Most clinical tools for measuring spasticity, such as the Modified Ashworth Scale (MAS) and the Modified Tardieu Scale (MTS), are not sufficiently accurate or reliable. This study investigated the clinimetric properties of an instrumented spasticity assessment. Twenty-eight children with spastic cerebral palsy (CP) and 10 typically developing (TD) children were included. Six of the children with CP were retested to evaluate reliability. To quantify spasticity in the gastrocnemius (GAS) and medial hamstrings (MEH), three synchronized signals were collected and integrated: surface electromyography (sEMG); joint-angle characteristics; and torque. Muscles were manually stretched at low velocity (LV) and high velocity (HV). Spasticity parameters were extracted from the change in sEMG and in torque between LV and HV. Reliability was determined with intraclass-correlation coefficients and the standard error of measurement; validity by assessing group differences and correlating spasticity parameters with the MAS and MTS. Reliability was moderately high for both muscles. Spasticity parameters in both muscles were higher in children with CP than in TD children, showed moderate correlation with the MAS for both muscles and good correlation to the MTS for the MEH. Spasticity assessment based on multidimensional signals therefore provides reliable and clinically relevant measures of spasticity. Moreover, the moderate correlations of the MAS and MTS with the objective parameters further stress the added value of the instrumented measurements to detect and investigate spasticity, especially for the GAS.

For all motor and sensory assessments, interrater and test-retest reliability was moderate to very high. Test-retest reliability was clearly higher than interrater reliability. To improve interrater reliability, it was recommended to strictly standardize the test procedure, refine the scoring criteria and provide intensive rater trainings.

Several studies indicated that walking with an ankle foot orthosis (AFO) impaired third rocker. The purpose of this study was to evaluate the effects of two types of orthoses, with similar goal settings, on gait, in a homogeneous group of children, using both barefoot and shoe walking as control conditions. Fifteen children with hemiplegia, aged between 4 and 10 years, received two types of individually tuned AFOs: common posterior leaf-spring (PLS) and Dual Carbon Fiber Spring AFO (CFO) (with carbon fibre at the dorsal part of the orthosis). Both orthoses were expected to prevent plantar flexion, thus improving first rocker, allowing dorsiflexion to improve second rocker, absorbing energy during second rocker, and returning it during the third rocker. The effect of the AFOs was studied using objective gait analysis, including 3D kinematics, and kinetics in four conditions: barefoot, shoes without AFO, and PLS and CFO combined with shoes. Several gait parameters significantly changed in shoe walking compared to barefoot walking (cadence, ankle ROM and velocity, knee shock absorption, and knee angle in swing). The CFO produced a significantly larger ankle ROM and ankle velocity during push-off, and an increased plantar flexion moment and power generation at pre-swing compared to the PLS (<0.01). The results of this study further support the findings of previous studies indicating that orthoses improve specific gait parameters compared to barefoot walking (velocity, step length, first and second ankle rocker, sagittal knee and hip ROM). However, compared to shoes, not all improvements were statistically significant.

The present study documents the correlation between gait analysis data and clinical measurements and evaluates the combined predictive value of static and dynamic clinical measurements on gait data of children with cerebral palsy. Two hundred patients were evaluated using a set of measurements of range of motion (ROM), alignment, spasticity, strength and selectivity, and by three-dimensional gait analysis. Fair to moderate correlations were found between clinical measurements and gait data, the overall highest correlation being 0.60. Clinical data of strength and selectivity had the highest degree of significant correlations with gait data, compared to the ROM and spasticity. ROM, spasticity and strength measurements for the hip in the coronal plane and spasticity of rectus femoris most frequently showed fair to moderate correlations to gait data. Time and distance and EMG parameters mainly correlated with strength and selectivity parameters. Unexpectedly, alignment parameters only fairly correlated with hip rotation in stance. Multiple regression analysis revealed that adding dynamic clinical measurements (spasticity, strength and selectivity) to a static model (ROM) enhanced the link between clinical measurements and gait data. The variance of gait parameters was better explained by a combined model of static and dynamic clinical measurements, compared to a purely static model. However, R 2 -values were low. Gait analysis data cannot be sufficiently predicted by a combination of clinical measurements. The independence of the measurements supports the notion that both, clinical examination and gait analysis data provide important information for delineating the problems of children with CP. #

The instrumented spasticity assessment showed higher responsiveness than the clinical scales. The amount of RMS electromyography is considered a promising parameter to predict treatment response.

This study investigated interrater reliability and measurement error of the Melbourne Assessment of Unilateral Upper Limb Function (Melbourne Assessment) and the Quality of Upper Extremity Skills Test (QUEST), and assessed the relationship between both scales in 21 children (15 females, six males; mean age 6y 4mo [SD 1y 3mo], range 5-8y) with hemiplegic CP. Two raters scored the videotapes of the assessments independently in a randomized order. According to the House Classification, three participants were classified as level 1, one participant as level 3, eight as level 4, three as level 5, one participant as level 6, and five as level 7. The Melbourne Assessment and the QUEST showed high interrater reliability (intraclass correlation 0.97 for Melbourne Assessment; 0.96 for QUEST total score; 0.96 for QUEST hemiplegic side). The standard error of measurement and the smallest detectable difference was 3.2% and 8.9% for the Melbourne Assessment and 5.0% and 13.8% for the QUEST score on the hemiplegic side. Correlation analysis indicated that different dimensions of upper limb function are addressed in both scales.

AimDespite the impact of spasticity, there is a lack of objective, clinically reliable and valid tools for its assessment. This study aims to evaluate the reliability of various performance- and spasticity-related parameters collected with a manually controlled instrumented spasticity assessment in four lower limb muscles in children with cerebral palsy (CP).MethodThe lateral gastrocnemius, medial hamstrings, rectus femoris and hip adductors of 12 children with spastic CP (12.8 years, ±4.13 years, bilateral/unilateral involvement n=7/5) were passively stretched in the sagittal plane at incremental velocities. Muscle activity, joint motion, and torque were synchronously recorded using electromyography, inertial sensors, and a force/torque load-cell. Reliability was assessed on three levels: (1) intra- and (2) inter-rater within session, and (3) intra-rater between session.ResultsParameters were found to be reliable in all three analyses, with 90% containing intra-class correlation coefficients >0.6, and 70% of standard error of measurement values <20% of the mean values. The most reliable analysis was intra-rater within session, followed by intra-rater between session, and then inter-rater within session. The Adds evaluation had a slightly lower level of reliability than that of the other muscles.ConclusionsLimited intrinsic/extrinsic errors were introduced by repeated stretch repetitions. The parameters were more reliable when the same rater, rather than different raters performed the evaluation. Standardisation and training should be further improved to reduce extrinsic error when different raters perform the measurement. Errors were also muscle specific, or related to the measurement set-up. They need to be accounted for, in particular when assessing pre-post interventions or longitudinal follow-up. The parameters of the instrumented spasticity assessment demonstrate a wide range of applications for both research and clinical environments in the quantification of spasticity.

Several positive influences of orthoses on gait in children with cerebral palsy have been documented, as well as some detrimental effects. Most importantly, push‐off is decreased in orthoses, compromising a physiological third ankle rocker. The aim of this study was to evaluate the effect of three types of orthosis on gait in a homogeneous group of children. All orthoses aimed at improving push‐off and normalizing the pathological plantarflexion–knee extension couple. Thirty‐seven children (22 females, 15 males) with hemiplegia, aged 4 to 10 years (30 Gross Motor Function Classification System [GMFCS] Level I, six GMFCS Level II), walked barefoot and with orthoses being either Orteams® (orthoses with the dorsal part containing 11 sleeves), posterior leafsprings (PLS), or Dual Carbon Fibre Spring ankle foot orthosis (AFOs®; CFO: carbon fibre at the dorsal part of the orthosis). All orthoses were expected to prevent plantarflexion and allow dorsiflexion, thus improving first, second, and third rocker. The orthoses were compared through objective gait analysis, including 3D kinematics and kinetics. All orthoses successfully improved the gait pattern and only small differences were noted between the configurations of the different orthoses. The CFO®, however, allowed a more physiological third ankle rocker compared with the Orteam®/PLS. Although the PLS ensured the highest correction at the ankle around initial contact, the CFO® created a significantly higher maximal hip flexion moment in stance. In general, the results of this study indicated a substantial functional flexibility of the CFO®.