Reliability and sources of variability of 3D kinematics and electromyography measurements to assess newly-acquired gait in toddlers with typical development and unilateral cerebral palsy.

The aim was to 1) determine intersession and intertrial reliability and 2) assess three sources of variability (intersubject, intersession and intertrial) of lower limb kinematic and electromyographic (EMG) variables during gait in toddlers with typical development (TD) and unilateral cerebral palsy (UCP) (age <3 years, independent walking experience ≤6 months). Gait kinematics and surface EMG were recorded in 30 toddlers (19 TD and 11 UCP), during two, 3D-motion capture sessions. Standard error of measurement (SEM) between trials (gait cycles) of the same session and between sessions was calculated to assess reliability. Standard deviations (SD) between subjects, sessions and trials were calculated to estimate sources of variability. Sixty-four percent of kinematic SEM-values were acceptable (2°-5°). Frontal plane measurements were most reliable (SEM 2°-4.6°). In toddlers with UCP, EMG variables were most reliable for affected side, distal muscles. Intrinsic (intertrial and intersubject) variability was high, reflecting both motor immaturity and the high variability of toddler gait patterns. In toddlers with UCP, variability was amplified by motor impairment and delayed motor development. 3D gait analysis and surface EMG are partially reliable tools to study individual gait patterns in toddlers in clinical practice and research, although some variables must be interpreted with caution.

Characteristics of newly acquired gait in toddlers with unilateral cerebral palsy: Implications for early rehabilitation.

BACKGROUND: Knowledge of the characteristics of newly acquired gait in toddlers with cerebral palsy (CP) is limited. OBJECTIVES: This study compared gait characteristics (spatiotemporal parameters, kinematics and lower-limb muscle activation) within the first 6 months of independent walking in toddlers with unilateral cerebral palsy (UCP) and typically developing (TD) children. METHODS: The gait of 28 TD toddlers and 13 toddlers with UCP, all up to 3 years old with maximum walking experience of 6 months, was recorded by using a 3-D optoelectronic system and surface electromyography (EMG). Statistical parametric mapping was used to compare the kinematic parameters and EMG envelopes. Mann-Whitney U test was used to compare spatiotemporal parameters between groups. Principal component analysis was used to determine whether the main kinematic results were related to the clinical measures. RESULTS: Toddlers with UCP had bilateral modifications of the spatiotemporal parameters during gait as compared with TD toddlers and temporal asymmetry. The largest kinematic difference between the UCP and TD groups was external pelvic rotation on the affected side (13.3°). Foot progression angle was external during swing phase on the affected side. The groups did not differ in muscle activation for the set of muscles recorded. Pelvic rotation was not associated with any of the clinical measures on the affected or non-affected sides of toddlers with UCP. CONCLUSIONS: Alterations in kinematic gait parameters were mostly found at the pelvis in toddlers with UCP and newly acquired gait. At that age, the external pelvic rotation on the affected side is more likely due to primary motor control disorders than compensatory mechanisms. These findings suggest that early rehabilitation should focus on proximal motor control, balance and symmetry to optimize gait development from the early stages in children with UCP.

Impact of Injection-Guiding Techniques on the Effectiveness of Botulinum Toxin for the Treatment of Focal Spasticity and Dystonia: A Systematic Review.

OBJECTIVE: To conduct a systematic review of the impact of different injection-guiding techniques on the effectiveness of botulinum toxin type A (BoNT-A) for the treatment of focal spasticity and dystonia. DATA SOURCES: MEDLINE via PubMed, Academic Search Premier, PASCAL, The Cochrane Library, Scopus, SpringerLink, Web of Science, EM Premium, and PsycINFO. STUDY SELECTION: Two reviewers independently selected studies based on predetermined inclusion criteria. DATA EXTRACTION: Data relating to the aim were extracted. Methodological quality was graded independently by 2 reviewers using the Physiotherapy Evidence Database assessment scale for randomized controlled trials (RCTs) and the Downs and Black evaluation tool for non-RCTs. Level of evidence was determined using the modified Sackett scale. DATA SYNTHESIS: Ten studies were included. Seven were randomized. There was strong evidence (level 1) that instrumented guiding (ultrasonography [US], electrical stimulation [ES], electromyogram [EMG]) was more effective than manual needle placement for the treatment of spasmodic torticollis, upper limb spasticity, and spastic equinus in patients with stroke, and spastic equinus in children with cerebral palsy. Three studies provided strong evidence (level 1) of similar effectiveness of US and ES for upper and lower limb spasticity in patients with stroke, and spastic equinus in children with cerebral palsy, but there was poor evidence or no available evidence for EMG or other instrumented techniques. CONCLUSIONS: These results strongly recommend instrumented guidance of BoNT-A injection for the treatment of spasticity in adults and children (ES or US), and of focal dystonia such as spasmodic torticollis (EMG). No specific recommendations can be made regarding the choice of instrumented guiding technique, except that US appears to be more effective than ES for spastic equinus in adults with stroke.