Unusual Walk in Toddlers with Cerebral Palsy Linked to Outward Hip Rotation in Study

An analysis of the body movement as toddlers with cerebral palsy walked found that an unusual, external rotation to the pelvis contributed to an abnormal walking pattern, and may be due to difficulties in motor control.

These results point to beginning rehabilitation at an early age to improve body core strength, and the position of the pelvis and the condition of the hip muscles. 

The study, “Characteristics of newly acquired gait in toddlers with unilateral cerebral palsy: Implications for early rehabilitation,” was published in the journal Annals of Physical and Rehabilitation Medicine. 

Cerebral palsy (CP) is the most common motor disability of childhood affecting movement, balance, and posture. As such, children with CP can have an abnormal walk (gait). 

Many studies have analyzed gait in children with CP between the ages of 6 and 18 years. And a few evaluated the gait in CP toddlers, but these studies also included older children with different levels of walking experience.

To get a clearer picture of the walking habits of in toddlers only, researchers based in France and Romania designed a study (NCT03902886) to analyze the gait characteristics of toddlers with CP within the first six months of independent walking, and compared them to the gait of toddlers without this disease.

These efforts may help guide early age rehabilitation, in addition to providing the means to distinguish  if the abnormal gait patterns in children with CP are primary (caused by brain lesions affecting motor control), secondary (caused by brain lesions affecting the musculoskeletal system), or compensatory (movements that compensate for lower-limb injury or deformities).

The team tested 12 toddlers with unilateral CP — CP affecting one side of the body — identified from pediatric rehabilitation centers in both countries, along with a group of 25 unaffected children. All were under the age of 3, walking independently for a maximum of six months, and able to walk five meters (about 16 feet) without falling or assistance (GMFSC level 1).

Walking analysis was performed using cameras and reflective markers placed on the body to record movement. 

Each child was equipped with 19 reflective markers attached to joints, with additional markers placed on the knees and ankles. Another eight electrodes (electromyography or EMG) were placed over the upper and lower leg muscles to record electrical activity during movement. 

Toddlers, encouraged by their parents, walked barefoot down a corridor in a straight line, as their movement was recorded by a camera, and their body motions analyzed by 3-D software. 

An overall walking analysis revealed that the limbs of toddlers not affected by CP move significantly faster than the limbs both on the affected and unaffected side of the child with CP.

The period of time between individual walking cycles (heel-strike to heel-strike) was significantly longer for both sides of the body in children with CP, and the time during the walk cycle when a single foot supported the whole body was lesser on the affected side compared to the unaffected side or the control group. 

A detailed body motion (kinematic) analysis showed that the predominant alteration in motion was caused by the pelvis rotating externally on the affected side. These results suggested, the researchers said, that “this pelvic external rotation is more likely caused by the primary [brain] lesions.”

In addition, the angle of the foot as the leg swings was bent externally about 60% to 80% of the time in toddlers with CP compared to unaffected toddlers. 

Finally, no significant differences in the electrical activity of the leg muscles were found in toddlers with CP, suggesting that, in this particular sample studied, “the activation patterns of the [four] lower limbs muscles recorded during newly acquired gait in toddlers with [CP] … is similar to that of [typically developing] toddlers,” the researchers wrote.

Based on these findings, they recommended “that early rehabilitation, before the child is able to stand independently, should focus on proximal [center of the body] motor control, pelvic positioning and strengthening of the trunk and hip muscles in order to improve the motor control of the pelvis.”

“Further research is needed to clearly define the origin of the changes and to provide guidelines for early motor rehabilitation,” the researchers concluded.