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Background The use of TheraTogs orthotic undergarments has been suggested to improve the ability to stabilize the posture, to correct or prevent deformities, to improve functionality, and to enable the user a more appropriate functional pattern. The aim of this study was to investigate the efficacy of TheraTogs orthotic undergarment on modulation of spinal geometry in children with diplegic cerebral palsy. Forty children with diplegic cerebral palsy, with ages ranging from 6 to 9 years, were selected for this randomized controlled study. They were randomly assigned to (1) an experimental group that received TheraTogs orthotic undergarment (12 h/day, 3 days/week) plus traditional physical therapy for 3 successive months and (2) a control group that received only traditional physical therapy program for the same time period. Spinal geometry was measured at baseline and after 3 months of intervention using the Formetric system. Results Children in both groups showed significant improvements in the spinal geometry (P < 0.05), with significantly greater improvements in the experimental group than the control group. The post-treatment mean values of lateral deviation (mm), pelvic tilt (mm), trunk imbalance (mm), and surface rotation (mm) were 5.45, 6.35, 8.8, and 3.65 and 8, 8.9, 11.2, and 5.9 for the experimental and control group, respectively. Conclusions TheraTogs orthotic undergarment may be a useful tool for improving spinal geometry in children with diplegic cerebral palsy. Trial registration This study was registered in the ClinicalTrial.gov PRS (NCT04271618).

The longitudinal stability of sagittal gait patterns in diplegic cerebral palsy (CP), stratified using the Rodda classification, is currently unknown.What is the trajectory of sagittal plane gait deformities as defined by the Rodda classification in a large cohort treated with orthopedic surgery guided by gait analysis?A retrospective study utilized gait analysis to evaluate sagittal gait parameters before age 8 and after age 15 years. Individual limbs were categorized at each time point according to the Rodda classification based on mean sagittal plane knee and ankle angle during stance. Welch's t-tests compared gait variables from early childhood with maturity and examined changes associated with plantarflexor lengthening surgery.100 youth with CP were evaluated twice: at a mean age of 5.49 ± 1.18 and 19.09 ± 4.32 years, respectively. Gross Motor Function Classification System distribution at maturity was I (10.5 %), II (55.2 %), III (28.6 %), and IV (5.7 %). At the initial visit, most limbs were in either true equinus (30 %) or jump-knee gait (26.5 %). At maturity, crouch gait (52.5 %) was the most common classification, of which 47.6 % were mild (1-3 standard deviations from age-matched norm; 21°-30°) and 52.4 % moderate or severe. For the entire cohort, at initial and final visits, respectively, mean knee flexion in stance was 26.8°±14.8° and 25.9°±11.4° (p = 0.320), ankle dorsiflexion in stance increased from -0.3°±11.5° to 9.0°±6.0° (p0.001), and passive knee flexion contracture was -2.3°±7.0° and -3.9°±8.0° (p = 0.043). In children who started in true equinus, apparent equinus, and crouch, there was no difference in stance phase knee flexion at maturity between those who underwent plantarflexor lengthenings versus those who did not (p0.18).The trend in this cohort was toward crouch with increased stance phase ankle dorsiflexion from early childhood to maturity. Plantarflexor lengthenings were not a significant factor in the progression of stance phase knee flexion.

Children with cerebral palsy at rehabilitation centers had difficulty performing walking rehabilitation with the existing walker. The resulted in children with cerebral palsy feeling dissatisfied with existing walkers, and this dissatisfaction resulted in their interest in ongoing rehabilitation. The existing walker does not accommodate the needs of cerebral palsy children, resulting in lousy form and dissatisfaction when using a walker for rehabilitation and reduce their interest in rehabilitation. Therefore it is necessary to redesign the walker to prevent bad form and increase the satisfaction level of children with cerebral palsy. The QUEST 2.0 questionnaire was used as a reference for designing. Based on the dimensions from the QUEST 2.0 questionnaire, the walker design criteria were determined. Then use the TRIZ method to resolve any technical contradictions that occur at the design stage. Assistive device

Institutional physiotherapy as a standard of care for management of cerebral palsy (CP) has certain shortcomings, especially in resource-constrained settings. This is a proof-of-concept trial to evaluate the efficacy of individualized home-centered activity-based therapy in children with spastic diplegic CP. Randomized controlled trial (open-label). Tertiary-care hospital with pediatric neurology services (July, 2014 to July, 2016). Consecutive sample of 59 children (5–12 y) with spastic diplegic CP (Gross Motor Function Classification System scores II–III) without fixed lower-limb contractures, illnesses impeding physiotherapy or history of recent botulinum toxin injection/surgery were recruited. Children were randomized to Intervention or Control arms. Their 6-minute-walk Test (6MWT) scoring and clinical examination were performed at baseline, 3 and 6 months. Children in Intervention arm (n=30) were prescribed parent-supervised home-centered activity-based therapy (walking, standing, squatting, climbing upstairs/downstairs, kicking a ball, dancing, riding a tricycle/bicycle) in addition to their institutional physiotherapy. Children in Control arm (n=29) were prescribed ongoing institutional physiotherapy alone. Logbooks, home videos and telephonic follow-ups were used to ensure compliance. Comparison of the mean change in 6MWT scores at 6 months (from baseline) between the two groups. Median (IQR) change in 6MWT scores at 6 months (from baseline) in the Intervention and Control arms were 3.5 (−5.3, 9) m and 3 (−7.8, 6.3) m Adjunct home-centered activity-based therapy was safe and feasible, but did not result in appreciable gains over 6 months.

Femoral derotation osteotomy (FDO) is a treatment option in children and adolescents with cerebral palsy who have transverse plane deviations in their lower limbs. When the transverse kinematic deviations are asymmetric, the osteotomy indication can be unilateral.Unilateral FDO has a kinematic effect on ipsilateral transverse plane deviations along with those of the pelvis and contralateral side.Among the 170 diplegic children that our team has operated on, 34 underwent unilateral FDO. Their mean age was 12.5±2.7 years; 12 were GMFCS level I and 22 were level II. The kinematic changes 18 months after surgery were evaluated with a paired Student's t test and correlations were determined with the Spearman test (p0.05). The mean preoperative femoral anteversion was 45°±8°. In terms of kinematics, on the operated side, the children had a mean internal hip rotation of 26°±7°, external pelvis rotation of -8°±6° and inward foot progression angle of 8°±12°.The anteversion was corrected surgically by -28°±5°. Postoperatively, the ipsilateral hip rotation (10°±10°), pelvis rotation (-2°±5°) and foot rotation (6°±12°) were significantly improved. No correlations were identified between the resulting kinematic parameters and surgical correction. The five feet that had inward rotation (13°±9°) were improved to (-5°±7°).Unilateral FDO of the hip in patients with asymmetry not only reduces the internal rotation of the operated hip, it also normalizes the rotation of the pelvis and both feet. However, these improvements are not directly related to the amount of surgical correction.IV: case series.

Objective:The aim of this study was to compare the fine and gross motor skills of children with diplegic cerebral palsy (CP) according to gender.Methods:This study included 73 children with diplegic CP (39 males, mean age: 8.76±1.4; 34 females mean age: 8.29±1.31 years) aged between 6 to 12 years. Bruininks-Oseretsky Test 2-Short Form (BOT2-SF), consisting of 8 subtests and 12 items, was used to evaluate the gross and fine motor skills of children. Fine and gross motor skills of children with CP were compared with Student’s t-test.Results:According to gender, the BOT2-SF total score and fine motor precision, bilateral coordination and upper-limb coordination scores of sub-tests were statistically significant higher in girls than in boys (p

BACKGROUND This long-term consecutive, retrospective single-center cohort study evaluates long-term outcomes of single-event multilevel surgery in diplegic cerebral palsy with respect to functional status, gait, and patient satisfaction. METHODS All patients with diplegic cerebral palsy who underwent single-event multilevel surgery >10 years previously were included. Retrospective gait assessment was performed using the Edinburgh Visual Gait Score (EVGS) and Gillette Functional Assessment Questionnaire Walking Scale (FAQWS) preoperatively and at midterm postoperative follow-up (median 2.6 y) and prospectively at most recent review [median 18 y, interquartile (IQ) range: 14.4 to 20.5 y]. The Short Form-36 (SF-36) was used prospectively to evaluate outcome compared with population norms for adults from the UK. RESULTS The complete assessment was possible in 26 of 39 patients who met the inclusion criteria. There was a statistically significant improvement at most recent follow-up compared with the preoperative assessment for EVGS and FAQWS [Wilcoxon Matched Pairs Signed Rank test -4.42 (P

The study by Alkan et al. (2021) investigated the effect of an 8-week basic photography education program on Health-Related Quality of Life (HRQoL), among other outcomes, in children and adolescent...

Background In children with spastic diplegia, efficient use of the upper extremity especially the hands play an important role in participation in daily living. Hands can perform heavy activities and also enable to perform extremely gentle, skillful, and precise activities. Inadequate hand strength and fine motor skills may lead to functional limitations. This study was planned to investigate the pinch grip strength and fine manual control in children with spastic diplegic cerebral palsy and to determine if there is a relation between them. Thirty children with diplegic cerebral palsy and 30 normal developed children from both sexes between 5 and 10 years old were included in this study as diplegic and control groups. For all children, pinch grip strength measured by Baseline Mechanical Pinch Gauge and Bruininks-Oseretsky Test of Motor Proficiency, Second Edition used to evaluate fine manual control. Results Children with diplegic cerebral palsy have significant impairment in the pinch grip strength (tip, tripod, and key) and the fine manual control (fine motor precision and integration) compared to their healthy peers of the same age. There was large positive significant correlation (r > 0.5, p < 0.05) between tip and tripod pinch strength, and fine motor precision and medium positive significant correlation (r = 0.47, p < 0.05) between key pinch and fine motor precision in children with spastic diplegia. Also, there was large positive significant correlation between tip pinch and fine motor integration (r = 0.54, p < 0.05). The correlations are small and medium positive between tripod and key pinch strength, and fine motor integration respectively but they are not statistically significant. Conclusions Pinch grip strength and fine manual skills are affected in children with spastic diplegia. Also, there is a significant correlation between the pinch strength and activities require precise control of the hand.

Aims To investigate the effects of basic photography education and practices on health-related-quality-of-life (HRQoL), self-esteem, life satisfaction, and moods of children with diplegic cerebral palsy (CP). Methods Twenty children with diplegic CP who did not have an intellectual or communication disability were included in this prospective randomized controlled clinical study and divided into two equal groups using a computer-generated list of random numbers to receive either eight weeks of basic photographic training or a control group. Basic photography training including a total of 20 hours theoretical and 30 hours practice was given during the eight weeks in this study. HRQoL, self-esteem, life satisfaction, depression and anxiety were assessed at baseline and at the end of the training. Results At the end of the treatment, statistically significant improvements were found for self-reported HRQoL, life satisfaction, and self-esteem in the basic photographic training group compared to the control group (p < 0.05). However, no statistically significant between group difference was found for parents' version of the HRQoL (p > 0.05). Conclusions The findings suggest that basic photography training can improve HRQoL, life satisfaction, and self-esteem in children with diplegic CP.

Impaired motor control and musculotendon tightness in the lower extremities are characteristic features of patients with diplegic cerebral palsy (CP). Tendon release surgery (TRS) helps improve joint and leg stiffness, but the effects of TRS on inter-limb coordination in terms of the total leg stiffness, and the bilateral symmetry in leg stiffness during gait, remain unknown. Ten children with spastic diplegic CP scheduled for TRS and ten healthy controls participated in this study. The inter-limb sharing of total leg stiffness during double-limb support phase and bilateral leg stiffness symmetry during stance phase of gait were calculated using the kinematic and ground reaction force data measured by a motion analysis system. Before TRS, the patients with diplegic CP walked with a decreased share of total leg stiffness during weight-acceptance (p &lt, 0.05) and with increased bilateral leg stiffness asymmetry during single-limb support and weight-transfer during gait (p &lt, 0.05) when compared to healthy controls. After TRS, the bilateral leg stiffness asymmetry was significantly reduced in the CP group, especially in the terminal stance phase, with inter-limb sharing of total leg stiffness becoming similar to that in controls (p &gt, 0.05). The surgery seemed to improve the lower limb control and increased the bilateral limb symmetry during gait.

Background One of the most common causes of severe physical disability in childhood is cerebral palsy (CP). Mobility is one of the most important functions to fulfill the activities of daily living. We aimed to determine the effectiveness of cold application to improve the ambulation in spastic diplegic CP children. Materials and Methods In this clinical trial study, 40 subjects were included for the study. They were divided into two groups, namely experimental (n=20), and conventional group (n=20). Study was carried out in Holy Cross College, Department of Rehabilitation Science, Tiruchirappalli, India. Conventional group was given regular conventional training and experimental group was given cold therapy, passive stretching in both legs before training. Both groups received training for 45 minutes, 3 times a week for a duration of 6 weeks. Modified Ashworth scales were used to measure spasticity step length, stride length and Cadences were used to measure the gait parameters, and Timed Up and Go test (TUG) was used to measure the functional activity. Results Significant effect was observed in decrease in spasticity, there was increase in gait parameters and timed up and go test in two studied groups. The post-test mean values of all the variables of cold therapy, passive stretching in experimental group are improved compared with that of conventional group. The experiment improved with stride length, step length, cadence, timed up and go test and Modified Ashworth scale (p Conclusion Based on the derived results, there was decreased tone in spastic muscles and improvement in gait parameters and functional ability in children with diplegic CP after application of cold therapy and passive stretching.

Objective The purpose of the study was to find out effect of toeing on balance in children with diplegic cerebral palsy. Methods An observational study was conducted. Thirty children with spastic diplegic cerebral palsy, aged 5 to 8 years, participated in this study. They were classified into 2 groups: group A was children with out-toeing, and group B was children with in-toeing. Foot progression angle was measured by using dynamic footprint, and balance was evaluated using Biodex Balance System equipment. The outcome of interest was postural control (overall stability, anteroposterior stability, and mediolateral stability). Results Statistical analysis revealed a significant difference for the tested variables of interest between the 2 tested groups. Multiple pairwise comparison tests revealed that there was significantly better overall stability, anteroposterior stability, and mediolateral stability (P Conclusion It can be concluded that children with out-toeing have higher balance and stability than children with in-toeing.

Objective: The aim of the present study was to evaluate the effectiveness of multilevel Botulinum Toxin A (BTX-A) injection, as part of an integrated approach, for the treatment of spasticity in non-ambulatory young children with diplegic cerebral palsy (CP). Subjects and Methods: Seventeen non-ambulatory patients aged 4–8 years with diplegic CP (Gross Motor Function Classification System [GMFCS] level IV) were evaluated before and at 1st, 3rd, and 6th months after BTX-A injection. The effect of BTX-A on spasticity of gastrocnemius and hamstring muscles was assessed using the Modified Ashworth Scale (MAS) and Modified Tardieu Scale (MTS). The velocity-dependent properties of spastic muscle as both slow (R2) and fast (R1) stretches were evaluated in MTS. Results: A statistically significant improvement was observed in R1 angles of gastrocnemius and hamstring muscles at 1st and 3rd months after BTX-A injection in non-ambulatory young children with CP. Statistically significant improvement was found in MAS of gastrocnemius and hamstring muscles and R2 angles of knee and ankle joint after 1st month of BTX-A injection. Conclusion: Multilevel BTX-A injection, as part of an integrated approach, can be used for focal treatment of spasticity, especially of hamstring and gastrocnemius muscles, in non-ambulatory young children with CP GMFCS level IV.

A new summary index for kinetic gait data is proposed (Gait Kinetic Index - GKI), BASED on six kinetic selected variables: hip, knee and ankle moments and powers on the sagittal plane. This method was applied on a control group (CG) of 18 subjects and on 57 patients with diplegic Cerebral Palsy (CP). CP showed statistical different GKI value in comparison with CG. The same is for the sub GKI with the exclusion of GKI Knee Power. The GKI seems to be a promising tool useful to measure extensively the gait pathology taking into consideration kinetic aspects of gait pattern.

Running ability is critical to maintaining activity participation with peers. Children and adolescents with cerebral palsy (CP) are often stated to run better than they walk, but running is not often quantitatively measured. The purpose of this study was to utilize overall gait deviation indices to determine if children with diplegic CP run closer to typically developing children than they walk. This retrospective comparative study utilized 3D running kinematics that were collected after walking data at two clinical motion analysis centers for children with diplegic cerebral palsy. Separate walking and running Gait Deviation Indices (GDI Walk and GDI* Run), overall indices of multiple plane/joint motions, were calculated and scaled for each participant so that a typically developing mean was 100 with standard deviation of 10. An analysis of variance was used to compare the variables Activity (walking vs running) and Center (data collected at two different motion analysis laboratories). Fifty participants were included in the study. The main effect of Activity was not significant, mean GDI Walk = 76.4 while mean GDI* Run = 77.1, p = 0.84. Mean GDI scores for walking and running were equivalent, suggesting children with diplegic cerebral palsy as a group have similar walking and running quality. However, individual differences varied between activities, emphasizing the need for individual assessment considering specific goals related to running.

BACKGROUND Children with cerebral palsy (CP) often present a loss of effectiveness of the plantarflexors/knee-extensors couple that leads to crouch gait. When treating a child with crouch gait by means of ankle foot orthoses, preserving or restoring push off power is a key issue. AIM To compare carbon-fiber spring (Carbon Ankle Seven® [CAFO], Ottobock® HealthCare, Duderstadt, Germany) and hinged ankle-foot orthoses (HAFO) effectiveness in improving functionality and walking ability in children with diplegic CP and crouch gait. DESIGN Randomized crossover trial. SETTING Hospital center. POPULATION Ten children with diplegic CP and crouch gait, 5 males and 5 females, aged 11 (4) years. METHODS The gait of each child was evaluated by means of instrumental gait analysis with both CAFO and HAFO, in a randomized order and after a 4-week adaptation period. The primary outcome measure was the change in ankle power generation. As secondary outcome measures, knee joint kinematics, stride length, walking speed, Observational Gait Scale, and preferred orthosis were considered. RESULTS The median of the energy produced in stance was superior with CAFO (+2.2 J/kg, IQR 4.7, P=0.006), and the energy absorbed inferior (-3.3 J/kg, IQR 4.3, P=0.011). No statistically significant difference was found for any other parameter. Preference of the children was equally distributed between the two orthoses. CONCLUSIONS No evident superiority of CAFO with respect to HAFO was found in improving gait performance of children with CP and crouch gait. Nevertheless, the results suggest the possibility that CAFO permits an energy saving and reduction of the more compromising deficits. CLINICAL REHABILITATION IMPACT The final choice of the participants indicates that CAFOs are preferred by older and heavier children, but the preference does not correlate with the performance of the orthoses during gait.

Aims To compare changes in gait kinematics and walking speed 24 months after conventional (C-MLS) and minimally invasive (MI-MLS) multilevel surgery for children with diplegic cerebral palsy (CP). Methods A retrospective analysis of 19 children following C-MLS, with mean age at surgery of 12 years five months (seven years ten months to 15 years 11 months), and 36 children following MI-MLS, with mean age at surgery of ten years seven months (seven years one month to 14 years ten months), was performed. The Gait Profile Score (GPS) and walking speed were collected preoperatively and six, 12 and 24 months postoperatively. Type and frequency of procedures as part of MLS, surgical adverse events, and subsequent surgery were recorded. Results In both groups, GPS improved from the preoperative gait analysis to the six-month assessment with maintenance at 12 and 24 months postoperatively. While reduced at six months in both groups, walking speed returned to preoperative speed by 12 months. The overall pattern of change in GPS and walking speed was similar over time following C-MLS and MI-MLS. There was a median of ten procedures per child as part of both C-MLS (interquartile range (IQR) 8.0 to 11.0) and MI-MLS (IQR 7.8 to 11.0). Surgical adverse events occurred in seven (37%) and 13 (36%) children, with four (21%) and 13 (36%) patients requiring subsequent surgery following C-MLS and MI-MLS, respectively. Conclusion This study indicates similar improvements in gait kinematics and walking speed 24 months after C-MLS and MI-MLS for children with diplegic CP. Cite this article: Bone Joint J 2021;103-B(1):192–197.

BACKGROUND The children with diplegic cerebral palsy (CP) commonly have abnormal alignment of lower extremities affecting their abilities of keeping balance. Orthoses are one of the many approaches that can be prescribed to improve balance and walking in diplegic children. OBJECTIVE This study was conducted to assess the moderate effect of solid ankle foot orthosis (AFO) vs. the ground reaction ankle foot orthosis (GRAFO) on balance in children with diplegic CP. STUDY DESIGN A randomized controlled trial. METHODS Thirty children with spastic diplegic CP from both genders participated in this study; their ages were between 6 and 9 years. They were divided randomly into two study groups of equal numbers; the first study group A received the regular physical therapy program besides wearing the AFO for successive three months. The second study group B received the regular physical therapy program besides wearing the GRAFO for successive 3 months. All childrens' balance was evaluated before starting the treatment program and after 3 months by using the Biodex balance system (anteroposterior and mediolateral stability indices). RESULTS There were significant improvement of all stability indices in both groups (P < 0.05), with significant difference between groups when comparing post-treatment mean values of the measured indices in favor to study group B (P < 0.05). CONCLUSION The GRAFO achieved more balance control in children with spastic diplegic CP compared with solid AFO.

We compared the effect of visual information on the dominant upper limb position sense of children with diplegic cerebral palsy (n = 10) and normally developing children (n = 10). An isokinetic dyn...

Purpose To report functional mobility in patients with diplegic cerebral palsy (CP) at long-term follow-up after single-event multilevel surgery (SEMLS). The secondary aim was to assess the relationship between functional mobility and quality of life (QoL) in patients previously treated with SEMLS. Methods A total of 61 patients with diplegic CP, mean age at surgery 11 years, eight months (sd 2 years, 5 months), were included. A mean of eight years (sd 3 years, 10 months) after SEMLS, patients were contacted and asked to complete the Functional Mobility Scale (FMS) questionnaire over the telephone and given a weblink to complete an online version of the CP QOL Teen. FMS was recorded for all patients and CP QOL Teen for 23 patients (38%). Results Of patients graded Gross Motor Function Classification System (GMFCS) I and II preoperatively, at long-term follow-up the proportion walking independently at home, school/work and in the community was 71% (20/28), 57% (16/28) and 57% (16/28), respectively. Of patients graded GMFCS III preoperatively, at long-term follow-up 82% (27/33) and 76% (25/33) were walking either independently or with an assistive device at home and school/work, respectively, while over community distances 61% (20/33) required a wheelchair. The only significant association between QoL and functional mobility was better ‘feelings about function’ in patients with better home FMS scores (r = 0.55; 95% confidence interval 0.15 to 0.79; p = 0.01). Conclusion The majority of children maintained their preoperative level of functional mobility at long-term follow-up after SEMLS. Level of Evidence IV