Sharon Walt

Reliability and validity of the Observational Gait Scale in children with spastic diplegia

The aim of this study was to establish the reliability and validity of visual gait assessment in children with spastic diplegia, who were community or household ambulators, using a modified version of the Physicians Rating Scale, known as the Observational Gait Scale (OGS). Two clinicians viewed edited split-screen video recordings of 20 children/adolescents (11 males, 9 females; mean age 12 years, range 6 to 21 years) made at the time of three-dimensional gait analysis (3-DGA). Walking ability in each child was scored at initial assessment and reassessed from the same videos three months later using the first seven sections of the OGS. Validity of the OGS score was determined by comparison with 3-DGA. The OGS was found to have acceptable interrater and intrarater reliability for knee and foot position in mid-stance, initial foot contact, and heel rise with weighted kappas (wk) ranging from 0.53 to 0.91 (intrarater) and 0.43 to 0.86 (interrater). Comparison with 3-DGA suggests that these sections might also have high validity(wk range 0.38-0.94). Base of support and hind foot position had lower interrater and intrarater reliabilities (wk 0.29 to 0.71 and wk 0.30 to 0.78 respectively) and were not easily validated by 3-DGA.

Intraobserver reliability of the modified Tardieu scale in the upper limb of children with hemiplegia

This study investigated the reliability of the modified Tardieu scale in the assessment of biceps spasticity in the upper limbs of children with hemiplegic cerebral palsy (CP). Ten children, with hemiplegic CP participated in the study: six males (mean age 9 years, SD 4 years) and four females (mean age 12 years, SD 3 years). Blinded, duplicate measures of dynamic elbow extension were performed on the hemiplegic arm at time 0 and 7 days later, using the three angular velocities described in the Tardieu scale (V1, slow; V2, speed of gravity; V3, as fast as possible). The resulting elbow joint angles were defined as R1, the angle of catch following a fast velocity stretch at either V2 or V3; and R2, the passive range of movement achieved following a slow velocity stretch at V1. Both elbow joint angle and movement angular velocity were measured by three‐dimensional kinematics. Median error in measured elbow joint angle within one session ranged from 3 to 5°. Between sessions median absolute differences in measured elbow joint angle ranged from 4 to 13°, with measurement errors of up to 25 to 30° in some participants at the fastest velocity (V3). The therapist was able to apply three significantly different angular velocities as required for the Tardieu scale (p < 0.001). However, the ranges of the three angular velocities overlapped, with fast velocities for some participants being equivalent to slow velocities for other participants. Three out of 10 participants had an intersessional difference in their R2‐R1 score of more than 20°. From this study, we concluded that the R2‐R1 value determined from the modified Tardieu scale may be of limited value in assessing biceps spasticity the upper limbs in children with hemiplegic CP.

Treatment for Idiopathic Toe-walking: Results at Skeletal Maturity

Thirteen skeletally mature subjects who had been treated as children for idiopathic toe-walking underwent gait analysis and calf muscle strength testing at an average of 10.8 years from the last intervention. Six had had serial casting only; seven had had either a percutaneous tendo Achilles lengthening or a Bakers gastroc-soleus lengthening. Sagittal plane kinematics at the ankle was altered in 12 of the 13 subjects, but the changes were detectable visually in only 3 subjects. One subject had increased ankle plantarflexion at initial contact, but the other 12 subjects had a normal first rocker. Peak ankle dorsiflexion in stance averaged only 9°, and 11 of the subjects had a peak ankle dorsiflexion in stance greater than 2 standard deviations below normative values. Ankle dorsiflexion was also restricted on passive measures, but there was no correlation between ankle dorsiflexion non-weight-bearing and in gait. Inversion of second rocker was seen in two subjects with peak ankle dorsiflexion in stance occurring before 25% of the gait cycle. Power generation by the calf during a single heel-rise test was variable between subjects but within normative values compared with controls. The authors conclude that most subjects showed persistent changes in ankle kinematics and kinetics despite treatment but that this was not detectable visually in most subjects.

Reliability and validity of an activity monitor (IDEEA) in the determination of temporal–spatial gait parameters in individuals with cerebral palsy

This study evaluated within- and between-session reliability and validity of temporal-spatial gait parameters derived from the intelligent device for energy expenditure and activity (IDEEA) activity monitor (Minisun, Fresno, CA) in subjects with cerebral palsy, using three-dimensional gait analysis (3-DGA) as the criterion standard. Twenty-five subjects with cerebral palsy (mean age 14.1 years, range 8-23) and 30 control subjects (mean age 14.2 years, range 7-24) completed two 3-DGA, 1 week apart with simultaneous IDEEA data collection. The IDEEA had lower within-session reliability than the 3-DGA for both groups, indicated by greater measurement errors and wider repeatability values for all temporal-spatial parameters. Between-session reliability of 3-DGA was high for both groups with intra-class correlation coefficients (ICC) >0.80. The IDEEA monitor showed high between-session reliability for control subjects (ICC 0.71-0.89), but lower reliability in subjects with cerebral palsy, particularly for walking velocity and stride length (ICC 0.53 and 0.62, respectively). Validity comparison between IDEEA and 3-DGA measures using Bland Altman 95% limits of agreement showed a measurement bias, with the IDEEA over-estimating step and stride length and underestimating cadence in both subject groups compared to 3-DGA. The 95% limits of agreement were smaller in controls (step +/-0.20 m; stride +/-0.27 m; walking velocity +/-0.28 m/s) than in subjects with cerebral palsy (step +/-0.36 m; stride +/-0.37 m; velocity +/-0.58 m/s). Modifications may be necessary to improve the reliability and validity of the IDEEA in children, particularly for use in neurological conditions.

The Sensitivity and Specificity of an Activity Monitor in Detecting Functional Activities in Young People With Cerebral Palsy

OBJECTIVE To evaluate the sensitivity and specificity of the Intelligent Device for Energy Expenditure and Activity (IDEEA) monitor in detecting functional activities in young people with cerebral palsy (CP). DESIGN Validation study. SETTING Two identical data collections completed 1 week apart at a gait laboratory. PARTICIPANTS Twenty-five young people with CP and 30 able-bodied (AB) peers (age 8-25 y; mean age CP 14.1 y, Gross Motor Function Classification System Level I-III; mean age AB, 14.2 y). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Each participant completed 5 functional activities (sitting, lying, standing, walking, and stairs), with the monitor attached. The sensitivity and specificity of the monitor in detecting each activity was calculated by comparison to a written timed report. RESULTS Sitting, lying, and standing were detected with median 100% sensitivity in both participant groups and across both testing sessions. Accuracy of walking detection was reduced compared with static activities (P<.05) across the 2 sessions and groups. The CP group had a significantly higher number of participants where the activity was not detected with 100% sensitivity (lie: 18% CP, 5% AB, P<.04; stand: 12% CP, 0% AB, P<.02; walk: 96% CP, 81% AB, P<.03). Stair climbing was detected in only half of the 12 participants with CP who could achieve the task. The IDEEA demonstrated high specificity (range, 97%-100%) for both participant groups. CONCLUSIONS The IDEEA activity monitor had high levels of sensitivity and specificity in determining everyday static activities in participants with CP, with greater difficulties in detecting dynamic activities of walking and stair climbing.

Use of three‐dimensional kinematic analysis following upper limb botulinum toxin A for children with hemiplegia

Background and purpose:  To examine whether three‐dimensional (3‐D) kinematic analysis can detect changes in upper limb tasks (reach and hand‐to‐mouth) in children with hemiplegia, following upper limb botulinum toxin A injections.

Metabolic Cost, Mechanical Work, and Efficiency During Normal Walking in Obese and Normal-Weight Children

Purpose: This study aimed to investigate the influence of childhood obesity on energetic cost during normal walking and to determine if obese children choose a walking strategy optimizing their gait pattern. Method: Sixteen obese children with no functional abnormalities were matched by age and gender with 16 normal-weight children. All participants were asked to walk along a nearly circular track 30 m in length at a self-selected speed. Spatiotemporal data, kinematics, and ground reaction force were collected during walking using a three-dimensional motion analysis system. Metabolic cost was collected by a portable gas analyzer simultaneously. Results: The mechanical energy expenditure (MEE) was 72.7% higher in obese children than in normal-weight children. The net metabolic cost was 65.7% higher in obese children. No difference was found in the metabolic rate (J·kg− 1·m− 1), normalized MEE (J·kg− 1·m− 1) and mechanical efficiency between the obese and normal-weight groups. The obese children walked with a 0.15 m/s slower walking speed, 10.0% shorter cadence, and 30.9% longer double-support phase compared with normal-weight children. In addition, no differences were found in the mediolateral and vertical body center of mass displacement. Conclusion: Body mass played a dominant role in the total metabolic and mechanical cost per stride. Obese children may adopt a walking strategy to avoid an increase in the metabolic cost and the mechanical work required to move their excess body mass.

Botulinum Toxin Type A in Ambulant Children with Cerebral Palsy

Summary Botulinum toxin type A has recently become a treatment option in the management of spasticity in children with cerebral palsy. Intramuscular injections of botulinum toxin A block the release of acetylcholine at the motor end plate, leading to reversible chemodenervation of muscle. This has been shown to provide a clinically useful reduction in localised spasticity for 12-16 weeks with flow-on into more long-term improvements in function in about 5% of children (termed golden responders). This review discusses the role of botulinum toxin A in the management of spasticity in children with cerebral palsy, to help therapists to select appropriate patients and maximise the potential gains from botulinum toxin A treatment.