Gross Motor Patterns in Children with Cerebral Palsy and Spastic Diplegia Kenji Yokochi, MD*, Akihiko Hosoe, MD*, Satoshi Shimabukuro, MD*, and Kazuo Kodama, MD*

We retrospectively analyzed 403 videotaped sessions of 72 children (38 males, 34 females) with spasdc diplegia. The children's locomotion

and play were recorded in the playroom or therapy room at the hospital. The mean recording time was about 5 min. The first recording of each patient was obtained before 3 years of age and the last by 3-7 years. The patients demonstrated bilateral hypertonicity primarily in the lower extremities, with le~er involvement of the upper extremities, and absence of involuntary movements. IQs were 50 or higher. Head circumferences were within the mean + 2 S.D. Table 1 lists the birth weights of all children; 63 were less than 2,500 gm. All children underwent physical therapy before the age of 3 years. Physical therapy was based on methods described by Bobath and Bobath [I I] or Vojta [12]. Four children underwent surgical treatment; 4 had correction of chronic hip adduction and 1 had correction of pes equinus deformity. Anklefoot orthoses were prescribed for 21 children. The children were divided into 4 groups according to the severity of motor developmental abnormality which was evaluated by the ability of locomotion without bracing at 2-3 years of age, corrected for gestational age (Table 1): Group I - - Children could walk unassisted at the age of 2 years. Group 2 - - Children could not walk at 2 years, but were able to walk unassisted by 3 years. Group 3--Children could only walk sideways with support at 3 years. Group 4 - - Children could not walk with support at 3 years. On the recordings, the gross motor patterns (i.e., rolling, sitting, and crawling) of each child were analyzed. In the rolling pattem (from supine to prone), truncal rotation and supporting posture on assuming a prone position were evaluated (Fig I). Rolling motion was accompanied by rotation of the shoulder and pelvis in the transverse axis; truncal rotation was divided into 3 types based on shoulder deviation and pelvic rotation. When the shoulder and pelvis simultaneously rotated and the pelvis subsequently followed, this rotation was termed block-pelvic rotation. In shoulder-pelvic rotation, the shoulder rotated ahead of the pelvis at the beginning of rolling. In block rolling, the shoulder and pelvis rotated simultaneously throughout rolling. The supporting posture on assuming a prone position was designated on the basis of the supporting point (i.e., the shoulder, the whole lateral aspect of the body, the caudal half of the trunk, or the elbow). The rolling panerns then were described on the basis of trun.cal rotation patterns and the supporting points. In the sitting pattern, the posture of the lower extremities was evaluated; 4 different patterns were observed (Fig 2). Cross-legged sitting consisted of abducted thighs and flexed knees with or without ankle crossing. In long sitting, the knees were extended. When 1 thigh was abducted with the other thigh adducted and both knees flexed, this position was termed side sitting. Between-heel sitting consisted of adducted thighs and flexed knees. A locomotive movement, "shuffling," while sitting also was examined. Shuffling was defined as a sliding action while the trunk was erect and the hips.were flexed, the weight

From the vsDepartment of Pediatric Neurology; Seirei-Mikatabara General Hospital; Hamarnatsu, Shizuoka; tDepartment of Pediatrics; Kagawa Rehabilitation Center; Takamatsu, Kagawa; :~Department of Pediatrics; National Rehabilitation Center for Disabled Children; Tokyo, Japan.

Communications should be addressed to: Dr. Yokochi; Department of Pediatric Neurology; Seirei-Mikatabara General Hospital; Mikatabaru 3453; Hamamatsu, Shizuoka 433, Japan. Received December 14, 1989; accepted March 19, 1990.

Roiling, sitting, and crawling patterns were motoscopically a n a l y z e d in 72 c h i l d r e n w i t h c e r e b r a l p a l s y a n d spastic diplegia; the relation between these patterns and the severity of the locomotive disability was studied. In rolling, trunk rotation and elbow support were difficult for the most severely diplegic children. When sitting, most patients had a between-heel sitting p a t t e r n in w h i c h t h e t h i g h s w e r e a d d u c t e d a n d t h e k n e e s w e r e flexed. W h e n c r a w l i n g , t h e r e c i p r o c a l t h i g h movements were insufficient and accompanied by l a t e r a l b e n d i n g o f t h e t r u n k in m a n y p a t i e n t s . I n t h e more impaired patients, the thighs supported the w e i g h t in f l e x i o n a n d d i d n o t m o v e r e c i p r o c a l l y . C r e e p i n g o n t h e e l b o w s w i t h o u t r e c i p r o c a l leg m o v e m e n t s w a s d e m o n s t r a t e d in t h e m o s t s e v e r e l y a f f e c t e d c h i l d r e n a f t e r 2 y e a r s o f age. Y o k o c h i K, H o s o e A, S h i m a b u k u r o S, K o d a m a K. G r o s s m o t o r p a t t e r n s in c h i l d r e n with c e r e b r a l palsy a n d spastic diplegia. P e d i a t r Neurol 1990;6:245-50.

Introduction Spastic diplegia is a c o m m o n f o r m o f c e r e b r a l palsy, especially a m o n g p r e m a t u r e infants. Bilateral h y p e r t o n i city, w h i c h is c a u s e d b y bilateral p e r i v e n t r i c u l a r infarction a n d / o r h e m o r r h a g e , p r i m a r i l y i n v o l v e s the l o w e r e x t r e m ities [1,2]. T h e l o c o m o t i v e or gross m o t o r p a t t e r n s in diplegic c h i l d r e n h a v e b e e n d e s c r i b e d [3-5], but the relation b e t w e e n e a c h pattern a n d the s e v e r i t y o f m o t o r a b n o r m a l ity has not b e e n clarified. P r e v i o u s studies o f l o c o m o t i v e p r o g n o s i s o f these c h i l d r e n stressed that earlier a c q u i s i t i o n o f sitting c o r r e l a t e d with b e t t e r p r o g n o s i s [6-10]. In o u r report, gross m o t o r patterns, such as rolling, sitting, a n d c r a w l i n g , were a n a l y z e d in c h i l d r e n with c e r e b r a l palsy a n d spastic diplegia. T h e r e l a t i o n s h i p b e t w e e n these patt e r n s a n d s e v e r i t y of l o c o m o t i v e disability were studied. Methods

Yokochi et al: Gross MotorPattems 245

Table 1.

Summary of group information

Birth Weight (gm) 2,000 1,500 1,000 Group

N

Male

Female

> 2,500

I

17

10

7

3

2

16

8

8

3

20

I1

4

19

Total:

72

-1,999

-1,499

I

3

7

3

3

I

4

7

I

9

2

2

6

8

2

9

10

1

3

6

8

I

38

34

9

7

19

30

7

being placed on the buttocks or, alternatively,on one buttock and a flexed lower limb; the feet and/or hands were used for propulsion. In the crawling or locomotive pattern in a prone position, the supporting points of the body weight and the reciprocal movementpattern at the hips were evaluated (Fig 3). When the body weight was supported by the abdomenand the elbows, locomotionwas divided into 3 different patterns: in arm creeping, the body was propelled by reciprocal arm movementwithout leg assistance; in arm and leg creeping, the reciprocal arm movement was accompanied by reciprocal leg movement; and when the weight was supported mainly by one elbow accompanied by leg movementsof the contralateralside, this was termed asymmetric creeping.When the weight was supported by the knees and hands, the body was propelled by reciprocal flexion and extension at the hips and shoulders. This motion was accompaniedby lateral bending of the trunk because separated flexion and extensionof the hip was not sufficient. Two different patterns were observed with this type of crawling: in one, the trunk was nearly parallel to the floor;, and in hipflexed crawling, the weight was supported by the knees, and the hips were lower than the shoulders in a flexed position. When the weight was supported by the cmra and hands, the body was propelled by synchronous extension at both hips. Two different patterns were observed: in bunny hopping,the leg posture was symmetric;and in asymmetric bunny hopping, the leg posture was asymmetric with external rotation of 1 hip.

Results

Rolling. Seventy recordings were obtained in 47 children. The first recording was obtained at 6 months to 3 years of age. When a child demonstrated different rolling patterns in a different direction, both patterns were analyzed. Figure 4 summarizes 71 recordings of rolling in 47 children. The number of patients with each roiling pattern Block -Pelvis

a

Shoulder -pelvis

b

-2,499

< 999

in the different groups is listed in Table 2. The rolling patterns in Group 4 were significantly different from those in Group I (P < 0.01, X2 test). Most of the children in Group 1 had the block-pelvis and elbow pattern, while most of the children in Group 4 had the block pattern. Sitting. In Groups 1-4, 61, 56, 84, and 61 recordings were obtained, respectively. When a child had multiple sitting patterns, the most stable pattern was used for analysis. In 4 children who underwent orthopedic surgery, no change in sitting pattern was observed following surgery. Chronologic changes in the sitting patterns of each group are demonstrated in Figure 5. The cross-legged pattern was prominent in the beginning but most of the children eventually demonstrated the between-heel sitting pattern. Long- and side-sitting patterns were observed in an exceptionally small number of the younger children. Shuffling was observed only in 1 child (Group I) at 1 year, 3 months of age. Table 3 lists the number of children with each sitting pattern, divided by age (older and younger than 2 years) and group number. No significant differences were observed between each group (X2 test). Crawling. Fifty-one, 53, 101, and 98 recordings were obtained in Groups 1-4, respectively. When a child had multiple crawling patterns, the fastest was used for analysis. Orthopedic surgery had no effect on crawling patterns. Chronologic changes in crawling patterns of each group are summarized in Figure 6. Table 4 lists the number of children in each group and the various crawling patterns observed before and after age 2 years. Crawling patterns Block

c

d

Figure 1. Rolling patterns. (A) The truncal rotation and (B) supporting posture are demonstrated. The basis of the supporting point is (a) the elbow, (b) the caudal half of the trunk, (c) the whole lateral aspect of the body, or (d) the shoulder.

246 PEDIATRIC NEUROLOGY Vol.6 No. 4

Arm creeping

Arm and leg creeping

Crosslegged sitting

Long sitting

Side sitting

Betweenheel sitting

Asymmetric creeping

0

Figure 2. Sitting patterns. (See text for details.)

Crawling

in Group 4 were significantly different from patterns in Groups 1 and 2 in both younger and older children (P < 0.01 and P < 0.05, 7(2 test). The children in Groups 1 and 2 had various crawling patterns, such as arm creeping, arm and leg creeping, asymmetric creeping, hip-flexed crawling, and bunny hopping before 2 years of age. Most of these children later had the crawling pattern. Most of the children in Group 4 demonstrated the arm-creeping pattern at the younger age; later, they exhibited various patterns, including arm creeping, crawling, hip-flexed crawling, bunny hopping, and asymmetric bunny hopping. Arm and leg creeping, however, was not observed in either age group. Hip-flexed crawling, bunny hopping, and asymmetric bunny hopping patterns were observed in many children in Groups 3 and 4, but were rarely observed in older children in Groups 1 and 2.

Bunny hopping

weakness) [13]. In hemiplegic adults, clinical scales, such as the Brunnstrom method [14], are used for assessing dysfunction in the spastic extremities. Children with spastic diplegia have spasticity of the lower extremities. They fail to develop a stable gait. When they attain independent ambulation, these children have abnormal gait patterns (e.g., flexed hips, flexed knees and hips, or flexed hips and extended knees) [15]. Our study clarified the preambulatory motor patterns and correlated these patterns with the severity of motor abnormality in children with cerebral palsy and spastic diplegia. In rolling, truncal rotations of block-pelvis and shoulder-pelvis were observed in many diplegic children but were rarely found in severely diplegic children. Weight

Spasticity is caused by an upper motor neuron lesion and is characterized by a velocity-dependent increase in tonic stretch reflexes with exaggerated tendon jerks [13]. Patients with spasticity have complex motor dysfunction. They exhibit abnormal behaviors, such as reflex release phenomena combined with performance deficits (e.g.,

d





Asymmetric bunny hopping

Figure 3. Crawling patterns. (See text for details.)

Discussion

Block

Hip-flexed crawling

0



m~ O O O l



C

b a

01



qDmO



Shoulder -pelvis Block -pelvis

m



oo

o m

b a

- 0 8 oo; I

• I

1

o

o

8oo.;oo oo I

O I

I

? AG

m

• o

3 E

n

I

4

(yrs)

Figure 4. Rolling: 47 rolling recordings are illustrated. The basis of the supporting point is (a) the elbow, (b) the caudal half of the trunk, (c) the whole lateral aspect of the body, or (d) the shoulder. O, [3, O, and • indicate the children who belong to Groups 1-4, respectively. When a child demonstrates a different rolling pattern, both patterns are indicated by small circles or squares. Most of the children in Group 1 have the block-pelvis and elbow patterns and most of the children in Group 4 have the block pattern.

Yokociiiet al: GrossMotOrPatte~' 247:

T a b l e 2.

N u m b e r o f children with each rolling pattern

support on the elbows was also observed in most of the diplegic children. Movement of the trunk and upper extremities was not affected during rolling because spastic diplegia mainly involved the lower extremities; however, certain children demonstrated difficulty in truncal rotation and weight support on the elbows. This type of difficulty was reported in diplegic children 15]; our study demonstrated that only the most severely diplegic children were affected. In sitting, most of the diplegic children exhibited the between-heel sitting pattern [5]. This pattern may stabilize sitting by widening the base and is easily obtained by internal rotation, the dominant pattern observed in diplegic children. This pattern was predominantly observed in many children regardless of the severity of diplegia. Even the mildly diplegic children inevitably exhibited betweenheel sitting. Although cross-legged sitting was observed, the younger children eventually changed to between-heel sitting. This change is probably due to the alteration in muscular tone secondary to age. Shuffling with spastic diplegic cerebral palsy has been reported [16], but in our study was observed only in I child. Shuffling is most likely a rare locomotive pattern in diplegic children.

Group I

2

3

4

0 0 0 0

1 0 0 I

0 0 0 7

4 3 4 8

0 0 0

0 0 0

0 0 1

0 0 0

I

2

1

0

0 0

0 0

0 0

0 0

Block

Shoulder Trunk* Abdoment Elbow Shoulder-pelvis

Shoulder Trunk* Abdoment Elbow Block-pelvis

Shoulder Trunk* Abdomen"~ Elbow

1

1

1

0

11

5

6

3

I

**

_ _ 1

* Whole lateral aspect of body. t Caudal half.,oftrunk. ** P < 0.01 ( g'test ).

Between-heel sitting Side Sitting Long sitting Cross-legged sitting

tl

i

_ I = = ___,____'_--_-=___'___

e-

_ Between-heel sitting

//-

/

- - -.......

-_a ~,-

/

• -

.

-

.g

/t-,,

II

Side sitting Long sitting Cross-legged sitting

Between-heel

n~

sitting

Side

a

sitting

Long sitting Cross-legged sitting o

_

u



Between-heel sitting Side sitting Long sitting Cross-legged sitting

~ I

1

0

0 I

0 I

0 n

2

I

3

I

I

4

,

I

I

I

567

A 6 E.(,r,) Figure 5. Sitting: 61 recordings in 17 children of Group 1, 56 in 16 children of Group 2, 84 in 20 children of Group 3, and 61 in 14 children of Group 4 are illustrated. When a child had the same sitting pattern successively, first and last points are shown, and intermediate points m'e omitted. Symbols are the same as in Figure 4. Most of tile children in all groups have the between-heel sitting pattern.

248

PEDIATRIC NEUROLOGY Voi. 6 No. 4

Table 3.

Number of children with each sitting pattern*

Sitting Patterns

I

Between-heel Side Long Cross-legged

9 0 4 7

Age _>2 yrs, for groups:

Age < 2 yr, for groups: 2 3 4

6 0 2 6

9 0 3 3

3 0 0 2

1

2

3

4

II 1 2 2

I1 0 I 1

18 0 2 0

12 0 2 2

* The patterns of sitting in each group are not significantly different ( ;(2 test ). In crawling, various patterns were observed in diplegic children. The arm-creeping pattern did not indicate the severity of motor impairment until the children were older. The arm- and leg-creeping patterns were observed in only mildly diplegic children. The most severely diplegic children could not kick their legs reciprocally in the prone

position. In crawling, separated flexion and extension at the hips were insufficient; lateral bending of the trunk was necessary for locomotion, indicating that the diplegic children had difficulty in releasing synergistic leg movements, as reported in hemiplegic adults by Brunnstrom [14]. Most of the severely diplegic children at the older age had hip-

Asymmetric bunny hopping

m-~llll

Hip-flexed crawling Crawling Arm and leg creeping Arm creeping

-

Asymmetric

bunny hopping

Bunny hopping Hip-flexedcrawllngCrawling

-

-

--

-

~.. I-

il

Asymmetric creeping Arm and leg creeping Arm creeping ............................................ Hip-flexed crawling Crawling Asymmetric creeping Arm and lag creeping Arm creeping Bunny hopping

Hip flexed crawling Crawling Asymmetric creeping Arm and leg creeping Arm creeping I

l

1

I

I

2

I

AG E (yr.)

~

'

'

4

'

l

l

l

567

Figure 6. Crawling: 51 recordings in 17 children of Group 1, 53 in 16 children of Group 2, 101 in 20 children of Group 3, and 98 in 19 children of Group 4 are illustrated. When a child had the same crawling pattern successively, first and last points are shown, and intermediate points are omitted. Symbols are the same as in Figure 4. The children in Groups I and 2 have various crawling patterns at the younger age, most of whom later exhibited the crawling pattern. Most of the children in Group 4 have the arm-creeping pattern at the younger age and later manifest various patterns, including arm creepmg, crawling, hip-flexed crawling, bunny hopping, and asymmetric bunny hopping.

Yokochi at al: GrossMotorpat~Sl

249

Table 4.

Number of children with each crawling pattern

Crawling Patterns

Asymmetric bunny hopping Bunny hopping Hip-flexed crawling Crawling Asymmetric creeping Arm and leg creeping Arm creeping

1

0 0 3 II I 6 5

Age < 2 yr, for groups: 2 3

0 2 1 10 I 6 4

0 0 5 6 3 2 7

Age _>2 yrs, for groups: 2 3

4

1

4

0

0

0

3

2

1

0

0

1

3

2

1

1

6

6

I

7

8

14

6

0 0 II

0 0 0

0 0 0

0 I 0

1 0 12

i

L.

_11

* P < 0.05

** P < 0.01 ( x" test ) flexed crawling, bunny hopping, and a s y m m e t r i c bunny h o p p i n g pattems. The children with these 3 patterns had difficulties not only in reciprocal hip m o v e m e n t s , but also in weight support by the hips. Our study r e v e a l e d that the gross motor patterns in rolling and c r a w l i n g correlated with the severity of the locom o t i v e disability. Disturbance of l o c o m o t i v e m o v e m e n t s in children with spastic cerebral palsy is due to a physiologic abnormality, such as co-contractions of a pair of f l e x o r / e x t e n s o r m u s c l e s during voluntary m o v e m e n t [17]. In rolling and crawling, reciprocal hip m o v e m e n t s , weight support by the hips, and truncal rotation were deficient. T h e s e d e f i c i e n t m o v e m e n t s m a y affect the severity of m o t o r d e v e l o p m e n t a l abnormality in diplegic children and physical therapy should attempt to i m p r o v e these m o v e ments. It is useful to assess these m o v e m e n t s before 2 years o f age to predict l o c o m o t i v e prognosis. Our study suggests that children w h o had the block pattem with absent truncal rotation had poor prognoses, and children w h o had arm and leg creeping with reciprocal leg m o v e ments had better prognoses.

We wish to thank Dr. Tsuneo Sakai, Seirei-Mikatabara General Hospital, for his helpful comments on the manuscript.

References [1] Bennet FC, Chandler LS, Robinson NM, Sells CJ. Spastic diplegia in premature infants. Etiologic and diagnostic considerations. Am J Dis Child 1981;135:732-7. [2] Veelken N, Hagberg B, Hagberg G, Olow I. Diplegic cerebral palsy in Swedish term and preterm children. Differences in reduced optimality, relations to neurology and pathogenetic factors. Neuropediatries 1983;14:20-8.

250 PEDIATRIC NEUROLOGY Vol. 6 No. 4

[3] Crothers B, Paine RS. Bilateral spastic cerebral palsies. In: The natural history of cerebral palsy. Cambridge: Harvard University Press, 1959;106-19. [4] lngram TTS. The clinical findings in 79 patients with diplegia. In: Paediatric aspects of cerebral palsy. London: E and S Livingstone, 1964;209-44. [5] Bobath B, Bobath K. Spastic diplegia. In: Motor development in the different types of cerebral palsy. London: Heinemann Medical, 1975;21-42. [6] Beals RK. Spastic paraplegia and diplegia. An evaluation of nonsurgical and surgical factors influencing the prognosis for ambulation. J Bone Joint Surg 1966:48A:827-46. [7] Crothers B, Paine RS. Extrapyramidal and mixed cerebral palsies. In: The natural history of cerebral palsy. C~unbridge: Harvard University Press, 1959;120--40. [8] Bleck EE. Locomotor prognosis in cerebral palsy. Dev Med Child Neurol 1975; 17:18-25. [9] Molnar GE, Gordon SU. Cerebral palsy: Predictive value of selected clinical signs for early prognostication of motor function. Arch Phys Med Rehabil 1976;57:153-8. [I0] BadelI-Ribera A. Cerebral palsy: Postural-locomotor prognosis in spastic diplegia. Arch Phys Med Rehabil 1985;66:614-9. [11] Bobath K, Bobath B. The neuro-developmental treatment. In: Scrutton D. ed. Management of the motor disorders of children with cerebral palsy. Clinics in developmental medicine, no. 90. Oxford: Blackwell Scientific, 1984;6-18. [12] Vojta V. The basic elements of treatment according to Vojta. In: Scrutton D, ed. Management of the motor disorders of children with cerebral palsy. Clinics in developmental medicine, no. 90. Oxford: Blackwell Scientific, 1984;75-85. [13] Katz RT, Rymer WZ. Spastic hypertonia: Mechanism and measurement. Arch Phys Med Rehabil 1989;70:144-55. [14] Brunnstrom S. Motor testing procedures in hemiplegia: Based on sequential recovery stages. Phys Ther 1966;46:357-75. [15] Bleek E. Spastic diplegia. In: Orthopedic management in cerebral palsy. Clinics in developmental medicine, no. 90/100. Oxford: Blackwell Scientific, 1987;282-391. [16] Robson P, Mac Keith RC. Shufflers with spastic diplegic cerebral palsy: A confusing clinical picture. Dev Med Child Neurol 1971; 13:651-9. [17] Milner-Brown HS, Penn RD. Pathophysiological mechanisms in cerebral palsy. J Neurol Neurosurg Psychiatry 1979;42:606-18.

Gross motor patterns in children with cerebral palsy and spastic diplegia.

Rolling, sitting, and crawling patterns were motoscopically analyzed in 72 children with cerebral palsy and spastic diplegia; the relation between the...
445KB Sizes 0 Downloads 0 Views