial gait parameters and O2 cost measures represented a different construct of physical function. The Child PODCI reports and both the Parent and Child PedsQL reports did not relate well to other measures, suggesting a pattern of answers not related to question content. The Parent PODCI, the FAQ Walking subscale, and GMFM Dimension E were found to be an appropriate minimum set of instruments for assessment of functional outcomes in patients with ambulatory CP.

Comparing functional profiles of children with hemiplegic and diplegic cerebral palsy in GMFCS Levels I and II: are separate classifications needed?

The goal was to compare children with hemiplegia with those with diplegia within Gross Motor Functional Classification System (GMFCS) levels using multiple validated outcome tools. Specifically, we proposed that children with hemiplegia would have better gait and gross motor function within levels while upper extremity function would be poorer. Data were collected on 422 ambulatory children with cerebral palsy: 261 with diplegia and 161 with hemiplegia, across seven centers. Those with hemiplegia in each level performed significantly and consistently better on gait or lower extremity function and poorer on upper extremity and school function than those with diplegia. In GMFCS Level II, the group with hemiplegia walked faster (p = 0.017), scored 6.6 points higher on Dimension E of the Gross Motor Function Measure (p = 0.017), 6.7 points lower on Upper Extremity subscale of the Pediatric Outcomes Data Collection Instrument, and 9.1 points lower on WeeFIM self-care (p = 0.002). Basing motor prognosis on GMFCS level alone may underestimate lower extremity skills of children with hemiplegia, and overestimate those of children with diplegia.