Muscle force production and functional performance in spastic cerebral palsy: Relationship of cocontraction

doi:10.1053/apmr.2000.5579

Archives of Physical Medicine and Rehabilitation

Volume 81, Issue 7, July 2000, Pages 895-900

https://doi.org/10.1053/apmr.2000.5579 Get rights and content

Abstract

Damiano DL, Martellotta TL, Sullivan DJ, Granata KP, Abel MF. Muscle force production and functional performance in spastic cerebral palsy: relationship of cocontraction. Arch Phys Med Rehabil 2000;81:895-900. Objective: To determine cocontraction's relation to strength and motor function in children with spastic cerebral palsy (CP). Design: Prospective evaluation with a convenience sample of 10 subjects. Setting: Pediatric rehabilitation center at a tertiary care hospital. Patients: Ten ambulatory children with spastic CP, mean age 5 to 14yrs. Main Outcome Measures: A single comprehensive assessment of hamstring and quadriceps muscle strength; gait analysis while monitoring electromyographic (EMG) activity in those muscles; administration of the Gross Motor Function Measure (GMFM); heart-rate monitoring during quiet rest versus gait to compute an energy expenditure index (EEI). Cocontraction ratios and magnitudes were determined for the gait and strength testing trials using the EMG data. Results: Cocontraction ratios during strength tests correlated directly with those during free gait. Cocontraction magnitude and total EMG magnitude had an inverse relationship to EEI; children with more muscle activity in the agonist and antagonist tended to be more energy efficient. Knee extensor muscle strength correlated positively with the GMFM and gait velocity. Neither cocontraction ratio nor magnitude during gait was related to strength. Conclusions: Children with CP used a similar muscle activation strategy across two different motor tasks. Strength and cocontraction were uniquely related to different aspects of motor function. Further research is needed to quantify more precisely cocontraction and force to EMG relations in this population. © 2000 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation

Section snippets

Subjects

Ten children with spastic CP ranging in age from 5 to 14 years (mean, 9.2yrs) agreed to participate in the study (table 1), and informed consent was obtained from each child's parent or legal guardian.

Table 1: Age, ambulatory status, diagnosis, and surgical history of all participants

Participant	Age (yrs)	Type CP	Ambulatory Level	Surgical History
1	8	H	I	—
2	6	D	III	GS, ST stapling
3	12	D	I	Hamstrings
4	9	D	III	SDR
5	9	D	II	—
6	10	D	II	IL, Add, Hamstrings
7	6	D	III	Add, Gracilis, Hamstrings, GS
8	5	D	I	—
9	14	D	III	Add, Hamstrings, PTT
				—
10	6	D	III

Results

The mean and standard deviation for each analyzed para meter are shown in table 2.

Table 2: Mean and standard deviations for CCR and CCM, gait parameters, GMFM, and EEI

Parameter	Mean	SD
CCR
Knee extension (H/Q EMG)	.53	.27
Knee flexion (Q/H EMG)	.43	.26
Free gait (Min/Max EMG)	.55	.11
Fast gait (Min/Max EMG)	.54	.15
CCM
Knee extension (Min EMG)*	32.1	18.7
Knee flexion (Min EMG)*	16.7	11.9
Free gait (Min EMG)*	37.8	16.8
Fast gait (Min EMG)*	57.8	23.7
Antagonist/Agonist Ratios
Hamstring	1.17	1.34
Quadriceps	.28	.13
% Normal strength

Discussion

Without being able to place force transducers in the muscles, precise quantification of cocontraction in a dynamic situation is an elusive goal. All reported values of cocontraction during movement, regardless of computation method, are at best estimations, each accompanied by a set of physiologic assumptions—some of which may not be valid in persons with abnormal muscle coordination. For example, in our scaling method, we assumed that a linear relationship existed between force and EMG in the

Conclusions

Quadriceps weakness and the magnitude of muscle activity, both antagonist and agonist, appeared to be most strongly related to functional parameters in children with CP. However, these functional relations did not overlap. Compared with their normally developing peers, children with CP more commonly use cocontraction during over-ground and treadmill walking and during isometric maximal exertions. Potential negative effects of excessive cocontraction include greater total muscle activation

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Muscle coactivation during gait in children with and without cerebral palsy
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Children with Cerebral Palsy (CP) walk with an uncoordinated gait compared to Typically Developing (TD) children. This behavior may reflect greater muscle co-activation in the lower limb; however, findings are inconsistent, and the determinants of this construct are unclear.
(i) Compare lower-limb muscle co-activation during gait in children with, and without CP, and (ii) determine the extent to which muscle co-activation is influenced by electromyography normalization procedures and Gross Motor Function Classification System (GMFCS) class.
An electromyography system measured muscle activity in the rectus femoris, semitendinosus, gastrocnemius, and tibialis anterior muscles during walking in 46 children (19 CP, 27 TD). Muscle co-activation was calculated for the tibialis anterior-gastrocnemius (TA-G), rectus femoris-gastrocnemius (RF-G), and rectus femoris-semitendinosus (RF-S) pairings, both using root mean squared (RMS)-averaged and dynamically normalized data, during stance and swing. Mann-Whitney U and independent t-tests examined differences in muscle co-activation by group (CP vs. TD) and GMFCS class (CP only), while mean difference 95% bootstrapped confidence intervals compared electromyography normalization procedures.
Using dynamically normalized data, the CP group had greater muscle co-activation for the TA-G and RF-G pairs during stance (p < 0.01). Using RMS-averaged data, the CP group had greater muscle co-activation for TA-G (stance and swing, p < 0.01), RF-G (stance, p < 0.05), and RF-S (swing, p < 0.01) pairings. Muscle co-activation calculated with dynamically normalized, compared to RMS-averaged data, were larger in the RF-S and RF-G (stance) pairs, but smaller during swing (RF-G). Children with CP classified as GMFCS II had greater muscle co-activation during stance in the TA-G pair (p < 0.05).
Greater muscle co-activation observed in children with CP during stance may reflect a less robust gait strategy. Although data normalization procedures influence muscle co-activation ratios, this behavior was observed independent of normalization technique.
Muscle co-contraction and co-activation in cerebral palsy during gait: A scoping review
2023, Gait and Posture
Cerebral palsy (CP) results from an injury to a developing brain. Muscle activation patterns during walking are disrupted in individuals with CP. Indeed, excessive muscle co-contraction or co-activation (MCo/MCa) is one of the characteristics of pathological gait. Although some researchers have studied MCo/MCa in individuals with CP during gait, inconsistent results limit our understanding of this literature. Increased knowledge of MCo/MCa patterns in individuals with CP may help the development of improved gait management approaches.
This review aims to summarize MCo/MCa patterns while walking in individuals with CP across the existing literature and compare them with their healthy peers.
This study follows the Joanna Briggs Institute (JBI) guidelines and the recommendations presented in PRISMA Extension for Scoping Reviews (PRISMA-ScR). The recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for scoping Reviews statement were respected. The following databases were searched: MEDLINE (Ovid), EMBASE (Ovid), CINAHL Plus with Full Text (Ebsco), SPORTDiscus with Full Text (Ebsco), and Web of Science.
Among 2545 identified studies, 21 studies remained after screening. In total, 337 participants with CP and 249 healthy participants were included. Both MCo and MCa terminologies are used for describing simultaneous muscle activation; however, when it is measured by electromyography (EMG), MCa terminology should be preferred to facilitate interpretation. A wide range of MCo/MCa patterns has been found across studies using different methodologies (e.g., gait protocol, computation methods). Finally, most of the included studies confirm that MCo/MCa is increased in individuals with CP during walking compared to controls.
This review identified missing concepts and common limitations in the literature which could be addressed in future research such as the association between MCo/MCa and gait deviations, and the most appropriate MCo/MCa computation method.
Dynamic electromyography findings of the lower leg muscles during walking in spastic cerebral palsy children with hindfoot valgus
2023, Clinical Biomechanics
Hindfoot valgus is one of the most prevalent foot deformities in cerebral palsy children. Investigating the muscle activation patterns of cerebral palsy children with hindfoot valgus is crucial to understand their abnormal gait different from typically developing children.
Electromyography data of 20 cerebral palsy children with hindfoot valgus and 20 typically developing children were recorded for tibialis anterior, peroneal longus, and gastrocnemius medialis. The activation onset and offset times, normalized peak electromyography amplitude, average electromyography amplitude and integral electromyography amplitude for 20 completed cycles were averaged for data analysis. The co-activation index and activation percentage of peroneal longus were used to evaluate the co-activation level for tibialis anterior and peroneal longus muscles.
Compared with typically developing children, the activation onset of tibialis anterior and the activation offset of tibialis anterior, peroneal longus, and gastrocnemius medialis were significantly delayed in cerebral palsy children; moreover, the muscle activation durations of tibialis anterior, peroneal longus, and gastrocnemius medialis were significantly longer, and the normalized average electromyography amplitude of tibialis anterior, peroneal longus and gastrocnemius medialis, and the normalized integral electromyography amplitude of tibialis anterior were significantly lower in cerebral palsy children. Furthermore, for cerebral palsy children, the co-activation index was greater, and the peroneal longus muscles activation percentage was lower in the stance phase and greater in the swing phase than that of typically developing children.
The lower leg muscle activation patterns in cerebral palsy children were found to be abnormal.
A modified surface EMG biomarker for gait assessment in spastic cerebral palsy
2021, Human Movement Science
Muscle clinical metrics are crucial for spastic cocontraction management in children with Cerebral Palsy (CP). We investigated whether the ankle plantar flexors cocontraction index (CCI) normalized with respect to the bipedal heel rise (BHR) approach provides more robust spastic cocontraction estimates during gait than those obtained through the widely accepted standard maximal isometric plantar flexion (IPF).
Ten control and 10 CP children with equinus gait pattern performed the BHR and IPF testing and walked barefoot 10-m distance. We compared agonist medial gastrocnemius EMG during both testing and CCIs obtained as the ratios of antagonist EMG during swing phase of gait and either BHR or IPF agonist EMG.
Agonist EMG values from the BHR were: (i) internally reliable (Cronbach's α = 0.993), (ii) ~50 ± 0.4% larger than IPF, (iii) and positively correlated. Derived CCIs were significantly smaller (p < 0.05) in both populations.
The bipedal heel rise approach may be accurate enough to reveal greater agonist activity of plantar flexors than the maximal isometric plantar flexion and seems to be more appropriate to obtain cocontraction estimates during swing of gait.
This modified biomarker may represent a step forward towards improved accuracy of spastic gait management in pediatric.
Energetics of walking in individuals with cerebral palsy and typical development, across severity and age: A systematic review and meta-analysis
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Individuals with cerebral palsy (CP) report physical fatigue as a main cause of limitation, deterioration and eventually cessation of their walking ability. A consequence of higher level of fatigue in individuals with CP leads to a less efficient and long-distance walking ability.
This systematic review investigates the difference in 1) walking energy expenditure between individuals with CP and age-matched typically developing (TD) individuals; and 2) energetics of walking across Gross Motor Function Classification System (GMFCS) levels and age.
Five electronic databases (PubMed, Web of Science, CINAHL, ScienceDirect and Scopus) were searched using search terms related to CP and energetics of walking.
Forty-one studies met inclusion criteria. Thirty-one studies compared energy expenditure between CP and age-matched controls. Twelve studies correlated energy expenditure and oxygen cost across GMFCS levels. Three studies investigated the walking efficiency across different ages or over a time period. A significant increase of energy expenditure and oxygen cost was found in individuals with CP compared to TD age-matched individuals, with a strong relationship across GMFCS levels.
Despite significant differences between individuals with CP compared to TD peers, variability in methods and testing protocols may play a confounding role. Analysis suggests oxygen cost being the preferred/unbiased physiological parameter to assess walking efficacy in CP. To date, there is a knowledge gap on age-related changes of walking efficiency across GMFCS levels and wider span of age ranges. Further systematic research looking at longitudinal age-related changes of energetics of walking in this population is warranted.
Comparison of the forward and sideways locomotor patterns in children with Cerebral Palsy
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^☆: Supported by grants from the United Cerebral Palsy Education and Research Foundation and from the National Center for Medical Rehabilitation Research at the National Institutes for Health.

^☆☆: No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the authors or upon any organization with which the authors are associated.

^★: Reprint requests to Diane L. Damiano, PhD, Motion Analysis and Motor Performance Laboratory, 2270 Ivy Rd, Charlottesville, VA 22903.

^★★: Suppliers

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ArticlesMuscle force production and functional performance in spastic cerebral palsy: Relationship of cocontraction☆,☆☆,★,★★

Abstract

Section snippets

Subjects

Results

Discussion

Conclusions

Am J Obstet Gynecol

Electroencephalogr Clin Neurophysiol

Brain Dev

Arch Phys Med Rehabil

The relationship of voluntary movement to spasticity in the upper motor neuron syndrome

Ann Neurol

Cerebral palsy and muscle transformation

Dev Med Child Neurol

Lower extremity strength profiles in spastic cerebral palsy

Dev Med Child Neurol

Quantitative evaluation of cocontraction of knee and ankle muscles in normal walking

Biomechanics and motor control of human movement

Reviewing muscle cocontraction: is it a developmental, pathological, or motor control issue

Phys Occup Ther Pediatr

Framework for the measurement of neurologic impairment and disability

Stretch reflexes of the normal infant

Dev Med Child Neurol

Articles
Muscle force production and functional performance in spastic cerebral palsy: Relationship of cocontraction☆,☆☆,★,★★