|Year : 2023 | Volume
| Issue : 5 | Page : 345-350
Asymmetry in sensory-motor function between the lower limbs in children with hemiplegic cerebral palsy: An observational study
Hsiu-Ching Chiu1, Louise Ada2, Rong-Ju Cherng3, Chiehfeng Chen4
1 Department of Physical Therapy, I-Shou University, Kaohsiung, Taiwan
2 Discipline of Physiotherapy, The University of Sydney, Camperdown, Australia
3 Department of Physical Therapy, College of Medicine, National Cheng Kung University, Tainan, Taiwan
4 Department of Public Health, College of Medicine, Taipei Medical University; Cochrane Taiwan; Division of Plastic Surgery, Department of Surgery, Taipei Municipal Wan-Fang Hospital, Taipei Medical University, Taipei, Taiwan
|Date of Submission||04-Apr-2023|
|Date of Decision||05-Jul-2023|
|Date of Acceptance||11-Jul-2023|
|Date of Web Publication||03-Oct-2023|
Prof. Hsiu-Ching Chiu
Department of Physical Therapy, I-Shou University, Kaohsiung
Source of Support: None, Conflict of Interest: None
The objective of this study was to examine the difference in sensory-motor impairments (i.e., balance, contracture, coordination, strength, spasticity, and sensation) between legs in children with hemiplegic cerebral palsy. An observational study measured both lower limbs of children with hemiplegic cerebral palsy over one session. Six sensory-motor impairments (balance, coordination, strength, spasticity, contracture, and proprioception) were measured. The between-leg differences were analyzed using the paired t-tests and presented as the mean differences (95% confidence interval (CI)). Twenty-four participants aged 10.3 years (standard deviation: 1.3) participated. The affected leg was less than the less-affected leg in terms of the strength of dorsiflexors (mean difference (MD) -2.8 Nm, 95% CI −4.2 to −1.4), plantarflexors (MD -2.6 Nm, 95% CI −4.1 to −1.0), knee extensors (MD -5.3 Nm, 95% CI −10.2 to −0.5) as well as range of ankle dorsiflexion (MD -8 deg, 95% CI −13 to −3), and balance (median difference -11.1, 95% CI −11.6 to −10.6). There was a trend toward a difference in terms of the strength of hip abductors (MD -2.6 Nm, 95% CI −5.3 to 0.1) and coordination (MD -0.20 taps/s, 95% CI −0.42 to 0.01). The legs were similar in terms of the strength of hip extensors (MD 0.3 Nm, 95% CI -4.7 to 5.3), proprioception (MD 1 deg, 95% CI 0 to 2), and spasticity (median difference 0, 95% CI 0 to 0). Examination of the difference in sensory-motor impairments between legs in children with hemiplegic cerebral palsy has given us some insights into the deficits in both legs. Not only was balance, strength, and coordination decreased compared with the less-affected leg but also the less-affected leg was markedly decreased compared with typically developing children. Therefore, an intervention aimed at increasing muscle strength and coordination in both legs might have a positive effect, particularly on more challenging physical activities. This may, in turn, lead to successful participation in mainstream sport and recreation.
Keywords: Cerebral palsy, coordination, hemiplegia, impairments, muscle strength
|How to cite this article:|
Chiu HC, Ada L, Cherng RJ, Chen C. Asymmetry in sensory-motor function between the lower limbs in children with hemiplegic cerebral palsy: An observational study. Chin J Physiol 2023;66:345-50
|How to cite this URL:|
Chiu HC, Ada L, Cherng RJ, Chen C. Asymmetry in sensory-motor function between the lower limbs in children with hemiplegic cerebral palsy: An observational study. Chin J Physiol [serial online] 2023 [cited 2023 Dec 4];66:345-50. Available from: https://www.cjphysiology.org/text.asp?2023/66/5/345/386897
| Introduction|| |
Cerebral palsy results from a brain lesion before maturity. This non-progressive neurological condition is accompanied by a variety of motor impairments, such as muscle weakness and incoordination, and the severity of these impairments can interfere with mobility over the lifespan. Cerebral palsy is the most common condition causing childhood disability, with a prevalence of 2 to 2.5 per live births. Children with hemiplegic cerebral palsy, who have one side of the body more affected than the other, represent more than 38%, of all cerebral palsy.
Most children with hemiplegic cerebral palsy achieve independent walking with or without aids, regardless of the loss of muscle mass and strength in the lower limbs. Shortland suggested that these individuals are able to maintain high levels of motor ability, like independent walking because their muscle impairments have not fallen below the threshold values required to perform everyday motor tasks. However, even though they can perform everyday tasks, they often have to use adaptive behaviors to accomplish them. In addition, they struggle to perform tasks requiring speed and accuracy and are, therefore, behind in physical education compared with typically developing children.
There has been little investigation of the nature of motor impairments underlying activity limitations in hemiplegic cerebral palsy. It is challenging to provide effective intervention for children with hemiplegic cerebral palsy unless we can understand their lower limb impairments thoroughly. We chose to investigate all the sensory-motor impairments that result from brain damage and, therefore, examined balance, contracture, coordination, strength, spasticity, and sensation. Furthermore, Huang et al. point out that children with hemiplegic cerebral palsy appear to have bilateral stiffness in the legs during walking, and they suggest that further investigation of impairments in both legs is essential for therapeutic planning. Therefore, our specific research objective was to examine the nature of sensory-motor impairments in both legs in children with hemiplegic cerebral palsy and the difference between legs. By identifying the major impairments, they can become the focus of assessment and intervention. Clinicians can then measure the amount of deficit to monitor the effect of an intervention aimed at addressing these impairments.
| Materials and Methods|| |
An observational study was carried out in Taiwan. Children with hemiplegic cerebral palsy were recruited through several sources, such as primary schools, related organizations, outpatient clinics, social media, and word of mouth. Both lower limbs of the participants were measured in one 1-h session by the first author, who was trained in the measurement procedures. We obtained ethical approval from the National Cheng Kung University Human Research Ethics Committee (Approval No: NCKU HREC-F-106-005-2, 2017). Informed consent was gained from all parents/guardians of the participants before data collection.
Children were invited to participate if they were diagnosed with spastic hemiplegic cerebral palsy before they were 5 years old and were now aged between 9 and 14 years. They were excluded if they had severe cognitive deficits, assessed by talking to teachers and parents and checking whether the children understood instructions. Characteristics of the participants were recorded, including age, sex, gestation, type of cerebral palsy, education, preferred and fast walking speed (10-m Walk Test), physiotherapy attendance, and functional classifications (Gross Motor Function Classification System, Manual Ability Classification System, Communication Function Classification System, and Eating and Drinking Ability Classification System) to describe the sample. Each classification system has five levels that describe the function during daily tasks for children with cerebral palsy, with Level I indicating the highest function. Previous botulinum toxin injections and surgery were also recorded due to their possible influence on the measurement of impairments. For example, moderate-to-severe spasticity may make it difficult for the child to produce a maximum voluntary muscle contraction.
Measurement of sensory-motor impairments
Six sensory-motor impairments (i.e., balance, contracture, coordination, strength, spasticity, and sensation) were measured on both legs.
The ability to balance in standing was measured twice using the One-Legged Stance Test, and the best attempt was reported in seconds. The participant stood unassisted on one leg with the eyes open and the hands on the hips. Timing began once one foot had left the floor and finished when it touched the ground, or the standing leg moved or an arm left the hips. When the participants were unable to lift one leg from the ground, they scored 0. When the participants stood longer than the normal value, they scored the maximum 30 s.
Coordination was measured twice using the Lower-Extremity MOtor COordination Test, which required the participants to move one leg rapidly through muscle coordination from agonist to antagonist with spatial and temporal accuracy, and the best attempt was reported in taps/s. The participants sat on a chair without shoes and with the feet resting on the floor, the heel on the proximal target, and the knee flexed as close as possible to 90°. Then, the participants had to move the foot as fast as possible between the targets placed 20–30 cm apart (based on the length of an individual participant's tibia) for 20 s, and the number of accurate taps was counted.
Strength (dorsiflexors/plantarflexors, knee extensors, and hip extensors/abductors) was measured using the PowerTrack IITM Commander (Australasian Medical and Therapeutic Instruments P/L, Australia, 125 pounds rated capacity and linearity 1%) during maximum voluntary isometric contraction and recorded in N. The standardized procedure for each muscle group included position, stabilization, the place of resistance, and level arm [Table 1]. For dorsiflexors/plantarflexors, knee extensors, and hip extensors, the measuring position of the lower limb was at the hip and knee flexed 90° with the lower leg supported on a bench. For hip abductors, the hips and knees were placed in a neutral position supine. The lever arm was measured using bony landmarks (malleolus, knee joint, and greater trochanter) with a tape measure [Table 1]. The best attempt of two trials measured for each muscle group was chosen for analysis. To report in Nm, the maximum voluntary isometric contraction recorded in N was multiplied by the length of the lever arm for each muscle group.
Spasticity of the plantarflexors was measured once using the Tardieu Scale as stretch-induced muscle activity during a fast passive stretch of the ankle and reported as a score from 0 to 4, with 0 representing no spasticity. The participant lay supine and relaxed while the examiner moved the foot into dorsiflexion as fast as possible. The quality of the muscle response was rated.
Contracture of the plantarflexors was measured once using a manual goniometer as the maximum passive angle of the ankle dorsiflexion and reported in degrees. The participant sat on a chair, knees flexed to 90°, with a weight of 5 kg placed on the top of the knee. Then, the examiner slid the participant's foot back until the heel lifted off the ground, which represents maximum dorsiflexion. The angle between the vertical and the lower leg was recorded. The lower leg was described by a line from the lateral malleolus to the head of the fibula.,
Proprioception was measured using a lower-extremity matching task where the position sense of the affected ankle is determined from the discrepancy between legs, and reported in degrees. The participant sat with closed eyes and both knees at 90° flexion. The examiner moved one leg between 20° and 60° flexion randomly five times, and simultaneously, the participant aligned the other leg to match each time. The examiner recorded errors using a vertical clear acrylic sheet inscribed with a protractor.
Descriptive statistics were calculated for all participants and impairments. The normality of all variables was checked for further analysis. For data that were normally distributed, the between-leg differences were analyzed using the paired t-tests and presented as the mean differences (95% confidence interval, CI) to ascertain the clinical significance. For data that were non-normally distributed, the between-leg differences were analyzed using the Wilcoxon matched-pairs test and presented as median differences (95% CI).
| Results|| |
Characteristics of the participants
Twenty-four children with hemiplegic cerebral palsy aged 10.3 years (standard deviation (SD) 1.3) participated; of which 13 (54%) were male and 16 (67%) were born prematurely [Table 2]. The preferred walking speed was 1.42 m/s (SD 0.4) and the fast walking speed was 1.86 m/s (SD 0.45), and this is similar to typically developing children whose preferred walking speed is 1.21 m/s (SD 0.22) and the fast walking speed is 1.83 m/s (SD 0.25). More than 80% of the participants were classified within Level I across all classification systems. Half of the participants (50%) still received physiotherapy services of 0.6 h/w (SD 0.6), 11 (46%) had received botulinum toxin injection in the lower limb, and two (8%) had experienced surgery of the lower limb.
Difference in sensory-motor impairments between legs
Group data for the affected and less-affected leg and between-leg differences in children with hemiplegia are presented in [Table 3]. The affected leg was less than the less-affected leg in terms of the strength of dorsiflexors (MD -2.8 Nm, 95% CI −4.2 to −1.4), plantarflexors (MD -2.6 Nm, 95% CI −4.1 to −1.0), knee extensors (MD -5.3 Nm, 95% CI −10.2 to −0.5) as well as range of ankle dorsiflexion (MD -8 deg, 95% CI −13 to −3), and balance (median difference -11.1, 95% CI −11.6 to −10.6). There was a trend toward a difference in terms of the strength of hip abductors (MD -2.6 Nm, 95% CI -5.3 to 0.1) and coordination (MD -0.20 taps/s, 95% CI -0.42 to 0.01). The legs were similar in terms of the strength of hip extensors (MD 0.3 Nm, 95% CI -4.7 to 5.3), proprioception (MD 1 deg, 95% CI 0 to 2), and spasticity (median difference 0, 95% CI 0 to 0). Twelve participants (50%) scored 0 on the Tardieu Scale, and 13 (54%) participants balanced for less than 3 s on the affected leg during the One-Legged Stance Test.
|Table 3: The mean (standard deviation) of outcomes for each leg and the mean difference (95% confidence interval) between legs in children with hemiplegia|
Click here to view
| Discussion|| |
This study found that overall, sensory-motor function in the affected leg of children with hemiplegic cerebral palsy was about two-thirds to three-quarters of that in the less-affected leg, except for hip extensor strength, which was the same between legs, and balance which was much worse on the affected leg. The children had little spasticity, contracture, or loss of sensation, but had poor strength and coordination in both legs.
It is often assumed that the less-affected leg in hemiplegic cerebral palsy has similar muscle strength to normal. However, we found that muscle strength in the less-affected leg was markedly less than typically developing children according to Eek et al. This suggests that intervention for children with hemiplegic cerebral palsy could include strengthening of the lower limb muscles for not only the affected leg but also the less-affected leg. There are two recent systematic reviews of over 20 randomized trials that have investigated the effect of lower limb strength training (including activities involving both legs like squatting) on strength and activity., Although there was some evidence for an increase in strength, there was no sign of an improvement in general mobility as measured using the Gross Motor Function Measure. This may be because these reviews included all types of cerebral palsy. Two of the trials investigated lower limb strength training of hemiplegic children only;, however, only one of them measured strength as an outcome. Kara et al. found that an increase in strength was accompanied by improvements in some lower limb activities such as walking distance (measured by 1-min Walk Test), sprinting (measured by Sprint Test), and balance (measured by Timed Up and Go Test).
Consistent with previous findings, children with hemiplegic cerebral palsy in our study were all classified as GMFCS Level I (88%) or II (12%) and had a similar walking speed to typically developing children. Perhaps, children with hemiplegic cerebral palsy have enough strength to walk even with their deficit in lower limb muscle strength. It may be that measuring more challenging motor activities such as running, jumping, and stair climbing would be more appropriate as outcomes to evaluate the effect of muscle strengthening on activity in children with hemiplegic cerebral palsy.,
Coordination was less than half of normal for both the affected and less-affected legs. This is consistent with a previous study that found that children with hemiplegic cerebral palsy had a large deficit in coordination even in the less-affected leg, and the authors suggest that the less-affected leg has been altered over time by cooperating with the affected leg during walking. Children with cerebral palsy under 12 years old within GMFCS Level I-III spend large amounts of the day in sedentary behavior, which is associated with cardiometabolic risk. Improvement of coordination in both legs of children with hemiplegic cerebral palsy is essential for better performance of most recreational activities, such as sports and games, and could result in higher participation, which in turn could reduce the cardiometabolic risk.
Balance showed a large deficit, with half of the children not able to stand on their affected leg at all. We hypothesize that this may be due to insufficient strength and coordination of the plantarflexors, since all our participants wore ankle-foot orthosis during early childhood, and these aid dorsiflexion and prevent plantarflexion. A study of walking up slopes in children with hemiplegic cerebral palsy found an increase in plantarflexors during propulsion only in the less-affected leg. It is interesting to note that the five participants who were able to stand for 30 s on the affected leg no longer wore ankle-foot orthoses and also participated in sporting activities. In addition, standing on one leg is a measure of static balance, whereas dynamic balance might better reflect daily activities such as walking or stair climbing.
A limitation of our study is that we did not collect data from typically developing children matched for age, sex, weight, and height. We, therefore, had to compare our results with currently available sources, where two of these sources (coordination and proprioception) were from adult data. This points to the need for the collection of reference values for sensory-motor function and mobility in children across the age range.
| Conclusion|| |
Examination of the difference in sensory-motor impairments between legs in children with hemiplegic cerebral palsy has given us some insights into the deficits in both legs. Not only was balance, strength, and coordination decreased compared with the less-affected leg but also the less-affected leg was markedly decreased compared with typically developing children. Therefore, an intervention aimed at increasing muscle strength and coordination in both legs might have a positive effect, particularly on more challenging physical activities. This may, in turn, lead to successful participation in mainstream sport and recreation.
This research was, in part, supported by the National Science and Technology Council, under Grant No. MOST107-2320-B-214-002-MY3 and MOST110-2320-B-214-005.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]