Background: As hyperactive muscle stretch reflexes hinder movement in patients with central nervous system disorders, they are a common target of treatment. To improve treatment evaluation, hyperactive reflexes should be assessed during activities as walking rather than passively. This study systematically explores the feasibility, reliability and validity of sudden treadmill perturbations to evoke and quantify calf muscle stretch reflexes during walking in children with neurological disorders. Methods: We performed an observational cross-sectional study including 24 children with cerebral palsy (CP; 6–16 years) and 14 typically developing children (TD; 6–15 years). Short belt accelerations were applied at three different intensities while children walked at comfortable speed. Lower leg kinematics, musculo-tendon lengthening and velocity, muscle activity and spatiotemporal parameters were measured to analyze perturbation responses. Results: We first demonstrated protocol feasibility: the protocol was completed by all but three children who ceased participation due to fatigue. All remaining children were able to maintain their gait pattern during perturbation trials without anticipatory adaptations in ankle kinematics, spatiotemporal parameters and muscle activity. Second, we showed the protocol’s reliability: there was no systematic change in muscle response over time (P = 0.21–0.54) and a bootstrapping procedure indicated sufficient number of perturbations, as the last perturbation repetition only reduced variability by ~ 2%. Third, we evaluated construct validity by showing that responses comply with neurophysiological criteria for stretch reflexes: perturbations superimposed calf muscle lengthening (P < 0.001 for both CP and TD) in all but one participant. This elicited increased calf muscle activity (359 ± 190% for CP and 231 ± 68% for TD, both P < 0.001) in the gastrocnemius medialis muscle, which increased with perturbation intensity (P < 0.001), according to the velocity-dependent nature of stretch reflexes. Finally, construct validity was shown from a clinical perspective: stretch reflexes were 1.7 times higher for CP than TD for the gastrocnemius medialis muscle (P = 0.017). Conclusions: The feasibility and reliability of the protocol, as well as the construct validity—shown by the exaggerated velocity-dependent nature of the measured responses—strongly support the use of treadmill perturbations to quantify stretch hyperreflexia during gait. We therefore provided a framework which can be used to inform clinical decision making and treatment evaluation.

@en

Early brain lesions which produce cerebral palsy (CP) may affect the development of walking. It is unclear whether or how neuromuscular control, as evaluated by muscle synergy analysis, differs in young children with CP compared to typically developing (TD) children with the same walking ability, before and after the onset of independent walking. Here we grouped twenty children with (high risk of) CP and twenty TD children (age 6.5–52.4 months) based on their walking ability, supported or independent walking. Muscle synergies were extracted from electromyography data of bilateral leg muscles using non-negative matrix factorization. Number, synergies’ structure and variability accounted for when extracting one (VAF₁ ) or two (VAF₂ ) synergies were compared between CP and TD. Children in the CP group recruited fewer synergies with higher VAF₁ and VAF₂ compared to TD children in the supported and independent walking group. The most affected side in children with asymmetric CP walking independently recruited fewer synergies with higher VAF₁ compared to the least affected side. Our findings suggest that early brain lesions result in early alterations of neuromuscular control, specific for the most affected side in asymmetric CP.

@en

In neurological diseases, muscles often become hyper-resistant to stretch due to hyperreflexia, an exaggerated stretch reflex response that is considered to primarily depend on the muscle's stretch velocity. However, there is still limited understanding of how different biomechanical triggers applied during clinical tests evoke these reflex responses. We examined the effect of imposing a rotation with increasing velocity vs. increasing acceleration on triceps surae muscle repsonse in children with spastic paresis (SP) and compared the responses to those measured in typically developing (TD) children. A motor-operated ankle manipulator was used to apply different bell-shaped movement profiles, with three levels of maximum velocity (70, 110, and 150°/s) and three levels of maximum acceleration (500, 750, and 1,000°/s²). For each profile and both groups, we evaluated the amount of evoked triceps surae muscle activation. In SP, we evaluated two additional characteristics: the intensity of the response (peak EMG burst) and the time from movement initiation to onset of the EMG burst. As expected, the amount of evoked muscle activation was larger in SP compared to TD (all muscles: p < 0.001) and only sensitive to biomechanical triggers in SP. Further investigation of the responses in SP showed that peak EMG bursts increased in profiles with higher peak velocity (lateral gastrocnemius: p = 0.04), which was emphasized by fair correlations with increased velocity at EMG burst onset (all muscles: r > 0.33–0.36, p ≤ 0.008), but showed no significant effect for acceleration. However, the EMG burst was evoked faster with higher peak acceleration (all muscles p < 0.001) whereas it was delayed in profiles with higher peak velocity (medial gastrocnemius and soleus: p < 0.006). We conclude that while exaggerated response intensity (peak EMG burst) seems linked to stretch velocity, higher accelerations seem to evoke faster responses (time to EMG burst onset) in triceps surae muscles in SP. Understanding and controlling for the distinct effects of different biological triggers, including velocity, acceleration but also length and force of the applied movement, will contribute to the development of more precise clinical measurement tools. This is especially important when aiming to understand the role of hyperreflexia during functional movements where the biomechanical inputs are multiple and changing.

@en

Purpose: Previous studies investigating the effectiveness of exergame balance-training (using video-games) in children with cerebral palsy (CP) yielded inconsistent results that could be related to underpowered studies. Therefore, in this multicenter intervention study, we investigated whether exergaming improves balance clinically in spastic CP. Materials and methods: In total, 35 children with unilateral or bilateral spastic CP (GMFCS-level I–II) were included (age-range: 7–16 years); 16 at VUMC (trial: NTR6034), 19 at UHG (trial: NCT03219112). All participants received care as usual. The intervention group (n = 24) additionally performed exergame-training; 6–8 weeks home-based X-box One Kinect training focused on balance. Balance performance was assessed with the pediatric balance scale (PBS) and two subscales of the Bruininks–Oseretsky Test of Motor Proficiency-2nd edition (“balance” [BOTbal] and “running speed and agility” [BOTrsa]). Mixed model ANOVAs with between and within factors were used to test differences between and within groups. Results: On group level, no post-intervention differences were found between the intervention and control group (PBS: p = 0.248, η_p² = 0.040; BOTbal: p = 0.374, η_p² = 0.024; BOTrsa: p = 0.841, η_p² = 0.001). Distribution of CP-symptoms (unilateral versus bilateral) did not affect training (PBS: p = 0.373, η_p² = 0.036; BOTbal: p = 0.127, η_p² = 0.103; BOTrsa: p = 0.474, η_p² = 0.024). Children with low baseline balance performance (based on PBS) in the intervention group showed improvements in balance performance after training (PBS: p = 0.003, η_p² = 0.304; BOTbal: p = 0.008, η_p² = 0.258), whereas children with high baseline balance performance did not. Conclusions: This exergame-training resulted in balance improvements for the current population of CP that had a low baseline function.IMPLICATIONS FOR REHABILITATION Exergame-training (training using video-games) shows mixed results in children with cerebral palsy (CP). Children with spastic CP (GMFCS level I–II) with a high baseline balance-level did not show functional balance improvements after this home-based exergame-training, suggesting that these children should not be enrolled in this type of exergame-training protocol. Children with spastic CP (GMFCS level I–II) with a low baseline balance-level showed clinically relevant functional balance improvements after this home-based exergame-training, suggesting that these children can benefit from enrolment in this type of exergame-training protocol to improve their balance. The distribution of CP-symptoms did not affect the effectiveness of this balance exergame-training in children with spastic CP with GMFCS-level I and II.

@en

The first years of life might be critical for encouraging independent walking in children with cerebral palsy (CP). We sought to identify mechanisms that may underlie the impaired development of walking in three young children with early brain lesions, at high risk of CP, via comprehensive instrumented longitudinal assessments of locomotor patterns and muscle activation during walking. We followed three children (P1–P3) with early brain lesions, at high risk of CP, during five consecutive gait analysis sessions covering a period of 1 to 2 years, starting before the onset of independent walking, and including the session during the first independent steps. In the course of the study, P1 did not develop CP, P2 was diagnosed with unilateral and P3 with bilateral CP. We monitored the early development of locomotor patterns over time via spatiotemporal gait parameters, intersegmental coordination (estimated via principal component analysis), electromyography activity, and muscle synergies (determined from 11 bilateral muscles via nonnegative matrix factorization). P1 and P2 started to walk independently at the corrected age of 14 and 22 months, respectively. In both of them, spatiotemporal gait parameters, intersegmental coordination, muscle activation patterns, and muscle synergy structure changed from supported to independent walking, although to a lesser extent when unilateral CP was diagnosed (P2), especially for the most affected leg. The child with bilateral CP (P3) did not develop independent walking, and all the parameters did not change over time. Our exploratory longitudinal study revealed differences in maturation of locomotor patterns between children with divergent developmental trajectories. We succeeded in identifying mechanisms that may underlie impaired walking development in very young children at high risk of CP. When verified in larger sample sizes, our approach may be considered a means to improve prognosis and to pinpoint possible targets for early intervention.

@en

Background: In this systematic review we investigate which instrumented measurements are available to assess motor impairments, related activity limitations and participation restrictions in children and young adults with dyskinetic cerebral palsy. We aim to classify these instrumented measurements using the categories of the international classification of functioning, disability and health for children and youth (ICF-CY) and provide an overview of the outcome parameters. Methods: A systematic literature search was performed in November 2019. We electronically searched Pubmed, Embase and Scopus databases. Search blocks included (a) cerebral palsy, (b) athetosis, dystonia and/or dyskinesia, (c) age 2-24 years and (d) instrumented measurements (using keywords such as biomechanics, sensors, smartphone, and robot). Results: Our search yielded 4537 articles. After inspection of titles and abstracts, a full text of 245 of those articles were included and assessed for further eligibility. A total of 49 articles met our inclusion criteria. A broad spectrum of instruments and technologies are used to assess motor function in dyskinetic cerebral palsy, with the majority using 3D motion capture and surface electromyography. Only for a small number of instruments methodological quality was assessed, with only one study showing an adequate assessment of test-retest reliability. The majority of studies was at ICF-CY function and structure level and assessed control of voluntary movement (29 of 49) mainly in the upper extremity, followed by assessment of involuntary movements (15 of 49), muscle tone/motor reflex (6 of 49), gait pattern (5 of 49) and muscle power (2 of 49). At ICF-CY level of activities and participation hand and arm use (9 of 49), fine hand use (5 of 49), lifting and carrying objects (3 of 49), maintaining a body position (2 of 49), walking (1 of 49) and moving around using equipment (1 of 49) was assessed. Only a few methods are potentially suitable outside the clinical environment (e.g. inertial sensors, accelerometers). Conclusion: Although the current review shows the potential of several instrumented methods to be used as objective outcome measures in dyskinetic cerebral palsy, their methodological quality is still unknown. Future development should focus on evaluating clinimetrics, including validating against clinical meaningfulness. New technological developments should aim for measurements that can be applied outside the laboratory.

@en

In children with cerebral palsy (CP), rigid ventral shell ankle-foot orthoses (vAFOs) are often prescribed to reduce excessive knee flexion in stance and lower the energy cost of walking (ECW). However, how vAFOs affect ECW is a complex issue, as vAFOs may have an impact on lower limb biomechanics, upper body movements, and balance. Besides, the vAFO's biomechanical effect have been shown to be dependent on its stiffness around the ankle joint. We examined whether vAFO stiffness influences trunk movements and gait stability in CP, and whether there is a relationship between these factors and ECW. Fifteen children with spastic CP were prescribed vAFOs. Stiffness was varied into a rigid, stiff and flexible configuration. At baseline (shoes-only) and for each vAFO stiffness configuration, 3D-gait analyses and ECW-tests were performed. From the gait analyses, we derived trunk tilt, lateroflexion, and rotation range of motion (RoM) and the mediolateral and anteroposterior Margins of Stability (MoS) and their variability as measures of gait stability. With the ECW-test we determined the netEC. We found that wearing vAFOs significantly increased trunk lateroflexion (Wald χ2 = 33.7, p < 0.001), rotation RoM (Wald χ2 = 20.5, p < 0.001) and mediolateral gait instability (Wald χ2 = 10.4, p = 0.016). The extent of these effects partly depended on the stiffness of the vAFO. Significant relations between trunk movements, gait stability and ECW were found r = 0.57–0.81, p < 0.05), which indicates that trunk movements and gait stability should be taken into account when prescribing vAFOs to improve gait in children with CP walking with excessive knee flexion.

@en

Gait of children with spastic paresis (SP) is frequently characterized by a reduced ankle range of motion, presumably due to reduced extensibility of the triceps surae (TS) muscle. Little is known about how morphological muscle characteristics in SP children are affected. The aim of this study was to compare gastrocnemius medialis (GM) muscle geometry and extensibility in children with SP with those of typically developing (TD) children and assess how GM morphology is related to its extensibility. Thirteen children with SP, of which 10 with a diagnosis of spastic cerebral palsy and three with SP of unknown etiology (mean age 9.7 ± 2.1 years; GMFCS: I–III), and 14 TD children (mean age 9.3 ± 1.7 years) took part in this study. GM geometry was assessed using 3D ultrasound imaging at 0 and 4 Nm externally imposed dorsal flexion ankle moments. GM extensibility was defined as its absolute length change between the externally applied 0 and 4 Nm moments. Anthropometric variables and GM extensibility did not differ between the SP and TD groups. While in both groups, GM muscle volume correlated with body mass, the slope of the regression line in TD was substantially higher than that in SP (TD = 3.3 ml/kg; SP = 1.3 ml/kg, p < 0.01). In TD, GM fascicle length increased with age, lower leg length and body mass, whereas in SP children, fascicle length did not correlate with any of these variables. However, the increase in GM physiological cross-sectional area as a function of body mass did not differ between SP and TD children. Increases in lengths of tendinous structures in children with SP exceeded those observed in TD children (TD = 0.85 cm/cm; SP = 1.16 cm/cm, p < 0.01) and even exceeded lower-leg length increases. In addition, only for children with SP, body mass (r = −0.61), height (r = −0.66), muscle volume (r = − 0.66), physiological cross-sectional area (r = − 0.59), and tendon length (r = −0.68) showed a negative association with GM extensibility. Such negative associations were not found for TD children. In conclusion, physiological cross-sectional area and length of the tendinous structures are positively associated with age and negatively associated with extensibility in children with SP.@en

Objective: To identify factors associated with long-term improvement in gait in children after selective dorsal rhizotomy (SDR). Design: Retrospective cohort study. Setting: University medical center. Participants: Children (N=36) (age 4-13y) with spastic diplegia of Gross Motor Function Classification System (GMFCS) level I (n=14), II (n=15), and III (n=7) were included retrospectively from the database of our hospital. Children underwent SDR between January 1999 and May 2011. Patients were included if they received clinical gait analysis before and 5 years post-SDR, age >4 years at time of SDR and if brain magnetic resonance imaging (MRI) scan was available. Intervention: Selective dorsal rhizotomy. Main Outcome Measures: Overall gait quality was assessed with Edinburgh visual gait score (EVGS), before and 5 years after SDR. In addition, knee and ankle angles at initial contact and midstance were evaluated. To identify predictors for gait improvement, several factors were evaluated including functional mobility level GMFCS, presence of white matter abnormalities on brain MRI, and selective motor control during gait (synergy analysis). Results: Overall gait quality improved after SDR, with a large variation between patients. Multiple linear regression analysis revealed that worse score on EVGS and better GMFCS were independently related to gait improvement. Gait improved more in children with GMFCS I and II compared to III. No differences were observed between children with or without white matter abnormalities on brain MRI. Selective motor control during gait was predictive for improvement of knee angle at initial contact and midstance, but not for EVGS. Conclusion: Functional mobility level and baseline gait quality are both important factors to predict gait outcomes after SDR. If candidates are well selected, SDR can be a successful intervention to improve gait both in children with brain MRI abnormalities as well as other causes of spastic diplegia.

@en

Comprehensive instrumented muscle and joint assessments should be considered when prescribing Botulinum NeuroToxin-A (BoNT-A) treatment in spastic paresis. In a child with spastic paresis, comprehensive evaluation following treatment with BoNT-A, serial casting, and physiotherapy showed that short-term improvements in gait occurred without changes in muscle morphology. Rather, foot flexibility increased.

@en

Background: Children with cerebral palsy (CP) often show impaired selective motor control (SMC) that induces limitations in motor function. Children with CP can improve aspects of pathological gait in an immediate response to visual biofeedback. It is not known, however, how these gait adaptations are achieved at the neural level, nor do we know the extent of SMC plasticity in CP. Aim: Investigate the underlying SMC and changes that may occur when gait is adapted with biofeedback. Methods: Twenty-three ambulatory children with CP and related (hereditary) forms of spastic paresis (Aged: 10.4 ± 3.1, 6–16 years, M: 16/F: 9) were challenged with real-time biofeedback to improve step length, knee extension, and ankle power while walking on an instrumented treadmill in a virtual reality environment. The electromyograms of eight superficial muscles of the leg were analyzed and synergies were further decomposed using non-negative matrix factorization (NNMF) using 1 to 5 synergies, to quantify SMC. Total variance accounted for (tVAF) was used as a measure of synergy complexity. An imposed four synergy solution was investigated further to compare similarity in weightings and timing patterns of matched paired synergies between baseline and biofeedback trials. Results: Despite changes in walking pattern, changes in synergies were limited. The number of synergies required to explain at least 90% of muscle activation increased significantly, however, the change in measures of tVAF₁ from baseline (0.75 ± 0.08) were less than ±2% between trials. In addition, within-subject similarity of synergies to baseline walking was high (>0.8) across all biofeedback trials. Conclusion: These results suggest that while gait may be adapted in an immediate response, SMC as quantified by synergy analysis is perhaps more rigidly impaired in CP. Subtle changes in synergies were identified; however, it is questionable if these are clinically meaningful at the level of an individual. Adaptations may be limited in the short term, and further investigation is essential to establish if long term training using biofeedback leads to adapted SMC.

@en

Objective: To investigate the immediate response to avatar-based biofeedback on 3 clinically important gait parameters: step length, knee extension, and ankle power in children with cerebral palsy (CP). Design: Repeated measures design. Setting: Rehabilitation clinic. Participants: Children with spastic paresis (N=22; 10.5±3.1y), able to walk without assistive devices. Intervention: Children walked on a treadmill with a virtual reality environment. Following baseline gait analysis, they were challenged to improve aspects of gait. Children visualized themselves as an avatar, representing movement in real time. They underwent a series of 2-minute trials receiving avatar-based biofeedback on step length, knee extension, and ankle power. To investigate optimization of biofeedback visualization, additional trials in which knee extension was visualized as a simple bar with no avatar; and avatar alone with no specific biofeedback were carried out. Main Outcome Measures: Gait pattern, as measured by joint angles, powers, and spatiotemporal parameters, were compared between baseline and biofeedback trials. Results: Participants were able to adapt gait pattern with biofeedback, in an immediate response, reaching large increases in ankle power generation at push-off (37.7%) and clinically important improvements in knee extension (7.4^o) and step length (12.7%). Biofeedback on one parameter had indirect influence on other aspects of gait. Conclusion: Children with CP show capacity in motor function to achieve improvements in clinically important aspects of gait. Visualizing biofeedback with an avatar was subjectively preferential compared to a simplified bar presentation of knee angle. Future studies are required to investigate if observed transient effects of biofeedback can be retained with prolonged training to test whether biofeedback-based gait training may be implemented as a therapy tool.

@en

Background: Virtual reality presents a platform for therapeutic gaming, and incorporation of immersive biofeedback on gait may enhance outcomes in rehabilitation. Time is limited in therapeutic practice, therefore any potential gait training tool requires a short set up time, while maintaining clinical relevance and accuracy. The aim of this study was to develop, validate, and establish the usability of an avatar-based application for biofeedback-enhanced gait training with minimal set up time. Methods: A simplified, eight marker model was developed using eight passive markers placed on anatomical landmarks. This allowed for visualisation of avatar-based biofeedback on pelvis kinematics, hip and knee sagittal angles in real-time. Retrospective gait analysis data from typically developing children (n = 41) and children with cerebral palsy (n = 25), were used to validate eight marker model. Gait outcomes were compared to the Human Body Model using statistical parametric mapping. Usability for use in clinical practice was tested in five clinical rehabilitation centers with the system usability score. Findings: Gait outcomes of Human Body Model and eight marker model were comparable, with small differences in gait parameters. The discrepancies between models were <5°, except for knee extension where eight marker model showed significantly less knee extension, especially towards full extension. The application was considered of ‘high marginal acceptability’ (system usability score, mean 68 (SD 13)). Interpretation: Gait biofeedback can be achieved, to acceptable accuracy for within-session gait training, using an eight marker model. The application may be considered usable and implemented for use in patient populations undergoing gait training.@en

To improve gait in children with spastic paresis due to cerebral palsy or hereditary spastic paresis, the semitendinosus muscle is frequently lengthened amongst other medial hamstring muscles by orthopaedic surgery. Side effects on gait due to weakening of the hamstring muscles and overcorrections have been reported. How these side effects relate to semitendinosus morphology is unknown. This study assessed the effects of bilateral medial hamstring lengthening as part of single-event multilevel surgery (SEMLS) on (1) knee joint mechanics (2) semitendinosus muscle morphology and (3) gait kinematics. All variables were assessed for the right side only. Six children with spastic paresis selected for surgery to counteract limited knee range of motion were measured before and about a year after surgery. After surgery, in most subjects popliteal angle decreased and knee moment-angle curves were shifted towards a more extended knee joint, semitendinosus muscle belly length was approximately 30% decreased, while at all assessed knee angles tendon length was increased by about 80%. In the majority of children muscle volume of the semitendinosus muscle decreased substantially suggesting a reduction of physiological cross-sectional area. Gait kinematics showed more knee extension during stance (mean change ± standard deviation: 34±13), but also increased pelvic anterior tilt (mean change ± standard deviation: 23±5). In most subjects, surgical lengthening of semitendinosus tendon contributed to more extended knee joint angle during static measurements as well as during gait, whereas extensibility of semitendinosus muscle belly was decreased. Post-surgical treatment to maintain muscle belly length and physiological cross-sectional area may improve treatment outcome of medial hamstring lengthening.@en

Children with cerebral palsy (CP) often show excessive knee flexion during walking. To counteract knee flexion, Ankle-Foot Orthoses (AFOs) are frequently prescribed. The effectiveness of AFOs is dependent on their mechanical characteristics, e.g. stiffness [1] and alignment [2]. The Roll-over Shape (RoS) has been proposed as a parameter to quantify the AFO’s mechanical behaviour and alignment [3]. The RoS has however never been investigated in children with CP walking with or without AFOs.@en

Real-time feedback may be useful for enhancing information gained from clinical gait analysis of children with cerebral palsy (CP). It may also be effective in functional gait training, however, it is not known if children with CP can adapt gait in response to real-time feedback of kinematic parameters. Sixteen children with cerebral palsy (age 6–16; GMFCS I–III), walking with a flexed-knee gait pattern, walked on an instrumented treadmill with virtual reality in three conditions: regular walking without feedback (NF), feedback on hip angle (FH) and feedback on knee angle (FK). Clinically relevant gait parameters were calculated and the gait profile score (GPS) was used as a measure of overall gait changes between conditions. All children, except one, were able to improve hip and/or knee extension during gait in response to feedback, with nine achieving a clinically relevant improvement. Peak hip extension improved significantly by 5.1 ± 5.9° (NF: 8.9 ± 12.8°, FH: 3.8 ± 10.4°, p = 0.01). Peak knee extension improved significantly by 7.7 ± 7.1° (NF: 22.2 ± 12.0°, FK: 14.5 ± 12.7°, p < 0.01). GPS did not change between conditions due to increased deviations in other gait parameters. Responders to feedback were shown to have worse initial gait as measured by GPS (p = 0.005) and functional selectivity score (p = 0.049). In conclusion, ambulatory children with CP show adaptability in gait and are able to respond to real-time feedback, resulting in significant and clinically relevant improvements in peak hip and knee extension. These findings show the potential of real-time feedback as a tool for functional gait training and advanced gait analysis in CP.

@en

Background and purpose: To support clinical decision-making in central neurological disorders, a physical examination is used to assess responses to passive muscle stretch. However, what exactly is being assessed is expressed and interpreted in different ways. A clear diagnostic framework is lacking. Therefore, the aim was to arrive at unambiguous terminology about the concepts and measurement around pathophysiological neuromuscular response to passive muscle stretch. Methods: During two consensus meetings, 37 experts from 12 European countries filled online questionnaires based on a Delphi approach, followed by plenary discussion after rounds. Consensus was reached for agreement ≥75%. Results: The term hyper-resistance should be used to describe the phenomenon of impaired neuromuscular response during passive stretch, instead of for example ‘spasticity’ or ‘hypertonia’. From there, it is essential to distinguish non-neural (tissue-related) from neural (central nervous system related) contributions to hyper-resistance. Tissue contributions are elasticity, viscosity and muscle shortening. Neural contributions are velocity dependent stretch hyperreflexia and non-velocity dependent involuntary background activation. The term ‘spasticity’ should only be used next to stretch hyperreflexia, and ‘stiffness’ next to passive tissue contributions. When joint angle, moment and electromyography are recorded, components of hyper-resistance within the framework can be quantitatively assessed. Conclusions: A conceptual framework of pathophysiological responses to passive muscle stretch is defined. This framework can be used in clinical assessment of hyper-resistance and will improve communication between clinicians. Components within the framework are defined by objective parameters from instrumented assessment. These parameters need experimental validation in order to develop treatment algorithms based on the aetiology of the clinical phenomena.

@en

Gait analysis is used for the assessment of walking ability of children with cerebral palsy (CP), to inform clinical decision making and to quantify changes after treatment. To simplify gait analysis interpretation and to quantify deviations from normality, some quantitative synthetic descriptors were developed over the years, such as the Movement Analysis Profile (MAP) and the Linear Fit Method (LFM), but their interpretation is not always straightforward. The aims of this work were to: (i) study gait changes, by means of synthetic descriptors, in children with CP that underwent Single Event Multilevel Surgery; (ii) compare the MAP and the LFM on these patients; (iii) design a new index that may overcome the limitations of the previous methods, i.e. the lack of information about the direction of deviation or its source. Gait analysis exams of 10 children with CP, pre- and post-surgery, were collected and MAP and LFM were computed. A new index was designed as a modified version of the MAP by separating out changes in offset (named OC-MAP). MAP documented an improvement in the gait pattern after surgery. The highest effect was observed for the knee flexion/extension angle. However, a worsening was observed as an increase in anterior pelvic tilt. An important source of gait deviation was recognized in the offset between observed tracks and reference. OC-MAP allowed the assessment of the offset component versus the shape component of deviation. LFM provided results similar to OC-MAP offset analysis but could not be considered reliable due to intrinsic limitations. As offset in gait features played an important role in gait deviation, OC-MAP synthetic analysis was proposed as a novel approach to a meaningful parameterisation of global deviations in gait patterns of subjects with CP and gait changes after treatment.

@en