Vol 8, No 4 (2022)
Research paper
Published online: 2022-09-26

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Impairments restricted knee flexion during gait in a child with cerebral palsy

Faustyna Manikowska1, Sabina Brazeviс1, Marek Jóźwiak1, Maria Lebiedowska2
Rheumatology Forum 2022;8(4):178-184.


Introduction: A child with cerebral palsy has multiple coexisting deficits that limit functional abilities such as walking. Their interaction shapes the kinematic gait pattern by modulating both the range and shape of the knee flexion movement during the swing phase. The significance of the effect of specific impairments on knee joint flexion range-of-motion is not clear.
Aim: The aim of this study is to comprehensively analyse the effect of coexisting deficits on the range and speed of flexion at the knee joint in the sagittal plane in a child with cerebral palsy.
Material and methods: In 132 patients (M = 76; F = 56; age: 11 ± 4) with spastic cerebral palsy, lower limb joint range-of-motion, selective motor control, strength and spasticity were assessed during the clinical examination. The range of knee flexion in the terminal stance phase, pre-swing and initial swing (TSt-ISw) was assessed during the laboratory three-dimensional gait analysis.
Results: The TSt-ISw knee flexion movement was most strongly (RS = –0.28) dependent on knee extensor hypertonia, similarly as in the KSt stance phase (RS = –0.22) and in the KSw swing phase (RS = –0.22). The velocity of flexion (V) was most strongly correlated with knee extensor muscle hypertonia (RS = –0.32) and successively with selective control of hip flexor movement (RS = –0.28), knee extensor strength (RS = –0.23) and plantar flexor hypertonia (RS = –0.21).
Conclusions: The range-of-motion of knee flexion in the sagittal plane depends on the hypertonia of the knee extensor muscles in both the TSt-ISw and KSt and KSw phases.
Velocity increase depends on the occurrence of knee extensor muscle hypertonia, selective control of hip flexor movement, knee extensor strength and plantar flexor hypertonia.

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  1. Rosenbaum P, Paneth N, Leviton A, et al. A report: the definition and classification of cerebral palsy April 2006. Dev Med Child Neurol Suppl. 2007; 109: 8–14.
  2. Sanger TD, Chen D, Delgado MR, et al. Definition and classification of negative motor signs in childhood. Pediatrics. 2006; 118(5): 2159–2167.
  3. Dreher T, Wolf SI, Maier M, et al. Long-term results after distal rectus femoris transfer as a part of multilevel surgery for the correction of stiff-knee gait in spastic diplegic cerebral palsy. J Bone Joint Surg Am. 2012; 94(19): e142(1–10).
  4. Goldberg SR, Ounpuu S, Arnold AS, et al. Kinematic and kinetic factors that correlate with improved knee flexion following treatment for stiff-knee gait. J Biomech. 2006; 39(4): 689–698.
  5. Ounpuu S, Muik E, Davis RB, et al. Rectus femoris surgery in children with cerebral palsy. Part II: A comparison between the effect of transfer and release of the distal rectus femoris on knee motion. J Pediatr Orthop. 1993; 13(3): 331–335.
  6. Perry J, Burnfield JM. Gait analysis: normal and pathological function. SLACK, Thorofaren NJ 2010.
  7. Lebiedowska MK, Wente TM, Dufour M. The influence of foot position on body dynamics. J Biomech. 2009; 42(6): 762–766.
  8. Lebiedowska MK, Fisk JR. Quantitative evaluation of reflex and voluntary activity in children with spasticity. Arch Phys Med Rehabil. 2003; 84(6): 828–837.
  9. Rha DW, Cahill-Rowley K, Young J, et al. Biomechanical and clinical correlates of swing-phase knee flexion in individuals with spastic cerebral palsy who walk with flexed-knee gait. Arch Phys Med Rehabil. 2015; 96(3): 511–517.
  10. Bar-On L, Molenaers G, Aertbeliën E, et al. The relation between spasticity and muscle behavior during the swing phase of gait in children with cerebral palsy. Res Dev Disabil. 2014; 35(12): 3354–3364.
  11. Ellington MD, Scott AC, Linton J, et al. Rectus femoris transfer versus rectus intramuscular lengthening for the treatment of stiff knee gait in children with cerebral palsy. J Pediatr Orthop. 2018; 38(4): e213–e218.
  12. Hislop H, Avers D, Brown M. Daniels and Worthingham's muscle Testing-E-Book: Techniques of manual examination and performance testing. Elsevier Health Sciences 2013.
  13. Bohannon RW, Smith MB. Interrater reliability of a modified Ashworth scale of muscle spasticity. Phys Ther. 1987; 67(2): 206–207.
  14. Manikowska F, Chen BPJ, Jóźwiak M, et al. Validation of manual muscle testing (MMT) in children and adolescents with cerebral palsy. NeuroRehabilitation. 2018; 42(1): 1–7.
  15. Gage JR. The treatment of gait problems in cerebral palsy. Mac Keith, London 2004.
  16. Sutherland DH, Cooper L, Daniel D. The role of the ankle plantar flexors in normal walking. J Bone Joint Surg Am. 1980; 62(3): 354–363.
  17. Fellows SJ, Kaus C, Ross HF, et al. Agonist and antagonist EMG activation during isometric torque development at the elbow in spastic hemiparesis. Electroencephalogr Clin Neurophysiol. 1994; 93(2): 106–112.
  18. Fowler E. Concepts in spasticity and selective motor control in children with spastic cerebral palsy. Technology and Disability. 2010; 22(4): 207–214.
  19. Levin MF, Hui-Chan C. Ankle spasticity is inversely correlated with antagonist voluntary contraction in hemiparetic subjects. Electromyogr Clin Neurophysiol. 1994; 34(7): 415–425.
  20. Ross SA, Engsberg JR. Relation between spasticity and strength in individuals with spastic diplegic cerebral palsy. Dev Med Child Neurol. 2002; 44(3): 148–157.
  21. Sanger TD, Delgado MR, Gaebler-Spira D, et al. Classification and definition of disorders causing hypertonia in childhood. Pediatrics. 2003; 111(1): e89–e97.
  22. Grimby L, Hannerz J. Recruitment order of motor units on voluntary contraction: changes induced by proprioceptive afferent activity. J Neurol Neurosurg Psychiatry. 1968; 31(6): 565–573.
  23. Myklebust BM, Gottlieb GL, Penn RD, et al. Reciprocal excitation of antagonistic muscles as a differentiating feature in spasticity. Ann Neurol. 1982; 12(4): 367–374.
  24. Desloovere K, Molenaers G, Feys H, et al. Do dynamic and static clinical measurements correlate with gait analysis parameters in children with cerebral palsy? Gait Posture. 2006; 24(3): 302–313.
  25. Sutherland DH, Santi M, Abel MF. Treatment of stiff-knee gait in cerebral palsy: a comparison by gait analysis of distal rectus femoris transfer versus proximal rectus release. J Pediatr Orthop. 1990; 10(4): 433–441.
  26. Ross SA, Engsberg JR. Relationships between spasticity, strength, gait, and the GMFM-66 in persons with spastic diplegia cerebral palsy. Arch Phys Med Rehabil. 2007; 88(9): 1114–1120.
  27. Sousa TC, Nazareth A, Rethlefsen SA, et al. Rectus femoris transfer surgery worsens crouch gait in children with cerebral palsy at GMFCS levels III and IV. J Pediatr Orthop. 2019; 39(9): 466–471.
  28. Campbell R, Tipping N, Carty C, et al. Orthopaedic management of knee joint impairment in cerebral palsy: A systematic review and meta-analysis. Gait Posture. 2020; 80: 347–360.
  29. Miller F, Cardoso Dias R, Lipton GE, et al. The effect of rectus EMG patterns on the outcome of rectus femoris transfers. J Pediatr Orthop. 1997; 17(5): 603–607.
  30. Manikowska F, Chen BP, Jóźwiak M, et al. Assessment of selective motor control in clinical Gillette's test using electromyography. Eur J Phys Rehabil Med. 2016; 52(2): 176–185.