Clinical assessment and three-dimensional movement analysis: An integrated approach for upper limb evaluation in children with unilateral cerebral palsy

Abstract

IntroductionThe clinical application of upper limb (UL) three-dimensional movement analysis (3DMA) in children with unilateral cerebral palsy (uCP) remains challenging, despite its benefits compared to conventional clinical scales. Moreover, knowledge on UL movement pathology and how this relates to clinical parameters remains scarce. Therefore, we investigated UL kinematics across different manual ability classification system (MACS) levels and explored the relation between clinical and kinematic parameters in children with uCP.Patients and methodsFifty children (MACS: I = 15, II = 26, III = 9) underwent an UL evaluation of sensorimotor impairments (grip force, muscle strength, muscle tone, two-point discrimination, stereognosis), bimanual performance (Assisting Hand Assessment, AHA), unimanual capacity (Melbourne Assessment 2, MA2) and UL-3DMA during hand-to-head, hand-to-mouth and reach-to-grasp tasks. Global parameters (Arm Profile Score (APS), duration, (timing of) maximum velocity, trajectory straightness) and joint specific parameters (angles at task endpoint, ROM and Arm Variable Scores (AVS)) were extracted. The APS and AVS refer respectively to the total amount of movement pathology and movement deviations of wrist, elbow, shoulder, scapula and trunk.ResultsLonger movement durations and increased APS were found with higher MACS-levels (p<0.001). Increased APS was also associated with more severe sensorimotor impairments (r = -0.30-(-0.73)) and with lower AHA and MA2-scores (r = -0.50-(-0.86)). For the joint specific parameters, stronger movement deviations distally were significantly associated with increased muscle weakness (r = -0.32-(-0.74)) and muscle tone (r = 0.33-(-0.61)); proximal movement deviations correlated only with muscle weakness (r = -0.35–0.59). Regression analysis exposed grip force as the most important predictor for the variability in APS (p<0.002).ConclusionWe found increased movement pathology with increasing MACS-levels and demonstrated the adverse impact of especially muscle weakness. The lower correlations suggest that 3DMA provides additional information regarding UL motor function, particularly for the proximal joints. Integrating both methods seems clinically meaningful to obtain a comprehensive representation of all aspects of a child’s UL functioning.

Kinematic motion abnormalities and bimanual performance in children with unilateral cerebral palsy

“…8 These results were reinforced by a recent study of Mailleux et al, 15 which found similar values of correlation between AHA score and the kinematic indices (AVS and APS) in reach-to-grasp vertically, hand-to-mouth, and hand-to-head tasks. In agreement with the clinical impression, a higher relationship could be expected for this degree of freedom.…”

“…15 Concurrently, 23 TDC (11 males, 12 females; 22 righthanded, one left-handed; mean age 11y 11mo [SD 2y 5mo]) were included in the study as a control group. 15 Concurrently, 23 TDC (11 males, 12 females; 22 righthanded, one left-handed; mean age 11y 11mo [SD 2y 5mo]) were included in the study as a control group.…”

“…As can be seen in Figure S2 (online supporting information), the unilateral CP group tended to perform the unimanual tasks with more pronation, wrist flexion, ulnar deviation, and less elbow extension than the TDC group. 15 Moreover, the upper limb is a complex kinematic chain with a lot of degrees of freedom; we could imagine that small deviations in the proximal segments (i.e. [8][9][10] One explanation could be that the muscle weakness and the increased muscle tone are more prominent distally, 7 and have a higher influence on distal movements.…”

“…Correlation coefficients between kinematic indices (Global Arm Variable Score [AVS], Arm Profile Score [APS], Global-APS) and Assisting Bold denotes significance. However, with regard to the findings of Mailleux et al,15 which suggest that the scapular movement deviations were correlated neither to the bimanual performance (AHA) nor to the manual abilities (MACS levels), the impact of the scapular movements on the functionality of the upper limb can be questioned.3DMA of the upper limb is complex because of the lack of cyclic movements, the variety of functions, and abundant degrees of freedom. Secondly, scapular motion was not calculated because of difficulties in our calibration of the acromial cluster, which was not precise enough and was responsible for erroneous measurement.…”

“…r p , Pearson correlation coefficient.Jaspers et al has been validated in a unilateral CP group with similar inclusion criteria 17. In the study by Mailleux et al,15 the kinematic indices (APS and distal AVS) were better correlated to the unimanual capacity than to the bimanual performance, highlighting that the 3DMA unimanual protocol assesses more the capacity of the affected hand (i.e. The International Society of Biomechanics' recommendations also have limitations as the markers are subject to displacement because of soft tissue artefacts.…”