Development of a core set of gait features and their potential underlying impairments to assist gait data interpretation in children with cerebral palsy

Background: The interpretation of clinical gait data in children with cerebral palsy (CP) is time-consuming, requires extensive expertise and often lacks transparency. Here we aimed to develop a set of look-up tables to support this process, linking typical gait features as present in CP to their potential underlying impairments.Methods: We developed an initial core set of gait features and their potential underlying impairments based on biomechanical reasoning, literature and clinical experience. This core set was further specified through a Delphi process in a multidisciplinary group of experts in gait analysis of children with CP and evaluated on 20 patient cases. The likelihood of the listed gait feature–impairment relationships was scored by the expert panel on a five-point scale.Results: The final core set included 120 relevant gait feature–impairment relations including likelihood scores. This set was presented in the form of look-up tables in both directions, i.e., sorted by gait features with potential underlying impairment, and sorted by impairments with potential related gait features. The average likelihood score for the relations was 3.5 ± 0.6 (range 2.1–4.6).Conclusion: The developed set of look-up tables linking gait features and impairments, can assist gait analysts and clinicians in standardized biomechanical reasoning, to support treatment decision-making for gait impairments in children with CP.</p

Minimization of metabolic cost of transport predicts changes in gait mechanics over a range of ankle-foot orthosis stiffnesses in individuals with bilateral plantar flexor weakness

Neuromuscular disorders often lead to ankle plantar flexor muscle weakness, which impairs ankle push-off power and forward propulsion during gait. To improve walking speed and reduce metabolic cost of transport (mCoT), patients with plantar flexor weakness are provided dorsal-leaf spring ankle-foot orthoses (AFOs). It is widely believed that mCoT during gait depends on the AFO stiffness and an optimal AFO stiffness that minimizes mCoT exists. The biomechanics behind why and how an optimal stiffness exists and benefits individuals with plantar flexor weakness are not well understood. We hypothesized that the AFO would reduce the required support moment and, hence, metabolic cost contributions of the ankle plantar flexor and knee extensor muscles during stance, and reduce hip flexor metabolic cost to initiate swing. To test these hypotheses, we generated neuromusculoskeletal simulations to represent gait of an individual with bilateral plantar flexor weakness wearing an AFO with varying stiffness. Predictions were based on the objective of minimizing mCoT, loading rates at impact and head accelerations at each stiffness level, and the motor patterns were determined via dynamic optimization. The predictive gait simulation results were compared to experimental data from subjects with bilateral plantar flexor weakness walking with varying AFO stiffness. Our simulations demonstrated that reductions in mCoT with increasing stiffness were attributed to reductions in quadriceps metabolic cost during midstance. Increases in mCoT above optimum stiffness were attributed to the increasing metabolic cost of both hip flexor and hamstrings muscles. The insights gained from our predictive gait simulations could inform clinicians on the prescription of personalized AFOs. With further model individualization, simulations based on mCoT minimization may sufficiently predict adaptations to an AFO in individuals with plantar flexor weakness

Skin marker-based versus bone morphology-based coordinate systems of the hindfoot and forefoot

Segment coordinate systems (CSs) of marker-based multi-segment foot models are used to measure foot kinematics, however their relationship to the underlying bony anatomy is barely studied. The aim of this study was to compare marker-based CSs (MCSs) with bone morphology-based CSs (BCSs) for the hindfoot and forefoot. Markers were placed on the right foot of fifteen healthy adults according to the Oxford, Rizzoli and Amsterdam Foot Model (OFM, RFM and AFM, respectively). A CT scan was made while the foot was loaded in a simulated weight-bearing device. BCSs were based on axes of inertia. The orientation difference between BCSs and MCSs was quantified in helical and 3D Euler angles. To determine whether the marker models were able to capture inter-subject variability in bone poses, linear regressions were performed. Compared to the hindfoot BCS, all MCSs were more toward plantar flexion and internal rotation, and RFM was also oriented toward more inversion. Compared to the forefoot BCS, OFM and RFM were oriented more toward dorsal and plantar flexion, respectively, and internal rotation, while AFM was not statistically different in the sagittal and transverse plane. In the frontal plane, OFM was more toward eversion and RFM and AFM more toward inversion compared to BCS. Inter-subject bone pose variability was captured with RFM and AFM in most planes of the hindfoot and forefoot, while this variability was not captured by OFM. When interpreting multi-segment foot model data it is important to realize that MCSs and BCSs do not always align.</p

Predictive simulations identify potential neuromuscular contributors to idiopathic toe walking

Background: Most cases of toe walking in children are idiopathic. We used pathology-specific neuromusculoskeletal predictive simulations to identify potential underlying neural and muscular mechanisms contributing to idiopathic toe walking. Methods: A musculotendon contracture was added to the ankle plantarflexors of a generic musculoskeletal model to represent a pathology-specific contracture model, matching the reduced ankle dorsiflexion range-of-motion in a cohort of children with idiopathic toe walking. This model was employed in a forward dynamic simulation controlled by reflexes and supraspinal drive, governed by a multi-objective cost function to predict gait patterns with the contracture model. We validated the predicted gait using experimental gait data from children with idiopathic toe walking with ankle contracture, by calculating the root mean square errors averaged over all biomechanical variables. Findings:A predictive simulation with the pathology-specific model with contracture approached experimental ITW data (root mean square error = 1.37SD). Gastrocnemius activation was doubled from typical gait simulations, but lacked a peak in early stance as present in electromyography. This synthesised idiopathic toe walking was more costly for all cost function criteria than typical gait simulation. Also, it employed a different neural control strategy, with increased length- and velocity-based reflex gains to the plantarflexors in early stance and swing than typical gait simulations. Interpretation: The simulations provide insights into how a musculotendon contracture combined with altered neural control could contribute to idiopathic toe walking. Insights into these neuromuscular mechanisms could guide future computational and experimental studies to gain improved insight into the cause of idiopathic toe walking.</p

Effects of fatigue of plantarflexors on control and performance in vertical jumping

INTRODUCTION: We investigated the effects of a mismatch between control and musculoskeletal properties on performance in vertical jumping. METHODS: Six subjects performed maximum-effort vertical squat jumps before (REF) and after the plantarflexors of the right leg had been fatigued (FAT) while kinematic data, ground reaction forces, and EMG of leg muscles were collected. Inverse dynamics was used to calculate the net work at joints, and EMG was rectified and smoothed to obtain the smoothed rectified EMG (SREMG). The jumps of the subjects were also simulated with a musculoskeletal model comprising seven body segments and 12 Hill-type muscles, and having as only input muscle stimulation. RESULTS: Jump height was approximately 6 cm less in FAT jumps than in REF jumps. In FAT jumps, peak SREMG level was reduced by more than 35% in the right plantarflexors and by approximately 20% in the right hamstrings but not in any other muscles. In FAT jumps, the net joint work was reduced not only at the right ankle (by 70%) but also at the right hip (by 40%). Because the right hip was not spanned by fatigued muscles and the reduction in SREMG of the right hamstrings was relatively small, this indicated that the reduction in performance was partly due to a mismatch between control and musculoskeletal properties. The differences between REF and FAT jumps of the subjects were confirmed and explained by the simulation model. Reoptimization of control for the FAT model caused performance to be partly restored by approximately 2.5 cm. CONCLUSION: The reduction in performance in FAT jumps was partly due to a mismatch between control and musculoskeletal properties. © 2011 The American College of Sports Medicine

Muscle length and lengthening velocity in voluntary crouch gait

The purpose of this study was to explore how origin-insertion length and lengthening velocity of hamstring and psoas muscle change as a result of crouch gait. The second purpose was to study the effect of changes in walking speed, in crouch, on muscle lengths and velocities. Eight healthy female subjects walked on a treadmill both normally and in crouch. In the crouch condition, subjects walked at three different walking speeds. 3D kinematic data were collected and muscle lengths and velocities were calculated using musculoskeletal modeling. It was found that voluntary walking in crouch resulted in shorter psoas length compared to normal, but not in shorter hamstrings length. Moreover, crouch gait did not result in slower muscle lengthening velocities compared to normal gait. These results do not support the role of hamstrings shortness or spasticity in causing crouch gait. Decreasing walking speed clearly reduced muscle lengths and lengthening velocities. Therefore, patients with short or spastic muscles are more likely to respond by walking slower than by walking in crouch. Also, differences in walking speed should be avoided as a confounding factor when comparing patient groups with controls

How does a systematic tuning protocol for ankle foot orthosis–footwear combinations affect gait in children in cerebral palsy?

Purpose: To investigate the effects of a systematic tuning protocol for ankle foot orthosis footwear combinations (AFO-FC) using incrementing heel height on gait in children with cerebral palsy (CP). Methods: Eighteen children with CP (10.8 ± 3 years, Gross Motor Function Classification System (GMFCS) I–II) underwent 3D gait analysis on a treadmill, while the AFO heel surface was systematically incremented with wedges. Children were subdivided based on their gait pattern, i.e., knee hyperextension (EXT) and excessive knee flexion (FLEX). Outcome measures included sagittal hip and knee angles and moments, shank to vertical angle (SVA), foot to horizontal angle, and gait profile score (GPS). Results: For both groups, incrementing heel height resulted in increased knee flexion, more inclined SVA, and increased knee extension moments. This resulted in gait improvements for some children of the EXT-group, but not in FLEX. High variation was found between individuals and within-subject effects were not always consistent for kinematic and kinetics. Conclusions: A systematic AFO-FC tuning protocol using incremented heel height can be effective to improve gait in children with CP walking with EXT. The current results emphasise the importance of including kinematics as well as kinetics of multiple instances throughout the gait cycle for reliable interpretation of the effect of AFO tuning on gait.Implications for rehabilitation A systematic ankle foot orthosis footwear combinations (AFO-FC) tuning protocol using incremented heel height can improve gait in children walking with knee hyperextension. Tuning results in changes throughout the gait cycle. Little evidence is found for an optimal SVA of 10–12° at midstance. For clinical interpretation, both joint kinematic and kinetic parameters should be considered throughout the gait cycle and evaluation should not be based on SVA only

Effects of fatigue of plantarflexors on control and performance in vertical jumping

INTRODUCTION: We investigated the effects of a mismatch between control and musculoskeletal properties on performance in vertical jumping. METHODS: Six subjects performed maximum-effort vertical squat jumps before (REF) and after the plantarflexors of the right leg had been fatigued (FAT) while kinematic data, ground reaction forces, and EMG of leg muscles were collected. Inverse dynamics was used to calculate the net work at joints, and EMG was rectified and smoothed to obtain the smoothed rectified EMG (SREMG). The jumps of the subjects were also simulated with a musculoskeletal model comprising seven body segments and 12 Hill-type muscles, and having as only input muscle stimulation. RESULTS: Jump height was approximately 6 cm less in FAT jumps than in REF jumps. In FAT jumps, peak SREMG level was reduced by more than 35% in the right plantarflexors and by approximately 20% in the right hamstrings but not in any other muscles. In FAT jumps, the net joint work was reduced not only at the right ankle (by 70%) but also at the right hip (by 40%). Because the right hip was not spanned by fatigued muscles and the reduction in SREMG of the right hamstrings was relatively small, this indicated that the reduction in performance was partly due to a mismatch between control and musculoskeletal properties. The differences between REF and FAT jumps of the subjects were confirmed and explained by the simulation model. Reoptimization of control for the FAT model caused performance to be partly restored by approximately 2.5 cm. CONCLUSION: The reduction in performance in FAT jumps was partly due to a mismatch between control and musculoskeletal properties

Torsion Tool: An automated tool for personalising femoral and tibial geometries in OpenSim musculoskeletal models

Common practice in musculoskeletal modelling is to use scaled musculoskeletal models based on a healthy adult, but this does not consider subject-specific geometry, such as tibial torsion and femoral neck-shaft and anteversion angles (NSA and AVA). The aims of this study were to (1) develop an automated tool for creating OpenSim models with subject-specific tibial torsion and femoral NSA and AVA, (2) evaluate the femoral component, and (3) release the tool open-source. The Torsion Tool (https://simtk.org/projects/torsiontool) is a MATLAB-based tool that requires an individual's tibial torsion, NSA and AVA estimates as input and rotates corresponding bones and associated muscle points of a generic musculoskeletal model. Performance of the Torsion Tool was evaluated comparing femur bones as personalised with the Torsion Tool and scaled generic femurs with manually segmented bones as golden standard for six typically developing children and thirteen children with cerebral palsy. The tool generated femur geometries closer to the segmentations, with lower maximum (−19%) and root mean square (−18%) errors and higher Jaccard indices (+9%) compared to generic femurs. Furthermore, the tool resulted in larger improvements for participants with higher NSA and AVA deviations. The Torsion Tool allows an automatic, fast, and user-friendly way of personalising femoral and tibial geometry in an OpenSim musculoskeletal model. Personalisation is expected to be particularly relevant in pathological populations, as will be further investigated by evaluating the effects on simulation outcomes