14.3 Spasticity. Treatment of postural dysfunction inchildren with cerebral palsy

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Chapter 14. Developmental sensory, motor and mental disorders

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Postural control in non-treated scoliotic subjects

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M. Beaulieu 1, G. Dalleau2, M. Simoneau 2, M. Eslami 1, C.H. Rivard 1, R Allard 1. 1Laboratoire d'FJtude du Mouvement, Research

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Cente~ Sainte-Justine Hospital, Montreal, QuEbec, Canada," 2Centre Universitaire de Recherche en ActivitEs Physiques et Sportives, FacultEs des' Sciences' et Technologies', UniversitE de La REunion, Le Tampon, France," 3Departement de Medecine Sociale et Preventive, Division de Kinesiologie, Universite Laval, QuEbec, Canada

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Introduction: Sahlstrand et a1.(1978) reported standing instability in scoliotic subjects but have not addressed the underlying postural control mechanisms. The aim of this study is to determine if a different postural control mechanism is used by scoliotic subjects to maintain quiet stance over a 64 s period using center of pressure (COP) velocity. Method: Balance in 29 AIS girls (12.7 years) having a Cobb angle of 19o and a right thoracic curve and 33 able-bodied girls (13.9 years) was tested on a force-plate (64 Hz). Two 10 s periods were chosen to determine if the on-set (IT) standing balance strategy (5 15 s) is maintained or not at the 54 64 s period (FT). Paired T-tests were performed on the CoP range and velocity between the IT and FT conditions of each group and ANOVAs between each group. Results: The absolute difference in the CoP range between IT and FT was higher (3.2mm) in the scoliotic group (p 0.04) by 1.34mm. CoP velocity of the scoliotic group remain constant at 10.62 m/s while that of the control group decrease by 7%(0.7 mm/s;p 0.004). Discussion: Scoliotic girls seem to have an impairment to integrate sensorial input coming from CoP velocity leading to greater oscillations observed in the CoP range. The able-bodied girls take into account postural information provided from the CoP velocity. Conclusion: Scoliotics' balance seems to be maintained by a different postural control requiring a higher neuromuscular demand during quiet stance.

References [1] Sahlstrand T, Oertengren R, Nachemson A. Postural equilibrium in adolescent idiopathic scoliosis. Acta Orthop Scand 1978; 49(4): 354 65.

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The use of botulinum toxin (BT) on rectus femoris (RF) and semitendinosus (ST) in cerebral palsy (CP) child. A preliminary report

A. Bonnefoy, B. Dohin, L. Ch~ze, E. Chaleat-Valayer, R. Kohler.

Laboratoire de BiomEcanique et ModElisation Humaine, UniversitE Lyon 1, and Service de chirurgie pEdiatrique H@ital Herriot Lyon, Centre des' Massues, France Introduction: The aim of this study is to assess the interest of treating spasticity with BT simultaneously on the rectus femoris and semitendinosus muscles. Methods: 3 CP children with spastic diplegia and free from any other treatment were studied. A total dose of 10U/kg (BOTOX ®AllerganTM) was used. Gait analysis (Motion Analysis system) was performed before treatment and 1 month later. A biomechanical model previously developed [1], was used. Results: Kinematics and kinetics data in sagittal plane showed improvement (Fig. 1) in hip extension, extension moment, knee extension, absorption moment of the RF and knee extension at heel strike.

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Figure 1: Kinematics and kinetics in the sagittal plane. Discussion: The effectiveness of BT in CP children is now well recognized. Its use on RF and on ST has not been so far reported. The results data show better improvement in using BT on both than only hamstrings [2,3]. Conclusion: Our preliminary results exhibit a significant improvement on the gait. A study involving a larger population is conducted at the present time to validate this hypothesis.

References [1] Doriot N, Ch~ze L. A three dimensional dynamic model of the lower limb during the stance phase of gait IEEE, 2001; vol. 51(1); 1 6. [2] Thompson N e t al. Musculoskeletal modelling in determining the effect of botulinum toxin on the hamstrings of patients with crouch gait. Dev Med Child Neurol 1998; 40(9): 622 625. [3] Reimers J. Functional changes in the antagonists after lengthening the agonists in cerebral palsy. Cin. Orth. Res. 1990; 253:35 7.

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Spasticity. Treatment of postural dysfunction in children with cerebral palsy

E. Brogren-Carlberg 1, M. Hadders-Algra 2. 1Dept. of Woman and

Child Health, Neuropediatric Research Unit, Karolinska Institutet, Astrid Lindgren Childrens Hospital, Q2.'07, 171 76 Stockholm, Sweden," 2Dept of Neurology, University Department of Neurology Developmental Neurology, University of Groningen, The Netherlands' Introduction: The performance of everyday activities in children with cerebral palsy (CP) is highly influenced by postural deficits. Knowledge on the pathophysiology of the postural problems can improve our choice of therapy and can be useful when adjusting therapy to the difficulties of a specific patient. Postural control in sitting children with CP has been studied using two experimental paradigms 1) a sudden destabilization by means of a movable supportsurface and 2) disturbing forces produced by voluntary movements. Results: Most children with CP exhibit muscular activity counteracting the disturbing forces. Only children with severe CR who cannot sit independently, has displayed a total lack of such 'direction-specific' muscular activity, possibly ruling out achievement of independent sitting. Children, who could sit independently only for a short while, exhibited incomplete direction appropriate adjustments. Commonly children with CP cannot adapt the postural adjustment to task

Chapter 14. Developmental sensory, motor and mental disorders

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specific constraints. Typical characteristics of this deficient adaptation are a top-down recruitment of postural muscles, a high degree of antagonistic co-activation during external perturbations (but not during reaching) and a lack or an incomplete modulation of the EMGamplitude. Conclusion: A cranio-caudal recruitment order and an excessive degree of antagonistic co-activation might represent strategies to cope with a lacking ability to modulate muscular amplitude. How could the child train this ability? Suggestions will be given.

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Binocular coordination of saccades at far and near viewing distance in children with vertigo

M.P. Bucci 1, Z. Kapoula 1, Q. Yang 1, D. Br~mond-Gignac2, S. Wiener-Vacher3. 1LPPA, CNRS UMR 7124 Coll~gede France,

11, place M. Berthelot, 75005 Paris', France," 2H@ital Robert Debrd, service d'Ophtalmologie, SH@ital Robert Debrd, service O.R.L. 48, Bld Sdrurie~ 75019 Paris', France Introduction: We reported [1,2] that children with symptoms of vertigo but normal vestibular function, revealed abnormal convergence eye movements (long latency and duration, poor accuracy). We tested whether vergence abnormalities affect other oculomotor aspects, as the quality of binocular coordination of saccades. Methods: LEDs were used to stimulate visually-guided saccades at far and close viewing distance; eye movements from 14 children were recorded. Results: At far distance disconjugacy of the eyes during the saccades and the fixation drift after the saccade was small (5% and 3% of the amplitude of saccade, respectively); these values are similar to those reported in normal children [3]. In contrast, at near distance, binocular coordination of saccades was worst than in normal children: 9% and 5% respectively. Conclusions: Poor binocular coordination of saccades and during fixation could lead to transient double vision at near distance. Based on these results, we predict abnormal binocular coordination of the VOR, but this needs further investigation. Poor binocular coordination of saccades and of the VOR could affect gaze stabilisation leading to vertigo.

References [1] Bucci MR Kapoula Z, Yang Q, Wiener-Vacher S, Br~mondGignac D. Abnormality of vergence latency in children with vertigo. J Neurology 2004; 251:204 213. [2] Bucci MR Kapoula Z, Yang Q, Br~mond-Gignac D, WienerVaccher S. Speed-accuracy of saccades, vergence and combined eye movements in children with vertigo. Exp Brain Res 2004; 157:286 295. [3] Yang Q, Kapoula Z. Binocular coordination of saccades at far and at near in children and in adults. Journal of Vision 2003; 3(8): 554 561.

Results: In the counting condition, the walking speed could be reduced up to 50%, with possible disruption of the linear relationships between stride length/cadence and walking speed. In four out of five children, moreover, math trials were associated with partial correction of kinematic abnormalities typical of the heel-strike gait of HTW (premature heel-off and/or reversal of the second rocker), as well as with a shift of the ankle joint range of motion toward more dorsiflexed value s. Discussion and Conclusion: Result indicate that cognitive factors might contribute to the expression of abnormal gait pattern in a subpopulation of subjects with HTW. This findings might have potential consequences for the diagnosis and treatment of this condition.

References [1] Crenna P. Fedrizzi E., Andreucci E., Frigo C., Bono R. The heel-contact gait pattern of habitual toe walkers. Gait & Posture, published in digital form.

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S.S. Eun 1 , S. Miyano 1 , C.I. Park 2, E.S. Park 2, J. Chu 3. 1Dept. of Rehabilitation Medicine, Jikei Univ. School of Medicine, Japan," Dept. of Rehabilitation Medicine, Yonsei Univ. College of Medicine, Korea," ORehabilitation Medicine, Hospital of the University of Pennsylvania, USA Introduction: The purpose of this study was to provide objective

information on the outcome of botulinum toxin-A treatment for the detection of abnormal ankle motion in cerebral palsy patients by using three-dimensional motion analysis system. Method: Recruited into the study were thirteen ambulatory cerebral palsy (CP) children ages 2 11 years old. Botulinum toxin A (BTXA) was injected into spastic gastrocnemius muscle of 19 legs (both leg of 6 diplegics and an affected leg of 7 hemiplegics). A clinical assessment and gait analysis were performed on the same day and two weeks after the first injection. Kinematics data were obtained by motion analyzer (Vicon 370 M.A). The smoothness of ankle range of motion (ROM) were quantified by the jerk-cost (JC) function. Before and after treatment comparisons were calculated using Wilcoxon test. Results: The kinematic data showed significant improvements in the active ankle ROM of both groups at two weeks. The smoothness of the ankle motion improved significantly in patients with hemiplegia at two weeks (p < 0.05), however, there were no significant improvements in diplegic CR Discussion: JC function provided useful information for the ankle kinematics as well as ROM. Conclusion: BTX injection improved smoothness in ankle motion in hemiplegic CP more than in diplegic CR

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Effects of a cognitive task on gait kinematics of habitual toe walkers

P. Crenna, A. Marzegan, L. Salvadori, L. San&in. Laboratory for

Analysis of Movement in Children Pierfranco & Luisa Mariani, Institute of Human Physiology L Faculty of Medicine, University of Milan, via Mangiagalli 32, 1-20133, Milan, Italy Introduction: Habitual Toe Walking (HTW) is a condition whereby

children preferentially adopt a tip-toe gait pattern in the absence of signs of neuro-muscular impairment. In addition to peripheral factors, a contribution from higher level central control has been postulated [1]. The present study was aimed at further testing this hypothesis using a dual task paradigm. Methods: By means of standard gait analysis we studied the effects a cognitive task (counting backwards) on the gait pattern of five school-age children exhibiting facultative toe walking.

The changes of ankle kinematics in children with cerebral palsy between before and after btx-A injection

Measuring hip and knee intra-limb coordination in gait of normal children: implications for children with cerebral palsy

S. Farmer, C. Stewart. Orthotic Research and Locomotor Assessment

Unit, Robert Jones' And Agnes' Hunt Orthopaedic and District NHS Trust, Oswestty, Shropshire, SYI O 7AG, UK Introduction: Normal infants walk independently at about 12 months.

Supported walking and early independent walking show synchronous hip and knee flexion followed by hip and knee extension [1]. As gait matures there is dissociation of this tight synchrony. Children with cerebral palsy often lack this normal intra-limb coordination [2]. We present data of intra-limb coordination (ILC) of normal children as a precursor to work in children with cerebral palsy. Method: A convenience sample of 16 normal children (6 13 years, mean 9.6 years) was recruited. 3-dimensional gait data were collected for 10 walks for each subject. The coefficient of multiple correlation (CMC) was calculated for intra-subject repeatability of hip and knee