Cerebral palsy related complications in adolescent gait biomechanics

N.E. Ereshko1
Dr. Hab., Associate Professor A.S. Makhov1
PhD, Associate Professor V.P. Kartashev1
M.S. Semiryazhko1
1Russian State Social University, Moscow

Corresponding author: ereshkone@rgsu.net

Abstract

Objective of the study was to offer theoretical provisions for special physical training model customizable for the cerebral-palsy-related movement remodeling to physiological motor stereotypes in the adolescent age, to facilitate progress in the postural control and gait biomechanics.

Results and Conclusion. Every cerebral-palsy-diagnosed child is known to develop his/her own walking strategy or movement pattern that can hardly be changed or standardized, otherwise the vertical postural controls may be heavily compromised. One of the key rehabilitation criteria in such cases is the postural control and movement control stability. The cerebral-palsy-related movement disorders form and aggravate spasticity with contractures, and this is why the functionality improvement/ rehabilitation trainings should be geared to remove/ mitigate certain individual clinical syndromes.

The study data and analysis showed benefits of special versatile physical trainings for functional progresses of children with cerebral palsy and their protection from potential adaptive overstrains by moderate healthy physical workouts. Such practices are recommended to include static postural control improvement exercises plus obligatory cyclic motor activities with an emphasis on the ground contact control to improve the inter-muscular responses and reflexive fast adaptation mechanisms mobilized and excelled by such physical activity. It should be emphasized that the endurance and strength exercises should be prudently designed and managed with respect to the heart rate variability test data since the autonomous nervous system responses and controls are still incomplete and imperfect in this age group.

Keywords: cerebral palsy, gait biomechanics, classified cerebral palsy dysfunctions.

Background. The cerebral-palsy-related motor/ postural control dysfunctions are known to be largely due to the central nervous system disorders in many parts with underdevelopments in their central structures and delayed myelination of nerve fibers associated with abnormal activity of the brain stem structures. Pathological motor stereotypes are finally formed at residual stages of cerebral palsy with the relevant compensatory adaptations that are needed for the orthograde postural control in every locomotion type [1].

Clinical cerebral-palsy-related disorders are commonly grouped into the primary ones caused by the central nervous system pathologies (muscle weakness, spasticity and disharmonies, hyperkinesis etc.); secondary complications of the primary musculoskeletal system defects and developmental disorders (short muscles, contractures, subluxations, dislocations, progressive skeletal deformities – i.e. orthopedic complications); and tertiary protective adaptation mechanisms mobilized by the growing body to offset the above two groups of disorders (gait disorders, dysfunctions, irreducible compensatory patterns, hypokinesia etc.) [4, p. 40].

Of special contribution among the above are the proprioceptive sensitivity dysfunctions with inhibition of signals from joints and tendons, and with the relevant complications for somatognosis. The primary proprioceptive data flow from peripheral structures is inadequate and complicated by hypokinesia and prolonged postural dysfunctions – that means that the child is unable to correctly perceive and control motor actions to develop a correct bodily control pattern. Intense signals from stressed muscles to the central nervous system in this case effectively hamper the data flow from proprioceptors in ligaments and tendons, particularly when relatively weak, short-amplitude and fine movements are attempted, making the child unable to correctly repeat passive movements and forcing to imitate them instead.

It is also common for cerebral palsy to impair sensory movement control and activity of gamma neurons in the spinal cord associated with permanent kinesthetic disorders in spastic forms [6]; with the children facing difficulties in identifying and naming body parts, fingers, movement vectors, spatial orientations, postures, postural aspects, arm/ hand/ finger positions etc. These issues contribute to the growing motor apraxia or ataxia with the related complications in the vertical postural control and body mass center movement control.

Objective of the study was to offer theoretical provisions for special physical training model customizable for the cerebral-palsy-related movement remodeling to physiological motor stereotypes in the adolescent age, to facilitate progress in the postural control and gait biomechanics.

Results and discussion. Every cerebral-palsy-diagnosed child is known to develop his/her own walking strategy or movement pattern that can hardly be changed or standardized, otherwise the vertical postural control may be heavily compromised. One of the key rehabilitation criteria in such cases is the postural control and movement control stability [5]. The cerebral-palsy-related movement disorders form and aggravate spasticity with contractures, and this is why the functionality improvement/ rehabilitation trainings should be geared to remove/ mitigate certain individual clinical syndromes.

The cerebral-palsy-related gait biomechanics disorders may be interpreted as combinations of pathological factors contributing to the habitual postural control dysfunctions. Thus, the common walking stereotype in case of spastic diplegia is rather monotonous, with the only gait biomechanics differences found in the stride pacing with the ground contact phase variations plus the relevant lower-limb flexion cycling stereotypes, key leg joint movement limitations, plus reductions and deformations in the ground contact curves indicative of the walking postural control issues. The ground contact phase is deformed to shorten the heel/ sole contract times and increase the forefoot contact times [3].

It is also common that spastic diplegia related ground contact disorders are complicated by equinus positions or foot deformities albeit the movement control rhythm ratio may be virtually normal due to the both legs equally compromised. Consequently, the key joint movement patterns in walking are transformed as well. The kinematic disorders may be grouped as follows: (1) primary flexion angles in every leg joint are shifted, with the angular displacements curves moving upward from the zero (standing) line; (2) the interlink angle amplitudes, angular move speeds and accelerations are reduced; and (3) startup and end phase are displaced in the movement cycle.

The cerebral-palsy-related individual vertical controls are typically referred to as the "mobile balance" [2] with constant muscle tone variations in the antigravity muscle groups to stabilize the body mass center and ground contact. Every cerebral palsy case shows postural control disorders, limb movement disharmonies, dominance of flexor adductor and penetrating muscle tones indicative of imbalances in the striated muscles and spinal column development pathologies – as a result of the primary central nervous system dysfunctions with impairments in the reciprocal innervation mechanisms.

It should be emphasized that active movements with sensors-driven activity attentive to feedbacks from the muscular apparatus – stimulate changes in the brain, with progress in responses to afferent signals facilitating improvements in the central nervous system functionality. Neurophysiological analysis of the brain functions in the cerebral-palsy-diagnosed adolescents subject to the movement disorders correction therapy found expressed qualitative/ quantitative transformations in the integrative brain activity due to improvements in the old functional links with new ones being formed, and with progress to the ontogenetically better cortical-subcortical links – to open up new opportunities for the brain functionality improvements in the cerebral palsy cases [3].

The compromised muscle functions largely limit or disable movements and, hence, develop forced postures and motor patterns associated with the musculoskeletal system developmental deficiencies – and that is why the efforts to recover the central nervous system functions may not be successful unless the muscle functionality is improved. When special physical training models are designed, therapists need to understand well every aspect of the cardiovascular system adaptation to muscle workouts in the cerebral-palsy-diagnosed children. When the individual adaptability is heavily compromised and, hence, physical stress tolerance is relatively low, whilst information about the functional limits, norms and applicable physical activity tests is short or lacking, the energy-cost- and adaptability-sensitive rehab methods may be difficult for design on the individual health issues customized basis [2, p. 126].

Physical inactivity of the cerebral-palsy-diagnosed adolescents contributes to the autonomic regulation disorders with symptoms of sympathicotonia, expressed neurohumoral regulation and vertical postural control dysfunctions. Physical workouts with complex movement coordination in vertical positions with a special attention to the ground contact to activate a wide range of muscle groups – help increase vagotonic activity and ease tones of the sympathetic and central regulation mechanisms in the cerebral-palsy-diagnosed young males; and decrease vagotonic activity with the simultaneous growths in tones of the vasomatory and suprasegmental regulatory centers in their female peers.

Conclusion. The study data and analysis showed benefits of special versatile physical trainings for functional progresses of children with cerebral palsy and their protection from potential adaptive overstrains by moderate healthy physical workouts. Such practices are recommended to include static postural control improvement exercises plus obligatory cyclic motor activities with an emphasis on the ground contact controls to improve the inter-muscular responses and reflexive fast adaptation mechanisms mobilized and excelled by such physical activity. It should be emphasized that the endurance and strength exercises should be prudently designed and managed with respect to the heart rate variability test data since the autonomous nervous system responses and control are still incomplete and imperfect in this age group.

References

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