Title: Study of upper limb movement patterns in children with hemiplegic cerebral palsy using three-dimensional movement analysis
Other Titles: Studie van de bewegingspatronen van het bovenste lidmaat bij kinderen met een hemiplegie ten gevolge van cerebrale parese aan de hand van driedimensionale bewegingsanalyse
Authors: Jaspers, Ellen
Issue Date: 15-Mar-2011
Abstract: In life, a good arm and hand function is crucial for various everyday activities, such as eating, grooming or dressing; but also for sports and play. Children with hemiplegic cerebral palsy (HCP) present with varying combinations of upper limb impairments, such as increased muscle tone, reduced selectivity, muscle weakness and sensory disturbances. As a consequence, the successful execution of basic functions with their hemiplegic arm and hand, i.e. reaching, grasping, releasing and object manipulation, is often compromised. Difficulties with one or more of these basic functions hinder the performance of many everyday activities, which in turn impacts on the independency and quality of life of the hemiplegic child. To improve the upper limb functionality of the child with HCP, a well-targeted treatment planning is crucial. This requires a thorough understanding of all upper limb dysfunctions. Although several clinical tools are readily available, there seems an emerging interest to use three-dimensional (3D) movement analysis to assess arm and hand function in children with HCP. The advantage of a 3D analysis is that it provides an objective and detailed description of the performance of the child. For the lower limbs, 3DMA of gait has proven to be a valuable tool for clinical decision-making and treatment evaluation in children with gait pathology. However, the transfer of knowledge and experience gained from gait analysis to the upper limb is not straightforward. The lack of cyclic movements, the variety of functions and abundant degrees of freedom make the upper limb analysis considerably more complex. Moreover, to obtain comparable and reliable results, a general consensus on the biomechanical model, which upper limb activities to analyze, and the outcome parameters is a prerequisite. To promote the standardization of upper limb 3DMA, the International Society of Biomechanics (ISB) therefore published recommendations on the selection of the biomechanical model. Several fundamental decisions were however still required to assure the clinical application in children with HCP. Furthermore, no consensus existed on the selection of tasks and outcome parameters. The scope of this doctoral project was to study upper limb movements in children with HCP by means of 3DMA. In the first part, the development of the 3D measurement procedure for the objective quantification of upper limb movement patterns was described (Chapter 1, 2, 3). The second part of the doctoral project focused on gaining further insights in the movement pathology seen in children with HCP (Chapter 4, 5, 6). As a first step in the development of the 3D measurement procedure, we conducted a systematic literature search to critically appraise the available quantitative assessments for upper limb movements in children with HCP (Chapter 1). This review clearly showed the diversity in applied biomechanical models, and variety of analyzed tasks and outcome parameters. A general consensus on these issues is however of utmost importance to attain reliable and comparable results usable in clinical practice. Hence, the relevance of the development of a clinically feasible and reliable protocol for the 3DMA of the upper limb was demonstrated. The development of this protocol was addressed in Chapter 2. To comply with the international guidelines, the ISB-recommendations on the biomechanical model were applied to calculate joint angles of the trunk, scapula, shoulder, elbow and wrist. Additionally, to attain a good understanding of the movement pathology in children with HCP, we constructed a comprehensive movement protocol that consisted of several functional and clinically relevant tasks: reaching in different directions, reach to grasp objects that required a different hand orientation and gross motor tasks representing common daily activities. Lastly, to maximize the standardization of the test set-up, we developed a custom-made chair with adjustable foot and back support, and reaching distance and height. Before any new measurement procedure can be used in clinical practice, its reliability needs to be verified. Chapter 2 reported on the reliability of the developed measurement procedure in a group of 10 typically developing children (TDC; mean age 10.3 years ± 3.2 years). Chapter 3 of this project addressed the reliability of upper limb movement patterns in 12 children with HCP (mean age 10.2 years ± 3.2 years). For both study groups, good to high reliability was reported for movement duration and speed, and the majority of the joint angles. Reliability results thus provided a sound base for the clinical utility of the developed protocol for upper limb 3DMA. The second part of the doctoral project focused on a more in-depth analysis of the upper limb movement pathology in children with HCP. It is well recognized that HCP is not caused by a uniform neurological abnormality. The relation between the underlying brain lesion and motor and sensory impairments and activity limitations, was addressed in Chapter 4. The study included 45 children with a congenital HCP and eight children with a postnatally acquired hemiplegia (mean age of the total group 9.7 years ± 2.4 years). Children with lesions that occurred early in the brain development (periventricular lesions) had less motor impairments and activity limitations compared to children with lesions that occurred at a later stage of brain development (cortical-subcortical lesions) or children with a postnatally acquired hemiplegia. Children with a pure periventricular lesion also had a better motor performance compared to children with a periventricular lesion with additional damage of other brain structures. Results from this study showed that the type and the location of the brain lesion distinguish children with HCP regarding upper limb function. In Chapter 6, we further explored whether these differences in motor performance between children with different lesion types could also be measured using the developed 3D measurement procedure. The 3D movement characteristics, i.e. movement duration, maximum velocity, trajectory straightness and joint angles were compared between 20 children with congenital HCP with different lesions types (mean age 10.9 years ± 2.9 years). This comparison confirmed that children with a pure periventricular lesion had a better performance for the different parameters, i.e. they moved faster, straighter and with less deviating joint angles, compared to children with a mixed periventricular lesion or a cortical-subcortical lesion. To further understand the hemiplegic child’s movement deficits, we compared several parameters obtained from the 3DMA between 20 children with HCP (mean age 10.9 years ± 2.9 years) and 20 individually age-matched TDC (mean age 10.9 years ± 3.0 years): movement duration, maximum velocity, trajectory straightness, and joint angles (Chapter 6). These analyses showed that children with HCP had longer movement durations, less straight hand trajectories, and lower maximum velocities compared to the TDC. When reaching or during reach to grasp, children with HCP used more trunk movements, altered scapular movements and less shoulder elevation. During all tasks, they also had more elbow and wrist flexion and less supination. Moreover, within the group of HCP, we also reported longer movement durations, less straight trajectory straightness and more deviating joint angles in children with a more severely affected upper limb. The outcomes of this study underlined the relevance of including both spatiotemporal and kinematic parameters to characterize a child’s upper limb motor performance. Lastly, to facilitate the interpretation of the complex data on joint angles obtained from the 3DMA, we proposed a new parameter, the Arm Profile Score (APS) in Chapter 5. This index gives the magnitude of deviation of the upper limb joint angles of the child with HCP relative to a reference dataset based on TDC. To ascertain that the APS was usable as a clinical parameter, it was first validated against clinical measures of upper limb function in the same group of 20 children with HCP (mean age 10.9 years ± 2.9 years). Results showed good correlations between the APS and muscle tone and strength of the elbow and wrist and between the APS and grip strength. This index also showed strong correlations with severity of the affected upper limb. Hence, we are confident to use the APS as a tool to evaluate the amount of movement pathology in children with HCP.In conclusion, this doctoral project proposed a standardized and reliable protocol for the objective assessment of upper limb movements, suitable for children with HCP and TDC. To facilitate the interpretation of the multiplicity of data obtained from the 3DMA, an index to grade the severity of upper limb movement pathology was proposed. The use of such an index adds to the clinical utility of the measurement procedure. A careful parameter selection to represent spatiotemporal and joint characteristics during the various tasks will add to our understanding of the upper limb movement deficits seen in children with HCP. In the long run, these insights will lead to an optimal delineation of therapy, based upon the individual needs of every child.
Publication status: published
KU Leuven publication type: TH
Appears in Collections:Research Group for Neuromotor Rehabilitation
Production Engineering, Machine Design and Automation (PMA) Section

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