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Ultramarathons are a unique model to study the effects of systemic fatigue in athletes. This investigation applied the spring-mass template to study runners before and 2 days after a road ultramarathon to characterize the effects of fatigue on systemic gait patterns. Overground kinetics were captured 7 days before and 2 days after the event in 14 runners. Traditional kinetic and spring-mass parameters were calculated, along with nonlinear regression-derived parameters and spring-mass model fit metrics. After the ultramarathon, vertical force magnitudes and loading rates were unchanged, but impact peaks increased (1.88 ± 0.08-1.95 ± 0.10 bodyweight). Ground contact times were modestly shorter (-3 ± 1 ms), resulting in increased leg stiffness (10.0 ± 0.5-10.3 ± 0.5 kN/m) with equivocal vertical stiffnesses. The deviation from the modeled spring-mass kinetics also increased (171.3 ± 15.0-181.4 ± 16.5 N). Overall, the systemic mechanical behaviors of the runners persisted despite the fatigue and stress induced by a road ultramarathon. These findings support previous observations that runners maintain gross mechanical behavior when fatigued with small compensatory changes in spatiotemporal and traditional spring-mass characteristics. However, these findings also suggest that the variability within that gross behavior may increase after stress, suggesting new opportunities for quantifying those deviations.

Socioeconomic status (SES) tends to influence an individual's access to health care. It is commonly assumed that a poorer SES is associated with a weaker physical health status, especially in disadvantaged populations such as people with cerebral palsy (CP). However, to our knowledge, no study has looked at this assumption. Therefore, the aim of this study was to describe and compare the physical health status of ambulant adults with bilateral CP with different SES backgrounds. In addition, the physical health status of the ambulatory adults with CP was compared to well-matched, typically developing adults. Twenty-eight ambulatory adults with CP (gross motor functional classification system Level I/II/III: n = 11/12/5; SES low/middle/high: n = 10/9/9), and 28 matched typically developing adults were recruited for this study. No differences were observed between adults with CP from different SES backgrounds. Differences in physical health status between typically developing adults and ambulatory adults with CP in all SES backgrounds were found in passive range of motion ( p < 0.05), muscle strength ( p < 0.001), selectivity ( p < 0.001), and muscle tone ( p < 0.001) and balance ( p < 0.05). The main finding of this study is that physical health status did not differ between ambulatory adults with CP from different SES backgrounds. This finding shows that SES does not always directly impact physical health status in ambulatory adults with CP and highlights the importance of an individual approach. Future research should determine the impact of SES on nonambulatory adults with CP., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2024 Maaike M. Eken et al.)

Design: Retrospective cohort study., Objective: Determine the course of burden and psychological distress of significant others (SOs) during initial spinal cord injury (SCI) rehabilitation and to predict the caregiver's burden at discharge with characteristics of SOs and persons with SCI (PSCIs) at the start of rehabilitation., Setting: Rehabilitation center Sint Maartenskliniek, Nijmegen, The Netherlands., Methods: All PSCIs admitted for initial rehabilitation between October 2020 and December 2022 were included. One of their SOs were asked to complete a set of screening questionnaires, collected in our routine context of care., Results: A total of 181 PSCIs (62% male, average age 60 years, 80% incomplete SCI, 60% paraplegia and 32 days after injury) and 158 SOs (40% male, average age 57 years) were screened at admission, and 145 and 93 at discharge, respectively. For SOs, the average caregiver's burden and feelings of depression and anxiety did not change during admission. The caregiver's burden score at discharge was best predicted by the burden score at admission, explaining 20% (P < 0.001) of the variance. An additional 13% (P = 0.02) of the variance was explained by other SO and PSCI variables gathered in this study., Conclusion: The caregiver's burden in this group of SOs during rehabilitation, was higher than that of a representative group in the chronic phase. On both assessments, around 20% scored above the cutoff. Scores of psychological distress are comparable to former studies. Standard screening of SOs during initial SCI rehabilitation is important to help the interdisciplinary team identify SOs at risk, and target their treatment during inpatient rehabilitation., (© 2024. The Author(s), under exclusive licence to International Spinal Cord Society.)

Purpose: To determine if post-exercise heart rate variability, in the form of logged transformed root mean square of successive differences of the R-R intervals (LnRMSSD) can be measured reliably during the recovery from a submaximal cycle test and what the relationship of LnRMSSD is with training status of the cyclists., Methods: Fourteen male cyclists participated in the reliability part for the study, which included performing six Lamberts Submaximal Cycle Test (LSCT), during which recovery LnRMSSD was measured over 30 s (LnRMSSD 30 s ), 60 s LnRMSSD 60 s )and 90 s LnRMSSD 90 s ). In addition, fifty male and twenty female cyclists completed a peak power output (PPO) test (including VO 2peak ) and 40 km time trial (40 km TT) before which they performed the LSCT as a standardized warm-up. Relationships between the LnRMSSD and PPO, VO 2peak and 40 km TT time were studied., Results: Due to the design of the LSCT, submaximal heart and breathing rate were similar at the end of stage 3 of the LSCT, as well as during the recovery periods. The highest reliability was found in LnRMSSD 60 s (ICC: 0.97) with a typical error of the measurement (TEM: 5.8%). In line with this the strongest correlations were found between LnRMSSD 60 s and PPO (r = 0.93[male]; 0.85[female]), VO 2peak (r = 0.71[male]; 0.63[female];) and 40 km TT (r = - 0.83[male]; - 0.63[female])., Conclusions: LnRMSSD 60 s can be measured reliably after the LSCT and can predict PPO, VO 2peak and 40 km TT performance well in trained-to-elite cyclists. These findings suggest that recovery LnRMSSD can potentially play an important role in monitoring and fine-tuning training prescriptions in trained-to-elite cyclists., (© 2024. The Author(s).)

Purpose: The investigators aimed to understand the unmet needs of adults with cerebral palsy (CP) living in urban South Africa and to ascertain similarities or differences to typically developing (TD) adults in the same community., Materials and Methods: Participants were interviewed with an adapted version of the Southampton Needs Assessment Questionnaire (SNAQ). Non-parametric statistical analysis was utilised for quantitative data and qualitative data were analysed using free coding to identify themes., Results: Thirty adults with CP (median age 34.8 years; GMFCS levels I/II/III/IV/V: n  = 6/6/5/7/6; socio-economic status (SES) low/average/high: n  = 8/17/5) were matched for gender, age, and SES. Adults with CP reported a higher unemployment rate and lower level of satisfaction with access to health services than TD peers. Core themes identified by the participants with CP that made community participation more difficult were physical capacity, poor access to accommodation, transport and health services, lack of socialising opportunities, poor universal design, and lack of financial independence., Conclusions: Adults with CP reported experiencing many challenges in their communities. Improved access to health care services and transport, and the universal design of housing and community buildings to accommodate individuals with a disability should be made a priority.Implications for rehabilitationAdults with cerebral palsy (CP) reported that their disability had an impact on their social life, home life, and work life.Accessibility issues have been identified as a major factor affecting adults with CP in a variety of areas, including access to and use of health services, housing, transportation, and community buildings.Adults with CP reported the need for support during the transition to adulthood, especially with developing life skills that will promote living independently in the community as adults with disabilities.

People with spinal cord injury (SCI) often experience secondary health conditions (SHCs), which are addressed during interdisciplinary follow-up clinics. We adapted the design of our clinic, by introducing a questionnaire concerning functioning and SHCs, additional measurements of blood pressure and saturation, and participants were seen by either a specialized nurse or rehabilitation physician. In this study, we investigated the effects of these adaptations and the experienced satisfaction of the participants. The results showed an increased number of recommendations in the adapted design, compared to the initial design. Further, the nature of the recommendations shifted from somatic issues to recommendations regarding psychosocial functioning and regarding (the use of) devices. The added measurements revealed an average high systolic blood pressure, which led to more referrals to the general practitioner. The clinical weight and pulmonary functions stayed stable over time. The current adaptations in design expanded and optimized the number and nature of recommendations regarding SHCs to participants. The questionnaire helps the participant to prepare for the clinic and the professionals to tailor their recommendations, resulting in highly satisfied participants.

Purpose: The aim of this study was to investigate the prevalence and level of disability due to pain, health-related quality of life (HRQoL) and mental health in adolescents and adults with cerebral palsy (CP), living in a low-to-middle income country (LMIC), compared to matched typically developing (TD) peers, and to explore associations with individual characteristics., Materials and Methods: This case-control study included 31 adolescents and 30 adults with CP (gross motor function classification system [GMFCS] Level I-V) and matched TD peers. Assessment tools used were a pain questionnaire, the Oswestry Disability Index (ODI), Short-Form Health Survey (SF-36v2), Hospital Anxiety and Depression Scale (HADS), and General Self Efficacy (GSE) scale., Results: Both CP cohorts reported more frequent pain in their lower limbs, higher level of disability due to pain (total ODI score) and lower perceived physical HRQoL compared to TD peers, while their mental health (mental HRQoL, HADS, and GSE) was not different., Conclusions: Despite the physical challenges faced by adolescents and adults with CP living in urban South Africa, the mental health scores showed no difference compared to TD peers. Care should be taken to maintain this positive mental state during ageing across their lifespan.IMPLICATIONS FOR REHABILITATIONThe prognosis of individuals with cerebral palsy (CP) has improved over the last three decades and CP should therefore be considered as a lifelong condition.Adolescents and adults with CP living in urban South Africa reported a higher level of disability due to pain and lower physical health-related quality of life compared to typically developing peers, while their level of depression, anxiety, and self-esteem was not different.These results were similar to findings of studies conducted in high-income countries, though it cannot be generalised to other low to middle-income countries with different cultural and government systems.In order to promote healthy ageing across their lifespan, intervention programmes should be considered to improve physical well-being, and care should be taken to maintain their positive mental health.

Objective: Determine if spinal curvatures, deformities, as well as level of disability (due to back pain) changes with aging in adults with bilateral spastic cerebral palsy after receiving orthopedic interval surgery approach treatment in childhood., Design: Consecutive case-series SETTING: Urban South Africa PARTICIPANTS: Twenty-seven ambulatory adults with cerebral palsy MAIN OUTCOME MEASURES: Spinal curvatures (scoliosis, thoracic kyphosis and lumbar lordosis) and deformities (spondylolysis and spondylolisthesis) were determined with X-rays, while the level of disability was assessed with the Oswestry Disability Index., Results: The prevalence of spinal abnormalities were: 30% scoliosis (mild: <30°), 0% thoracic hyperkyphosis, 15% lumbar hyperlordosis, 0%; spondylolysis, and 0% spondylolisthesis. No changes in scoliosis and lumbar lordosis angles were observed, while the change in thoracic kyphosis angle was smaller than the minimal clinically important difference and moved closer toward the norm-values for typically developing adults. Level of disability remained similar with 63% reporting minimal disability, 26% moderate disability and 11% severe disability. No associations with spinal curvatures were found., Conclusions: No clinically meaningful changes in spinal curvatures, deformities and level of disability due to pain were seen during the 6 years follow-up period in adults with cerebral palsy who have been treated with interval surgery approach in childhood., (Copyright © 2021 The American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Background: Although the short-term outcomes of selective dorsal rhizotomy (SDR) in children with cerebral palsy (CP) have been well documented, less is known about the long-term benefits of SDR, especially while aging., Research Question: Does the gait of adults with CP, who underwent SDR in childhood, change during a nine-year aging follow-up period? Do associations exists between the gait deviation index (GDI) and contextual factors at follow-up?, Methods: Three-dimensional motion data was captured (Vicon system) of 26 adults (10 female) with CP and spastic diplegia at baseline (17-to-26 years post-SDR) and at nine-year follow-up (26-to-35 years post-SDR), as well as 41 matched typically developed (TD) adults used for reference data. Kinematic, non-dimensional temporal distance and GDI parameters were determined, and associations with contextual factors were studied., Results: At follow-up the adults with CP had a (median [interquartile ranges]) age of 35.8 [34.2-41.2] years and classified as Gross Motor Function Classification System (GMFCS) level I (n = 13), level II (n = 10) and level III (n = 3). Overall no clinically relevant change in gait quality (GDI) was detected over the nine-year follow-up period. However, small changes were found in hip and knee range of motion, peak knee flexion and walking speed. In line with the baseline study, a number of gait parameters were different to TD adults. The only association found was between GDI and GMFCS at follow-up (r = 0.64, p < 0.01)., Significance: The overall walking pattern of the adults with CP who underwent SDR in childhood was characterised by mild crouch gait with minimal signs of spasticity, confirming former physical examination findings. Some small changes in certain gait parameters were determined, though clinically the gait quality remained stable during the nine-year aging period. This finding supports the stability of the gait pattern during mid-life in adults with CP, who met the strict SDR selection criteria., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Background: Research in high income countries shows that people with cerebral palsy (CP) are less physically active than typically developing (TD) peers, but less is known regarding physical activity (PA) in those with CP in low-to-middle income countries. The aim of this study was to determine daily step count and levels of PA in adolescents and adults with CP living in urban South Africa, compared to TD peers, and to determine associations with sex, Gross Motor Function Classification System (GMFCS) level, body mass index and socio-economic status. Materials and Methods: This case-control study included 26 adolescents and 22 adults with CP (GMFCS Level I-V) and matched TD peers (25 and 30, respectively). Participants wore an ActiGraph GT3X for 7 consecutive days to determine step count and time (minutes per hour) spent in PA levels, including sedentary (SED), low physical activity (LPA) and moderate to vigorous physical activity (MVPA). Results: The daily step count and PA levels for ambulant adolescents with CP (GMFCS level I-III) were similar to TD peers, while this was less for adolescents classified in GMFCS level IV-V. Daily step count, SED and MVPA were similar for adults classified in GMFCS level I-II compared to TD adults, while all parameters were lower for adults using assistive devices (GMFCS level III) and non-ambulant adults (GMFCS level IV-V) compared to TD peers. Daily step count and PA levels were inversely associated with GMFCS, while no other associations were found. Conclusion: People with CP who were more mobile dependent (higher GMFCS level) were less active. However, adolescents and adults with CP classified as GMFCS levels I-II living in urban South Africa recorded similar step count and PA levels as their TD peers. This was also the case for adolescents using assistive devices, though not for those in the adult group (GMFCS level III). Furthermore, it was apparent that even the ambulant individuals with CP and TD cohorts were relatively inactive. Intervention programs for CP and TD adolescents should be aimed at finding strategies to keep adolescents physically active well into adulthood, in order to promote physical health, social and emotional well-being and independence., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Salie, Eken, Donald, Fieggen and Langerak.)

Background: Insight into the day-to-day challenges faced by adults living with Cerebral Palsy (CP) in low-to-middle income countries (LMICs) will enable support towards healthy aging in this population., Objectives: To determine changes in level of pain, functional mobility and accomplishment as well as satisfaction in daily life of ambulant adults with CP living in a LMIC over a six-year period, compared to typically developed (TD) adults. In addition, to determine associations with individual characteristics., Methods: Twenty-eight adults with CP and spastic diplegia (median [interquartile ranges] age = 39.0 [34.0-45.7] years; Gross Motor Function Classification System level I/II/III: n = 11/12/5) participated in this study, together with 28 matched TD adults. Levels of accomplishment and satisfaction were assessed with the Life-Habits questionnaire, functional mobility was determined with the Functional Mobility Scale and (back, lower and upper limb) pain frequency was gauged with a standardized questionnaire., Results: Life-Habits accomplishment and satisfaction scores of adults with CP remained unchanged during the six-year follow-up, with 79% being independent and 100% satisfied. Functional mobility decreased and related to the total accomplishment score. No change in pain frequency was observed, but adults with CP experienced more pain than their peers. Back pain was significantly associated with the total satisfaction score., Conclusions: Relative high levels of accomplishment and satisfaction and no change in pain frequency were noted during a six-year follow-up study of adults with CP living in a LMIC. The importance of exercise/rehabilitation programs to reduce pain and maintain functional mobility in persons aging with CP was highlighted., Competing Interests: Conflicts of interest No potential conflict of interest was reported by the authors., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objectives: This systematic review and meta-analysis was designed to determine the overall mean blood pressure and prevalence of hypertension among a representative sample of adults living with cerebral palsy by combining individual participant data. Additional objectives included estimating variations between subgroups and investigating potential risk factors for hypertension., Methods: Potential datasets were identified by literature searches for studies published between January 2000 and November 2017 and by experts in the field. Samples of adults with cerebral palsy (n ≥ 10, age ≥ 18 years) were included if blood pressure data, cerebral palsy-related factors (e.g. cerebral palsy subtype), and sociodemographic variables (e.g. age, sex) were available. Hypertension was defined as at least 140/90 mmHg and/or use of antihypertensive medication., Results: We included data from 11 international cohorts representing 444 adults with cerebral palsy [median (IQR) age of the sample was 29.0 (23.0-38.0); 51% men; 89% spastic type; Gross Motor Function Classification System levels I-V]. Overall mean SBP was 124.9 mmHg [95% confidence interval (CI) 121.7-128.1] and overall mean DBP was 79.9 mmHg (95% CI 77.2-82.5). Overall prevalence of hypertension was 28.7% (95% CI 18.8-39.8%). Subgroup analysis indicated higher blood pressure levels or higher prevalence of hypertension in adults with cerebral palsy above 40 years of age, men, those with spastic cerebral palsy or those who lived in Africa. BMI, resting heart rate and alcohol consumption were risk factors that were associated with blood pressure or hypertension., Conclusion: Our findings underscore the importance of clinical screening for blood pressure in individuals with cerebral palsy beginning in young adulthood., (Copyright © 2021 The Author(s). Published by Wolters Kluwer Health, Inc.)

Objective: The primary purpose of selective dorsal rhizotomy (SDR) is to ameliorate spasticity in the lower extremities of children with cerebral palsy (CP). In correctly selected patients, this neurosurgical procedure has been shown to have a beneficial effect on many aspects of the child's life. However, given the challenges faced by adults with CP, it would be valuable to document the status of this population compared to their peers later in adulthood. Therefore, the aim of this study was to determine the physical status, mental health, and health-related quality of life (HRQoL) of adults with CP who underwent SDR at least 25 years ago, compared to matched typically developing (TD) individuals. The second aim was to investigate relationships between physical status and the other outcome measures., Methods: Adults with CP were recruited from a database of children who had undergone SDR performed using the technique introduced by Professor Warwick Peacock at Red Cross War Memorial Children's Hospital in Cape Town, South Africa, between 1981 and 1991. These individuals were matched for age, sex, body mass index, and socioeconomic status to a TD adult cohort from a similar background. The parameters assessed were lower-extremity muscle tone, passive range of motion, muscle strength, selectivity, functional mobility and dynamic balance (Timed Up and Go [TUG] test), HRQoL (SF-36), and anxiety and depression levels., Results: Twenty-six adults with CP who had a median age of 35.8 years (interquartile range 34.2-41.4 years) (female/male: n = 10/16; Gross Motor Function Classification System level I/II/III: n = 13/10/3), were compared to 26 TD adults. Muscle tone was similar, whereas passive range of motion, muscle strength, selectivity, TUG, and SF-36 physical functioning (concept and summary) scores differed between the cohorts. Other SF-36 parameters, anxiety levels, and depression levels were not different. Strong correlations were found between the muscle strength and TUG scores., Conclusions: Normalized lower-extremity muscle tone was sustained 25-35 years after SDR. Whereas the lower scores for physical assessments are in line with findings in other CP populations, remarkably, relatively good mental health and HRQoL scores were reported in this CP group despite their physical limitations. The strong correlation between muscle strength and TUG suggests that strength training after SDR may have value in improving functional mobility and balance.

Purpose: To determine changes in level of accomplishment and satisfaction in daily activities and social participation, and functional mobility in adults with cerebral palsy (CP) more than 25 years after selective dorsal rhizotomy (SDR)., Materials and Methods: This long-term observational nine-year follow-up study included 26 adults (median age 35 years) with CP and spastic diplegia, and 26 matched typically developing adults. Assessment tools used were the Life-Habits questionnaire and the Functional Mobility Scale., Results: Most of the adults with CP were independent and satisfied with accomplishing life habits and no changes were determined, except for a small change in the Housing accomplishment level. Compared to typically developing adults, the CP cohort was more dependent in accomplishing Mobility and Recreation. However, the level of satisfaction was similar for most life habits except for Mobility. Functional mobility did not change, but correlated with Life-Habits results., Conclusions: Adults with CP showed high and stable levels of accomplishment and satisfaction in daily activities and social participation more than 25 years after SDR. This is in contrast with the literature, where functional decline was shown for individuals with CP as they age. The relation with functional mobility highlights the importance to focus the rehabilitation on maintaining walking ability in order to enable high level of daily activities and social participation in adults with CP.Implications for rehabilitationSelective dorsal rhizotomy (SDR) is a valuable treatment option for a selective group of children with cerebral palsy (CP) in order to reduce spasticity.The long-term outcomes of SDR on level of accomplishment and satisfaction in daily activities and social participation as well functional mobility in adults with CP are not clear.More than 25 years after SDR adults with CP experienced stable and lasting high levels of functioning regarding daily activities and social participation and were satisfied with the way they accomplished life habits.Functional mobility was correlated to level of accomplishment and satisfaction in daily activities and social participation, which highlights the importance to focus rehabilitation programs on maintaining functional mobility in order to enable daily activities and social participation in adults with CP.

Objective: The main purpose of selective dorsal rhizotomy (SDR) is to reduce spasticity in the lower extremities of children diagnosed with cerebral palsy (CP) and spastic diplegia. The potential for developing spinal abnormalities and pain is a concern, especially in the aging CP population. Therefore, the aim of this study was to evaluate spinal abnormalities, level of pain, and disability (due to back or leg pain) in adults with CP, and associations with participant characteristics, more than 25 years after SDR., Methods: This is a 9-year follow-up study with data collection conducted in 2008 and 2017. Radiographs were assessed for the degree of scoliosis, thoracic kyphosis and lumbar lordosis curvatures, and prevalence of spondylolysis and spondylolisthesis, while level of pain and disability was determined with a self-developed questionnaire and the Oswestry Disability Index (ODI) questionnaire, respectively., Results: Twenty-five participants were included (15 males; median age 35.9 years, IQR 34.3-41.5 years), with a follow-up time after SDR ranging from 25 to 35 years. No clinically relevant changes were found for spinal curvatures, spondylolysis and spondylolisthesis, perceived pain frequency, and ODI scores between 2008 and 2017. While the prevalence of spondylolysis was 44%, spondylolisthesis was found in 20% (of whom 15% were grade I and 5% grade II), lumbar hyperlordosis was found in 32%, thoracic hyperkyphosis in 4%, and scoliosis in 20%. The Cobb angle was < 25°, and no patient required surgery for scoliosis. In addition, the low back was reported as the most common site of pain, with 28% of the adults with CP having daily pain. This resulted in 80% of the cohort indicating none or minimal disability due to pain based on the ODI. The only correlation found was between hyperkyphosis and female gender., Conclusions: At follow-up more than 25 years after SDR, no progression in spinal abnormalities, level of pain, and disability was found when compared with findings 15 years after SDR. The prevalence of scoliosis, thoracic hyperkyphosis, and lumbar hyperlordosis was within the range reported for adults with CP, while spondylolysis and spondylolisthesis occurred more often than would be expected. It is difficult, however, to establish the role of SDR in this finding, given the limited data on the natural history of CP. Despite the encouraging outcome of this long-term follow-up study after SDR, it is important to continue monitoring adults with CP during the aging process.

Purpose: The purpose of this study was to determine the incidence of spinal deformities in ambulant adults with cerebral palsy (CP) and spastic diplegia, more than 15 years after orthopaedic interval surgery approach (ISA) treatment, and its relationship to contextual factors, level of pain and physical status., Methods: Spinal X-rays, pain (Oswestry Disability Index (ODI) and location/frequency) questionnaires and physical examination assessing lower extremity muscle strength (Medical Research Council scale), motor control (selectivity scale) and muscle tone (Ashworth score) were conducted in 30 adults with spastic diplegic CP., Results: Mild scoliosis (curve 12-22°) was determined in eight (28%) participants. Hyperkyphosis (> 50°) was reported in two (7%) and lumbar hyperlordosis (> 60°) in five (17%) participants. Pain was most commonly reported at cervical (n = 19, 63%) and lumbosacral (n = 18, 60%) area, resulting in 'moderate disability' for six (20%) and 'severe disability' for one (3%) participant. Most apparent physical abnormalities determined were hip abduction weakness and increased rectus femoris muscle tone. Regarding correlations, no relations were found for scoliosis curvature, but kyphosis curvature was related to females, ODI scores (lifting and sitting) and increased muscle tone of ankle plantar flexor muscles, lordosis curvature to passive hip extension mobility, and hip flexors and ankle plantar flexors muscle tone., Conclusion: Adults with spastic diplegic CP who received their first orthopaedic intervention more than 15 years ago (based on ISA) showed similar incidence of spinal deformities as reported in the younger CP population, suggesting stability of spinal curvature into adulthood. These slides can be retrieved under Electronic Supplementary Material.

Background: The handheld dynamometer (HHD) is a well-accepted tool to assess muscle strength in children with cerebral palsy (CP), though reliability is not tested for adults with CP and no normative data are available., Objectives: To present strength levels of lower extremity muscle groups and test-retest reliability of HHD measurements in ambulatory adults with CP and typically developed (TD) adults., Design: Case-control study., Setting: Human motion laboratory., Participants: Fifty-four adults with CP (28 men; Gross Motor Function Classification System [GMFCS] level I/II/III: n = 25/20/9; mean age (SD) = 38 (7) year) and 62 TD adults (31 men; mean age (SD) = 37 (5) year)., Interventions: Not applicable., Main Outcome Measure(s): Maximum strength levels were obtained during voluntary isometric contraction of eight lower extremity muscle groups in adults with CP and spastic diplegia and TD adults using HHD. Three trials were performed per muscle group per leg. Test-retest reliability was investigated by calculating intraclass correlation coefficient (ICC), coefficient of variation (CV), and typical error of measurement (TEM)., Results: Force and torque levels were significantly lower in all eight lower extremity muscle groups. Excellent ICC levels were observed in TD, GMFCS I and II (>0.90), and moderate to excellent (0.82-0.97) in GMFCS III. CV and TEM were higher in adults with CP compared to TD adults, especially in GMFCS III., Limitations: No subtypes other than adults with CP and spastic diplegia were included., Conclusions: Lower extremity strength profiles demonstrate substantial muscle weakness in ambulatory adults with CP compared to TD adults, which highlights the importance to address muscle weakness in this population group. These strength profiles may serve as norm values for clinicians and researchers. In addition, HHD showed to be reliable to assess lower extremity strength in adults with CP., (© 2019 American Academy of Physical Medicine and Rehabilitation.)

Background: Orthopaedic surgery is commonly performed in children with cerebral palsy (CP) and spastic diplegia to improve functional mobility. However, no research has quantified levels of accomplishment and satisfaction in daily activities and participation long-term after surgery. Therefore, this study aimed to investigate 1) the level of accomplishment and satisfaction of life habits in adults with CP, 2) whether there were differences between Gross Motor Function Classification System (GMFCS) levels, and 3) associations with contextual factors, functional level and frequency of pain., Methods: Levels of accomplishment and satisfaction in activity and participation were assessed using the Life-Habits 3.1 questionnaire in 30 adults with CP and spastic diplegia who received the first orthopaedic intervention more than 15 years ago (age: median [interquartile range (IQR)] = 27:8 [21:7-33:8] y:mo; GMFCS level I/II/III: n = 15/11/4). GMFCS and Functional Mobility Scale (FMS) assessed mobility over 5 m, 50 m and 500 m. Participants reported frequency of back pain and pain in the lower and upper limb., Results: On average 63% of the participants were independent and faced no difficulties in the accomplishment of all life habits. Difficulties were mostly experienced for 'mobility', 'housing' and 'recreation' (all 61%). Participants were overall satisfied, with lowest scores for 'employment' (13% dissatisfied). Between the GMFCS levels, accomplishment scores of participants with level I were significantly higher than level II. In addition, negative associations were found between accomplishment of life habits and GMFCS level, FMS, and pain on spinal level., Conclusion: Levels of accomplishment and satisfaction were relatively high among adults with CP who underwent orthopaedic interventions during childhood. However, negative associations between accomplishment levels and level of functioning and back pain argue for rehabilitation programs specialized on these factors. This information is imperative for physicians and allied health care professionals to guide adults with CP during ageing., (Copyright © 2019 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.)

Background: Single-event multilevel surgery (SEMLS) approach is regarded as the golden standard in developed countries to improve gait and functional mobility in children with cerebral palsy (CP). However, this approach is not always feasible in developing countries. Therefore, orthopedic surgery based on an interval surgery approach (ISA) is still commonly used in developing countries, although little is known about the long term outcomes of an ISA. Therefore, the aim of this study was to describe the gait patterns of adults with CP, who have been treated with ISA, which started more than 15 years ago., Materials and Methods: Thirty adults with CP and spastic diplegia, who received ISA treatment 21.6-33.7 years ago, were recruited for this study and participated in three-dimensional gait analysis. Twenty kinematic and nondimensional temporal-distance parameters were captured, while the overall gait deviation index (GDI) was also calculated. Data of the adults with CP were compared to normative data of typically developing (TD) adults., Results: Although all adults with CP were still ambulant, their gait parameters significantly differed from TD adults, with a lower GDI in the adults with CP. The CP gait patterns were characterized by excessive hip flexion and hip internal rotation as well as a stiff-knee gait., Conclusion: Although different to TD adults, the gait patterns observed in the adult with CP treated with ISA is in line with other studies. Gait patterns suggest that derotation osteotomies potentially could have improved the long term gait patterns. Although SEMLS might be the preferred treatment method, potentially resulting in better outcomes, ISA can also be used to treat children with CP in developing countries as India and South Africa, where a SEMLS approach is not always feasible., Competing Interests: There are no conflicts of interest.

Selective dorsal rhizotomy is a key technique in the surgical management of spasticity in patients with cerebral palsy. The technique evolved from the late 1800s when pioneers like Dana and Abbe performed dorsal rhizotomy in their treatment of refractory pain. These surgeons noted a reduction in muscle tone associated with the operation. When Sherrington then published his Nobel prize-winning work on the corticospinal tract and its role in the neuromuscular system in the 1890s, the course was set for modifying spasticity by aiming surgery at the dorsal roots. This procedure underwent multiple modifications through the next century and today it is, arguably, the most commonly performed operation to treat cerebral palsy children with spasticity. Selective dorsal rhizotomy is a technique that still teaches us a great deal about neurophysiology on a daily basis and it is thanks to the pioneers, described in this article, that we have this tool in our armamentarium.

The regular monitoring of athletes is important to fine-tune training and detect early symptoms of overreaching. Therefore the aim of this study was to determine if a noninvasive submaximal running test could reflect a state of overreaching. 14 trained runners completed a noninvasive Lamberts Submaximal Running Test, one week before and 2 days after finishing an ultramarathon, and delayed onset of muscle soreness and the daily analysis of life demands for athletes questionnaire were also captured. After the ultramarathon, submaximal heart rate was lower at 70% (-3 beats) and 85% of peak treadmill running speed (P<0.01). Ratings of perceived exertion were higher at 60% (2 units) and 85% (one unit) of peak treadmill running speed, while 60-second heart rate recovery was significantly faster (7 beats, P<0.001). Delayed Onset of Muscle Soreness scores and the number of symptoms of stress (Daily Analysis of Life Demands for Athletes) were also higher after the ultramarathon (P<0.01). The current study shows that the Lamberts Submaximal Running Test is able to reflect early symptoms of overreaching. Responses to acute fatigue and overreaching were characterized by counterintuitive responses, such as lower submaximal heart rates and faster heart rate recovery, while ratings of perceived exertion were higher., Competing Interests: Conflicts of interest: The authors have no conflict of interest to declare., (© Georg Thieme Verlag KG Stuttgart · New York.)

Aim: To describe gross motor function in children with bilateral lower limb (BLL) spasticity due to human immunodeficiency virus encephalopathy (HIVE), and to investigate the association between age, CD4 percentage, and viral load at initiation of antiretroviral therapy (ART) and current gross motor function., Method: Thirty ambulant children with HIVE and BLL spasticity were recruited. Clinical parameters, including ART, were obtained from medical records. Gross motor function was assessed using the 88-item Gross Motor Function Measure (GMFM-88)., Results: The participant group was comprised of 14 males and 16 females (median age 8y; interquartile range [IQR] 7-11y). ART was initiated at a median age of 7 months (IQR 5-11mo) with a median CD4 percentage of 4.7% (IQR 2.3-8.0) and viral load of log 10 6.0 (IQR 5.6-6.4). The median total GMFM-88 score was 89% (IQR 78-94%), with a wide range of scores in the 'Standing' domain (26-97%) and 'Walking, Running, and Jumping' domain (8-99%). No associations were detected between age at initiation of ART, CD4 percentage, or viral load and total GMFM-88 score., Interpretation: Limitations in gross motor function in children with HIVE and BLL spasticity range from mild to severe. ART initiation factors were not able to predict functional status in this sample., (© 2017 Mac Keith Press.)

Aim: To describe upper limb motor function and level of activity and participation in children with HIV encephalopathy (HIVE) and bilateral lower limb (BLL) spasticity., Method: Thirty ambulant children with HIVE and BLL spasticity and 20 typically developing children, between 5 years and 12 years, were recruited. Upper limb motor function was assessed using the Purdue Pegboard and level of activity and participation using the Computer-Adapted Pediatric Evaluation of Disabilities Inventory (PEDI-CAT)., Results: The HIVE group comprised 14 males and 16 females (mean age [SD] 8y 8mo [2y 2mo], Gross Motor Function Classification System (GMFCS) level I [n=10], II [n=11], and III [n=9]) and the typically developing group comprised 11 males and 9 females (mean age 8y 8mo [2y 3mo]). The HIVE group had lower scores than the typically developing group for all pegboard tasks and three of the four PEDI-CAT domains (p≤0.001). However, individual outcome scores varied substantially within each GMFCS level., Interpretation: Children with HIVE and BLL spasticity may have significantly poorer upper limb motor performance and lower levels of activity and participation than typically developing children. These findings suggest that an assessment of upper limb motor function should form part of optimal care for this population., (© 2016 Mac Keith Press.)

Background: Three-dimensional gait analysis (3DGA) is commonly used to assess the effect of orthopedic single-event multilevel surgery (SEMLS) in children with spastic cerebral palsy (CP)., Purpose: The purpose of this systematic review is to provide an overview of different orthopedic SEMLS interventions and their effects on 3DGA parameters in children with spastic CP., Methods: A comprehensive literature search within six databases revealed 648 records, from which 89 articles were selected for the full-text review and 24 articles (50 studies) included for systematic review. The Oxford Centre for Evidence-Based Medicine Scale and the Methodological Index for Non-Randomized Studies (MINORS) were used to appraise and determine the quality of the studies., Results: Except for one level II study, all studies were graded as level III according to the Oxford Centre for Evidence-Based Medicine Scale. The MINORS score for comparative studies (n = 6) was on average 15.7/24, while non-comparative studies (n = 18) scored on average 9.8/16. Nineteen kinematic and temporal-distance gait parameters were selected, and a majority of studies reported improvements after SEMLS interventions. The largest improvements were seen in knee range of motion, knee flexion at initial contact and minimal knee flexion in stance phase, ankle dorsiflexion at initial contact, maximum dorsiflexion in stance and in swing phase, hip rotation and foot progression angles. However, changes in 3DGA parameters varied based on the focus of the SEMLS intervention., Discussion: The current article provides a novel overview of a variety of SEMLS interventions within different SEMLS focus areas and the post-operative changes in 3DGA parameters. This overview will assist clinicians and researchers as a potential theoretical framework to further improve SEMLS techniques within different SEMLS focus groups. In addition, it can also be used as a tool to enhance communication with parents, although the results of the studies can't be generalised and a holistic approach is needed when considering SEMLS in a child with spastic CP., Competing Interests: The authors have declared that no competing interests exist.

Background: This short report arose from a follow-up study of children previously diagnosed with human immunodeficiency virus (HIV) encephalopathy and spastic diplegia and is among the first to describe that increased lower limb muscle tone in children with a confirmed HIV encephalopathy diagnosis may resolve over time in some cases., Results: Of 19 children previously diagnosed with HIV encephalopathy and increased lower limb muscle tone, some were found to have resolved muscle tone abnormalities during a follow-up physical examination [resolved group, n = 13, median age 9 years 7 months (interquartile range 7 years 3 months-10 years 9 months)] whereas others continued to show increased lower limb muscle tone at follow-up [unresolved group, n = 6 median age 8 years 6 months (interquartile range 7 years 9 months-9 years 7 months)]. A review of clinical records showed no significant differences in age or follow-up time between the resolved and unresolved groups. However, the unresolved group appeared to have severe disease at an earlier age than the resolved group, based on the age at antiretroviral treatment initiation [median age at start of treatment 2 years 3 months (interquartile range 7 months-5 years 3 months) vs. 8 months (interquartile range 6-12 months), p = 0.08] and had more severe neurological signs at the initial assessment., Conclusions: It is anticipated that this information may be of immediate value to those involved in the treatment of children with HIV encephalopathy and increased lower limb muscle tone whilst awaiting the outcome of future controlled clinical trials.

Background: The Human Immune Deficiency Virus (HIV) can manifest neurologically in both adults and children. Early invasion of the central nervous system by the virus, affecting the developing brain, is believed to result in the most common primary HIV-related neurological complication, HIV Encephalopathy (HIVE). In countries such as South Africa where many children have not been initiated on antiretroviral treatment early, HIVE remains a significant clinical problem., Methods: Children were selected from a clinic for children with neurologic complications of HIV, located at the Red Cross War Memorial Children's Hospital, South Africa 2008-2012. Eligible subjects fulfilled the following inclusion criteria: aged 6 months-13 years; positive diagnosis of HIV infection, vertically infected and HIVE as defined by CDC criteria. Each participant was prospectively assessed by a Pediatric Neurologist using a standardized proforma which collated relevant details of background, clinical and immunological status., Results: The median age of the 87 children was 64 months (interquartile range 27-95 months). All except one child were on antiretroviral treatment, 45% had commenced treatment <12 months of age. Delayed early motor milestones were reported in 80% and delayed early speech in 75% of children in whom we had the information. Twenty percent had a history of one or more seizures and 41% had a history of behavior problems. Forty-eight percent had microcephaly and 63% a spastic diplegia. CD4 percentages followed a normal distribution with mean of 30.3% (SD 8.69). Viral loads were undetectable (

Aim: The aim of this study was to explore the physical status and gait patterns of children with spastic diplegia secondary to human immunodeficiency virus encephalopathy (HIVE)., Method: A cross-sectional study was conducted on children diagnosed with HIVE and spastic diplegia. Sociodemographic and clinical background information was obtained, followed by three-dimensional gait analysis (3DGA) and a physical examination including assessments of muscle tone, strength, motor control, contractures, and bony deformities of the lower extremities., Results: Fourteen children (eight males, six females; mean age 5 y 8 mo [SD 9 mo], range 4 y 4 mo-6 y 10 mo) were studied. The cohort was divided into two groups based on distinctive gait patterns. Nine participants in group I showed only limited abnormalities. Group II displayed a more pathological gait pattern including stiff knee and equinus ankle abnormalities. Results of 3DGA, as with the physical examination outcomes, showed increased impairments from proximal to distal (except for hip extension)., Interpretation: This study provides a first description of distinctive gait patterns and related physical characteristics of children with HIVE and spastic diplegia. Further research is necessary., (© 2013 Mac Keith Press.)

Aim: Information regarding the selection procedure for selective dorsal rhizotomy (SDR) in children with spastic cerebral palsy (CP) is scarce. Therefore, the aim of this study was to summarize the selection criteria for SDR in children with spastic CP., Method: A systematic review was carried out using the following databases: MEDLINE, CINAHL, EMBASE, PEDro, and the Cochrane Library. Additional studies were identified in the reference lists. Search terms included 'selective dorsal rhizotomy', 'functional posterior rhizotomy', 'selective posterior rhizotomy', and 'cerebral palsy'. Studies were selected if they studied mainly children (<18y of age) with spastic CP, if they had an intervention of SDR, if they had a detailed description of the selection criteria, and if they were in English. The levels of evidence, conduct of studies, and selection criteria for SDR were scored., Results: Fifty-two studies were included. Selection criteria were reported in 16 International Classification of Functioning, Disability and Health model domains including 'body structure and function' (details concerning spasticity [94%], other movement abnormalities [62%], and strength [54%]), 'activity' (gross motor function [27%]), and 'personal and environmental factors' (age [44%], diagnosis [50%], motivation [31%], previous surgery [21%], and follow-up therapy [31%]). Most selection criteria were not based on standardized measurements., Interpretation: Selection criteria for SDR vary considerably. Future studies should describe clearly the selection procedure. International meetings of experts should develop more uniform consensus guidelines, which could form the basis for selecting candidates for SDR., (© 2013 Mac Keith Press.)

The purpose of this study was to use three-dimensional gait analysis to describe the gait status of adults with spastic diplegia who underwent selective dorsal rhizotomy (SDR) in childhood. Outcome measures were the gait deviation index (GDI), non-dimensional temporal-distance parameters, and kinematics of the lower limbs. A total of 31 adults with spastic diplegia who had previously undergone SDR were eligible and participated in current study (SDR group). These participants had a median age of 26.8 years (range 21-44 years) with a mean time between surgery and assessment of 21.2±2.9 years (range 17-26 years). For comparison purposes, 43 typically developed adults also participated (CONTROL group), with a median age of 28.3 years (range 21-45 years). More than 17 years after SDR 58% of the SDR group showed improved GMFCS levels, while none of them deteriorated. The participants in the SDR group walked with a mild crouch gait, although there was a loading response, adequate swing-phase knee flexion, adequate swing-phase plantarflexion, reasonable speed and cadence. The gait status of the SDR group more than 17 years after SDR was similar to what has been reported in short-term follow-up studies, as well as our earlier 20 year follow-up study that did not include 3D gait analysis. Appropriate orthopaedic intervention was required in 61% of the study cohort. Whether the types and numbers of orthopaedic interventions are positively affected by SDR remains an open question. Further studies examining this question are warranted. In addition, long-term follow-up studies focused on other interventions would also be of clinical relevance., (Copyright © 2011 Elsevier B.V. All rights reserved.)

Objective: To evaluate the activity and participation levels of adults with spastic diplegia 17-26 years after selective dorsal rhizotomy; to investigate relationships between subjects' functioning and age, socio-economic-status, level of satisfaction and their perceptions of the post-operative outcomes., Design: Observational follow-up study., Patients: Thirty-one subjects with spastic diplegia, age range 21-44 years, who underwent selective dorsal rhizotomy between 1981 and 1991., Methods: A semi-structured interview was used to gather data on patients' characteristics and long-term experiences after the operation. The Functional Mobility Scale and Life-Habit questionnaire were completed., Results: Based on the Functional Mobility Scale 84% of subjects were reported as independent for a distance of 5 m, and 61% for 50 and 500 m. Eighty percent were independent in accomplishing all life habits, with most problems found for Mobility and Recreation. This was in agreement with the subjects' perception, with strong correlations between Life-Habit questionnaire accomplishment and satisfaction levels. No significant associations were found between functioning and age at selective dorsal rhizotomy, current age and socio-economic status., Conclusion: More than 15 years after selective dorsal rhizotomy, adults with spastic diplegia showed high levels of functioning, and similar levels of satisfaction with life habits. The majority had positive feelings about the neurosurgical procedure, although there is a need for better follow-up after subjects leave school.

Introduction: The aim of this study was to evaluate the mechanical status of the spine in patients with spastic diplegia 17-26 years after selective dorsal rhizotomy (SDR)., Methods: We compared original radiographic reports from our earlier short-term follow-up study with current X-rays. In addition, we obtained magnetic resonance images (MRI) of the spine and additional information regarding back pain and clinical assessments., Results: Thirty patients (17 males and 13 females; median age 26.8 years) participated in the current study, with median follow-up times of 4.0 and 21.4 years. Comparison of the X-ray results showed respectively: scoliosis 0% and 57%; kyphosis 0% and 7%; lordosis 21% and 40%; spondylolysis 18% and 37%; and spondylolisthesis grade I occurred in one patient. The only statistically significant difference was found for scoliosis (p < 0.01). The majority had Cobb angles <30 degrees with only two patients with curves of 35 degrees. MRI scans showed spinal stenosis in 27%, black discs in 10%, and disc protrusion in 3%. Daily back pain was reported in 17%, while 23% reported "moderate disability" as a result of back and leg pain. No patient to date has required any surgical intervention on the spine., Conclusions: Except for spondylolisthesis, spinal deformities did appear to progress with time. However, this increase was not marked, and the development of relatively mild scoliosis was the only statistically significant increase. This group of patients requires continued follow-up. Further studies are required to ascertain the natural history of spinal deformity in adults with spastic diplegia who have not had SDR.

Objective: To determine functional status of patients with cerebral palsy 20 years after they received selective dorsal rhizotomy (SDR)., Design: A prospective 20-year follow-up study., Setting: Red Cross Children's Hospital (SDR operation and 1-year follow-up assessment) and at institutional or private locations nearby patients' homes (20-year follow-up assessment)., Participants: Referred sample of 14 patients with spastic diplegia (6 women, 8 men; mean age, 27y; range, 22-33y) who were preoperatively ambulant and fulfilled strict selection criteria for SDR operation in 1985., Interventions: Patients were assessed before and 1 and 20 years after SDR., Main Outcome Measures: Standardized assessments of function according to 2 dimensions of the International Classification of Functioning, Disability and Health (ICF) model: (1) body structure and function (muscle tone, joint stiffness, voluntary movement) and (2) activity (rolling, sitting, kneeling, crawling, standing, walking, transitions) were obtained. In addition, based on assessments and questionnaires, Gross Motor Function Classification System (GMFCS) levels were determined before and at 1 year after SDR retrospectively and currently at 20 years after SDR., Results: One year after SDR, functional outcomes based on the 2 dimensions of the ICF model improved significantly, and these improvements were maintained at 20 years after surgery. Patients showed a shift in their GMFCS levels 1 and 20 years after SDR., Conclusions: In line with our 20-year follow-up study with gait parameters as outcome measures, patients with spastic diplegia still show improvements in their functional status 20 years after SDR. We acknowledge the presence of possible confounding factors and a small sample size, but we argue that the improvements found in this study were caused mainly by SDR. Finally, changes in GMFCS levels suggest a possible role for this tool to detect changes after an intervention.

Objectives: Selective dorsal rhizotomy (SDR) has been widely performed for the reduction of spasticity in patients with cerebral palsy during the past 2 decades. The objective of this study was to determine whether the surgery has yielded long-term functional benefits for these patients., Methods: The authors present results from a prospective 20-year follow-up study of locomotor function in 13 patients who underwent an SDR in 1985. For comparison, we also present gait data for 48 age-matched healthy controls (12 at each of 4 time points). Patients were studied preoperatively and then at 1, 3, 10, and 20 years after surgery. Study participants were recorded in the sagittal plane while walking using a digital video camera, and 6 standard gait parameters were measured., Results: In this group of patients 20 years after surgery, knee range of motion (ROM) was on average 12 degrees greater than preoperative values (p < 0.001). Hip ROM before surgery was no different from that in the healthy control group. This parameter increased markedly immediately after surgery (p < 0.001) but had returned to normal after 20 years. The knee and hip midrange values-a measure of the degree of "collapse" due to muscle weakness after surgery-had returned to preoperative levels after 20 years, although they were respectively 11 and 8 degrees greater than those in healthy controls. Both temporal-distance parameters (dimensionless cadence and dimensionless step length) were significantly greater at 20 years than preoperative values (cadence, p = 0.003; step length, p = 0.02), leading to improved walking speed., Conclusions: Twenty years after undergoing SDR, our patients showed improved locomotor function compared with their preoperative status.

Introduction: Given the large number of cerebral palsy patients who have undergone selective dorsal rhizotomy in the past two decades, it is clearly imperative that the clinical community be provided with objective and compelling evidence of the long-term sequelae of the procedure., Materials and Methods: In the early 1980s, Peacock in Cape Town shifted the site of the rhizotomy from the conus medullaris to the cauda equina, and in the past 25 years, more than 200 children have been operated on. We have studied the incidence of spinal deformities after multiple-level laminectomy and recorded a 20% incidence of isthmic spondylolysis or grade-I spondylolisthesis. We have also conducted a long-term prospective gait analysis study on a cohort of 14 ambulatory patients who were operated on in 1985., Results: Ten years after surgery, our patients had increased ranges of motion that were within normal limits. Step length was significantly improved, although cadence was unchanged postoperatively and was significantly less than normal age-matched control subjects., Discussion: We have recently tracked down all 14 patients from the original cohort and are currently completing a 20-year prospective follow-up analysis of their neuromuscular function and gait. Our preliminary data suggest that selective dorsal rhizotomy is not only an effective method for alleviating spasticity but it also leads to long-term functional benefits.

When two fundamental gait parameters--step length and step frequency--are scaled non-dimensionally, thereby accounting for increases in a child's physical size, ontogenetic changes in the locomotor control strategy are revealed. We believe dimensionless velocity beta, the product of dimensionless step length and frequency, serves as a measure of neural development. It increases from the age of 18 months and reaches a plateau between 50 and 90 months, attaining the adult value of 0.45. Based on a study of 200 children, our findings lend support to a theory that posits a neuromaturation growth curve with the form: beta (t)=0.45 (1-e(-0.05t)) where t is the age in months and 0.05 is the growth coefficient.