Movement deviation and asymmetry assessment with three dimensional gait analysis of both upper- and lower extremity results in four different clinical relevant subgroups in unilateral cerebral palsy
Introduction
In unilateral cerebral palsy (CP), even though the degree of involvement of the upper and lower extremities is variable, gait deviation and asymmetry is often noticeable (Riad et al., 2007, Winters et al., 1987). It is difficult to determine whether the movement deviations are directly related to the brain injury (primary), are secondary to changes developed in muscles and bone causing deformities, or are an expression of compensatory mechanisms (Gage, 2004, Miller, 2005). In addition movement deviations can be noted in the unaffected extremities (upper extremities in bilateral CP or the unaffected side in unilateral CP) and can be considered more or less primary, secondary, or compensatory. Separating unilateral and asymmetrical bilateral CP is an example of the complexity where deviations on the presumably unaffected side in unilateral CP could be a direct consequence of the affected side, or could represent asymmetrical bilateral CP involvement with primary- and possible secondary deviations, and/or compensatory mechanisms. The ability to distinguish between unilateral and asymmetrical bilateral CP is of clinical importance (Bax et al., 2005, Miller, 2005, Uvebrant, 2005).
Most existing classification systems for musculoskeletal impairments (e.g., the Gross Motor Functional Classification Scale (GMFCS) and the Manual Ability Classification System (MACS) (Carnahan et al., 2007, Damiano et al., 2006)) are based on clinical evaluation methods and typically subjective judgment (Damiano, 2007) which limit the possibility of identifying other general features of the patient's condition. Other features such as arm posturing during walking as well as stiff-knee gait and rotational malalignment of the hip are not identified within the MACS and GMFCS classifications. These classification systems are designed to address the functionality of a specific extremity. However for specific treatment, such as spasticity reduction with botulinum toxin injection in muscles and irreversible surgical intervention such as tendon lengthening and bony correction of deformity, it is important to define the movement deviation as clearly as possible. The use of each classification system on its own provides insufficient detail to describe distinct variability in other extremities. More detailed assessment with three dimensional GA provides the possibility of new measures of deviation and asymmetry, which give a more comprehensive assessment including movement pattern of both upper and lower extremities.
Deviation is defined as the amount/distance of the movement from normal (Baker et al., 2009, Riad et al., 2011) and the asymmetry the difference of deviation between extremities of the two sides (Dobson et al., 2007, Galli et al., 2010, Li et al., 2001, Toro et al., 2007). Symmetry implies symmetrical behavior of the extremities, measured between equivalent representatives (same angles in both sides), no matter what the actual movement is (restrained or increased motion) (Sadeghi, 2003). For example, the movement in the lower extremity on the affected side may be restrained (as in stiff knee gait; expressed as a deviation) and therefore asymmetry is noticed. On the other hand, the movement pattern on the contra-lateral unaffected side may be influenced by the stiff knee, with increased deviation (restrained or increased motion) rendering symmetry.
There are few studies on deviation and asymmetry with respect to body sides including the upper and lower extremities, as in rehabilitation and walking speed of adults (Kwakkel and Wagenaar, 2002), for example. Deviation in movement pattern and symmetry has also been used to address age and gender differences in adults' arm-swing and force (Li et al., 2001). Other studies have used deviation in movement pattern and symmetry to classify lower extremity gait patterns (Dobson et al., 2007, Galli et al., 2010, Toro et al., 2007) and to analyze upper extremity movement asymmetry during gait (Riad et al., 2011).
The aim was to develop a new, more comprehensive method to calculate deviation and asymmetry and to examine the deviation in movement pattern and asymmetry on the affected and the unaffected side in the upper and lower extremities during walking in teenagers and young adults with spastic unilateral CP.
Section snippets
Study population
Forty-seven patients with unilateral cerebral palsy, mean age 17.1 years (range 13.1 to 24.0 years), 24 females and 23 males participated. All patients were classified according to the Gross Motor Function Classification Scale (GMFCS) (Palisano et al., 1997), with 45 being GMFCS I and 2 GMFCS II, meaning that all participants were independent ambulators with no need of assistive devices. Patients were also classified according to the modified Winter's classification based on sagittal plane
Results
The clinical examination revealed a significant decreased (P < 0.001) elbow extension on the affected side compared to the unaffected. Elbow flexor and extensor muscle spasticity was present on the affected side compared to the unaffected. The clinical examination of the lower extremity revealed an increased (P = 0.001) internal and decreased (P = 0.004) external, rotation in the hip joint on the affected side. Both knee extension and flexion were decreased (P < 0.001) on the affected side compared to
Discussion
We found increased deviation and asymmetry within the group of adolescents and young adults with unilateral cerebral palsy compared to a control group. We identified four important clinical groups: close to normal (Group 1); deviations mainly in the leg (Group 2); deviations mainly in the arm (Group 3); and those with deviation in the arm and leg (Group 4). The clinical examination confirmed unilateral involvement.
The primary aim was to develop and apply a new comprehensive method to describe
Conclusion
We present a method to calculate deviation and asymmetry of movement pattern during walking in both upper and lower extremities in unilateral CP. Four different groups of clinical relevance were identified. This method can be used on any patient group to help identify the different movement patterns that could be of importance in planning of treatment and making prognoses.
Acknowledgment
Source of support: FoU Skaraborg Hospital, Skövde, Sweden.
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All authors were fully involved in the study and preparation of the manuscript. The material has not and will not be submitted for publication elsewhere.