Ki Hyuk Sung, MD Relationship between isometric muscle strength, gait parameters, and gross motor function Seoul National University Bundang Hospital.

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Ki Hyuk Sung, MD Relationship between isometric muscle strength, gait parameters, and gross motor function Seoul National University Bundang Hospital

SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL Introduction Muscle weakness is a common impairment in patients with cerebral palsy Lower limb muscle strength is reduced by 6%- 59% compared with peers with typical development

SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL Introduction Muscle strength had a significant association with gross motor function Muscle strengthening exercise could result in functional improvements Recent studies showed no improvement of functional activity after muscle strengthening training

SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL Introduction No single study which investigates the relationship between muscle strength and gross motor function, gait kinematics, and gait kinetics in patients with CP

SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL Purpose of the study To the correlation between isometric muscle strength and gross motor function, gait kinematics and kinetics in ambulatory patients with spastic CP

SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL Materials and Methods Prospective design Inclusion –consecutive ambulatory patients with spastic CP –patients who planned for single event multilevel surgery including DHL –preoperative 3D gait analysis and gross motor function measure (GMFM) scoring

SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL Measuring isometric muscle strength Handheld dynamometer

SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL Measuring isometric muscle strength Hip flexor muscle

SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL Measuring isometric muscle strength Hip extensor muscle

SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL Measuring isometric muscle strength Knee flexor muscle

SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL Measuring isometric muscle strength Knee extensor muscle

SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL Gross motor function measure (GMFM) –88 items within five dimension –Dimension D(standing) and E(walking, running, jumping) scoring 3D gait analysis –Kinematic, kinetic and temporal parameters

SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL Reliability of strength measurement Intra-session reliability, 3 trial ICC (intraclass correlation coefficient) & 95% confidence interval

SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL Statistical analysis Correlation between peak isometric strength and GMFM, gait kinematics and gait kinetics –Pearson’s correlation coefficient Difference in peak isometric muscle strength according to GMFCS level –One-way analysis of variance (ANOVA)

SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL Results

SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL Demographics, GMFM, and peak isometric strength of patients Muscle groupPeak isometric strength Age (year)11.5±7.7 (range )Hip flexor (N)8.71±6.53 Gender (M / F)13 / 12Hip flexor (N/kg)0.26±0.12 Type (hemi/di/quadri)7/ 17/ 1Hip extensor (N)15.46±12.30 GMFCS level (I/ II/ III)7/ 13/ 5Hip extensor (N/kg)0.51±0.36 Height (cm)130.6±20.9Knee flexor (N)6.60±5.47 Weight (kg)33.9±18.6Knee flexor (N/kg)0.21±0.14 GMFM-D (%)85.1±33.9Knee extensor (N)10.26±5.30 GMFM-E (%)73.9±20.7Knee extensor (N/kg)0.34±0.20

SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL Intra-session reliability of measurements of peak isometric muscle strength Muscle groupsICC95% CI Hip flexor to Hip extensor to Knee flexor to Knee extensor to ICC, intraclass correlation coefficient; CI, confidence interval

SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL Correlations between peak isometric muscle strength and GMFM Muscle groups GMFM-DGMFM-E rprp Hip flexor Hip extensor Knee flexor Knee extensor GMFM, gross motor function measure

SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL Peak isometric muscle strength according to GMFCS levels Muscle groupsGMFCS IGMFCS IIGMFCS IIIp Hip flexor (N/kg)0.27± ± ± Hip extensor (N/kg)0.53± ± ± Knee flexor (N/kg)0.24± ± ± Knee extensor (N/kg)0.36± ± ± Data are presented as mean ± SD. GMFCS, gross motor function classification system

SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL Correlations between peak isometric muscle strength and gait kinematics Parameters Hip flexorHip extensorKnee flexorKnee extensor rprprprp Stride length Cadence Walking speed Maximum pelvic tilt Mean pelvic tilt Maximum pelvic obliquity Mean pelvic obliquity Minimum hip flexion Maximum hip flexion in stance Maximum hip flexion in swing Knee flexion at initial contact Minimum knee flexion in stance Peak knee flexion in swing Knee flexion at terminal swing

SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL Correlations between peak isometric muscle strength and gait kinetics Kinetic parameters Hip flexorHip extensorKnee flexorKnee extensor rprprprp Hip Flexion/Extension Moment Peak Extensor in early stance Peak Flexor in stance Peak Extensor in swing Hip Flexion/Extension Power Peak generation in early stance Peak absorption in mid-stance Peak generation in terminal stance Knee Flexion/Extension Moment Peak extensor in early stance Peak Flexor in mid-stance Peak extensor in terminal stance Peak flexor in swing Knee Flexion/Extension Power Peak absorption in early stance Peak generation during stance Peak absorption in terminal stance Peak absorption in terminal swing

SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL Conclusions There is no correlation between muscle strength and gross motor function. However, higher muscle strength, especially extensor muscle group of hip and knee joint, stabilizes the pelvic motion and makes walking more energy-efficient in flexed knee gait.

SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL Thank you !