Elsevier

Gait & Posture

Volume 25, Issue 1, January 2007, Pages 140-152
Gait & Posture

Review
Gait classification in children with cerebral palsy: A systematic review

https://doi.org/10.1016/j.gaitpost.2006.01.003Get rights and content

Abstract

This systematic review of the literature evaluates the validity of existing classifications of gait deviations in children with cerebral palsy (CP). Numerous efforts have been made to develop classification systems for gait in CP to assist in diagnosis, clinical decision-making and communication. The internal and external validity of gait classifications in 18 studies were examined, including their sampling methods, content validity, construct validity, reliability and clinical utility. Half of the studies used qualitative pattern recognition to construct the gait classification and the remainder used statistical techniques such as cluster analysis. Few adequately defined their samples or sampling methods. Most classifications were constructed using only sagittal plane gait data. Many did not provide adequate guidelines or evidence of reliability and validity of the classification system. No single classification addressed the full magnitude or range of gait deviations in children with CP. Although gait classification in CP can be useful in clinical and research settings, the methodological limitations of many classifications restrict their clinical and research applicability.

Introduction

One of the most striking features of cerebral palsy (CP) is the variability of its clinical presentation [1]. The diversity of gait deviations observed in children with CP has led to repeated efforts to develop gait classification systems to assist in diagnosis, clinical decision-making and communication [2], [3], [4], [5], [6], [7], [8], [9], [10], [11], [12], [13], [14], [15], [16], [17], [18], [19]. Gait classifications may enable clinicians to differentiate gait patterns into clinically significant categories that assist with clinical decision-making. This is possible when the underlying variables that define the classification groups can be modified by intervention. Gait classifications can also provide clinicians and researchers with a common language that quickly conveys a “clinical snapshot” of an individual's gait impairments. The term “gait classification” refers to a system that allows the allocation of gait patterns into groups that can be differentiated from one another based on a set of defined variables. This is distinct from gait indexes, assessment scores and scales, which score individual gait variables or provide an overall index to quantify deviations from normal gait without group allocation.

In order to understand the range and quality of existing gait classifications for children with CP, a systematic review of the available literature was performed. This was considered to be an essential step before the development of a new gait classification. The review was conducted to highlight both the positive qualities and limitations of previous classification systems and to provide evidence as to whether existing systems were adequate, required modification or required re-conceptualisation. The main aim was to critically evaluate the internal and external validity of existing gait classifications by critically appraising their design, sampling methods, content, construct, psychometric properties and clinical utility.

Section snippets

Search strategy

An electronic search of the following publication databases was performed in March 2005: MEDLINE (1966–March 2005), Embase (1988–Week 10, 2005), Current Contents (1993–Week 10, 2005), AMED (1985–March 2005), CINAHL (1982–March 2005), Health and Psychosocial Instruments (1985–December 2004), PsycINFO (1967–March 2005), Inspec (1987–Week 9, 2005) and Recal Bibliographic Database (1991–2005). Keywords used in the search strategy included cerebral palsy, gait, gait analysis, classification, gait

Search strategy yield

The electronic search of selected databases identified 333 published studies. A further five studies were identified from the targeted journal/proceedings search and a further two studies were found from the hand-search giving a yield of 340 publications. Following the application of a priori inclusion/exclusion criteria (Section 2.2), two reviewers (FD and MM) identified 18 studies for inclusion in the systematic review. The details of these studies are summarised in Table 2.

Descriptive aspects of reviewed studies

Subject

Sample definition

Adequate sample definitions and inclusion criteria were provided in only 4 of the 18 publications included in the evaluation [13], [15], [17], [18]. None of the studies provided information about the functional severity of participants. It was difficult to determine if the classifications from studies without adequate definitions applied to a wide spread of individuals of varying severity across the childhood and adolescent years or only to a select age group and severity.

Adequate documentation

Conclusions

Although CP gait classifications are used for diagnostic purposes, to streamline communication and to facilitate clinical decision-making, the overall methodological quality of the studies evaluated in this systematic review was low. No single classification system appeared to reliably and validly describe the full range of gait deviations in children with CP. Many classifications appeared to use arbitrary decisions to allocate patients into groups as opposed to using clinical decision-making

Acknowledgments

This work was supported by the CCRE Clinical Gait Analysis and Gait Rehabilitation NHMRC grant. Fiona Dobson received support from the Sir Robert Menzies Allied Health Sciences Scholarship and the Faculty of Health Sciences, La Trobe University.

References (60)

  • A.M. Moseley et al.

    Evidence for physiotherapy practice: a survey of the Physiotherapy Evidence Database (PEDro)

    Aust J Physiother

    (2002)
  • J.J. Carollo et al.

    Gait pattern classification in children with cerebral palsy: results from a 12-state hidden Markov model created with a large training set

    Gait Posture

    (2004)
  • M.G. Hullin et al.

    Gait patterns in children with hemiplegic spastic cerebral palsy

    J Pediatr Orthop Part B

    (1996)
  • M.P. Kadaba et al.

    Gait pattern recognition in spastic diplegia

    Dev Med Child Neurol

    (1991)
  • J.M. O’Byrne et al.

    Quantitative analysis and classification of gait patterns in cerebral palsy using a three-dimensional motion analyzer

    J Child Neurol

    (1998)
  • M.J. O’Malley et al.

    Fuzzy clustering of children with cerebral palsy based on temporal-distance gait parameters

    IEEE Trans Rehabil Eng

    (1997)
  • J.M. Rodda et al.

    Sagittal gait patterns in spastic diplegia

    J Bone Joint Surg [Br]

    (2004)
  • A.J. Salazar et al.

    Novel approach for spastic hemiplegia classification through the use of the support vector machines

  • J. Stebbins et al.

    Gait classification in hemiplegic cerebral palsy based on EMG

    Gait Posture

    (2004)
  • S.R. Simon et al.

    Genu recurvatum in spastic cerebral palsy. Report on findings by gait analysis

    J Bone Joint Surg [Am]

    (1978)
  • D.H. Sutherland et al.

    Common gait abnormalities of the knee in cerebral palsy

    Clin Orthop Relat Res

    (1993)
  • T. Winters et al.

    Gait patterns in spastic hemiplegia in children and adults

    J Bone Joint Surg [Am]

    (1987)
  • M.A. Wong et al.

    Statistical analysis of gait patterns of persons with cerebral palsy

    Stat Med

    (1983)
  • A.M. Wong et al.

    Gait analysis through foot pattern recognition for children with cerebral palsy

    J Musculoskelet Res

    (1999)
  • H.K. Graham et al.

    The functional mobility scale (FMS)

    J Pediatr Orthop

    (2004)
  • R. Palisano et al.

    Development and reliability of a system to classify gross motor function in children with cerebral palsy

    Dev Med Child Neurol

    (1997)
  • National Health and Medical Research Council. How to review the evidence: systematic identification and review of the...
  • A. Oxman

    Checklist for review articles

    BMJ

    (1994)
  • D.J. Cook et al.

    Systematic reviews: synthesis of best evidence for clinical decisions

    Ann Intern Med

    (1997)
  • P.M. Bossuyt et al.

    Standards for Reporting of Diagnostic Accuracy. The STARD statement for reporting studies of diagnostic accuracy: explanation and elaboration

    Ann Intern Med

    (2003)
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