Anticipatory Postural Adjustments duringin Gait Initiation: Children with Spastic

Diplegic Cerebral Palsy

Introduction
Cerebral palsy (CP) is a group of disorders of the development of movement and posture that
are attributed to non-progressive lesions that occur in the developing foetalfetal or infant
brain12. Children with CP often present with abnormal muscle tone, impaired voluntary motor
control, reduced muscle activation and maximal voluntary contraction. These impairments
often affect balance and gait function in individuals with CP 12.

Anticipatory postural adjustments (APAs) occur before the initiation of a movement or

action. Activation of postural muscles compensates for potential imbalance before it occurs
and ensures postural stability before the initiation of voluntary movement1. They can be leg
or trunk muscle activation up to 100ms before a predicted perturbation 4.

Gait initiation (GI) from a static upright stance involves a transfer of body weight from the
leading limb to the upcoming stance foot, and the creation of conditions for forward
progression3.There are two phases in GI. First, an anticipation phase that occurs prior to heel
off, and an execution phase, which starts from the heel off of the leading limb 5. During the
anticipatory phase, there is a posterior-lateral shift of centre of foot pressure towards the
stepping foot. This causes a simultaneous forward shift of the centre of mass towards the
stance limb due to the resultant ground reaction force, as the body prepares for a given
acceleration and velocity for the first step5. APAs are essential in GI to weight shift laterally
and unload the swing leg2. There is evidence of a developmental trajectory in GI, as the
magnitude of centre of pressure (COP) displacement backwards increases with age 5, and
younger children have a larger mediolateral COP displacement compared to posterior COP
shift in adults, with lower magnitude of muscle activation compared to adults8.

APAs have been studied in children with CP in a variety of tasks. Girolami et al. 4 and
Tomita et al. 16 investigated arm movement, Liu et al. 7 looked at reaching tasks and Shiratori
et al.13 studied loading tasks. Only one study has investigated APAs during gait initiation in
children with CP. Stackhouse et al. 15 compared APAs in GI between children with CP
(hemiplegia and diplegia) and typically developing children. There are no studies that
investigate how APAs during GI in children with CP change across gait acquisition.

The purpose of this study is to investigate changes in APA during GI at different stages of
walking ability in children with spastic diplegia CP. The variables of interest are the centre of
pressure trajectory prior to heel off, the muscles activated, timing of muscle activation and
amount of muscle activation. Surface EMG was selected to examine muscle activation
patterns made in APA during GI. A force plate will be used to quantify centre of pressure
(COP) trajectory, and to determine the anticipation phase that occurs prior to heel off. The
start of the anticipation phase will be defined as the onset of COP displacement after the walk
signal has been given, following the protocol used by Stackhouse et al. 15

Methods
Subjects
This project will aim to recruit 20 children diagnosed with spastic diplegia cerebral palsy via
convenience sampling. This is to allow for dropouts or individuals who undergo botox or
surgical interventions within the follow-up period. Data collection will be done at
recruitment, then 6 months, 1 year, 1.5 years and 2 years after the first data collection session.
If participants undergo any botox or surgical intervention during the follow up period, any
data collected after the intervention will be separated from the group analysis and looked at
individually.

Inclusion criteria: diagnosis of spastic diplegic cerebral palsy, walk independently <1 month.
Able stand independently, ambulate independently 1 metre (without any orthoses or aid) at
baseline. No surgical or Botox interventions for 6 months prior to enrolment and the ability to
follow instructions. Exclusion criteria: other neurological disorders, uncontrolled seizures,
inability to follow experimental protocol

Instrumentation
Active electrodes will be used to reduce motion artifacts 10. The skin will be cleaned with
alcohol wipes prior to electrode placement to reduce impedance. Electrodes will be placed
according to the SENIAM guidelines13 along the soleus, gastrocnemius, tibialis anterior,
hamstrings (medial & lateral), rectus femoris, erector spinae (left & right), and rectus
abdominis (left & right). This is similar to the EMG placement used in Shiratori et al.14 and
captures trunk muscles not included in the protocol by Stackhouse et al. 15. Given that trunk
control is often impaired in children with CP, trunk muscle activation should also be
considered when investigating APAs. The electrodes will be orientated in the direction of the
muscle fibres on the midline of the muscle to increase selectivity of the EMG recording10.
Electrode size will be 10mm with an inter-electrode distance of 20mm10,14. EMG sampling
frequency should be at a rate at least double the highest frequency component in the signal to
achieve accurate reconstruction according to the Nyquist theorem10. As the highest frequency
component in sEMG is at 450-500Hz, the minimum sample rate should be 1000Hz10.
McManus et al 10 recommends at least double the minimal sample rate to ensure that the
signal is captured accurately. Hence, EMG will be sampled at 2400Hz, which is well above
the minimal sample rate, and double the rate used in Stackhouse et al.15

Ground reaction force will be collected at 1200Hz with 2 force plates (Advanced Mechanical
Technology, Inc., Watertown, MA)9, 17 in 3 orthogonal planes (Fz - along the force of gravity,
Fy - parallel to the frontal plane of the body, Fx - Parallel to the sagittal plane of the body).

Protocol
Each trial will start with participants standing quietly with hands beside their body,
barefoot (no orthotics) on two force plates in their preferred stance with one foot on each
plate 9. They should be dressed in everyday clothing that they are comfortable walking in,
which does not restrict or constrain their gait pattern. Their feet position will be marked out
on each force plate around the heel and big toe to ensure consistency in starting position
between each trial 15. Young subjects who may struggle with positioning themselves in quiet
standing consistently on the force plate may be placed in standing by an investigator/parent.
Data collection will begin only when the child is standing independently without any support.

A signal will be given to prompt the participant to start walking 3 seconds after data
collection begins. The signal will be a simultaneous visual & auditory cue in front of the
subject (LED light and buzzer tone) 15. Participants will be told that they can start walking at a
comfortable pace (as close to everyday walking performance as possible) at any time after the
cue is given. This is to ensure that GI and APAs are not affected by any perceived temporal
constraints. Participants will take at least five steps or walk at least 1 metre along a walkway.
This will ensure that they reach steady-state walking. Their self-selected leading limb will be
noted for each trial. A minimum of 3 valid trials for each self-selected leading limb will be
collected at each data collection point 9. Rest time of 3 minutes will be given between trials.

Data Processing
In order to record baseline EMG in a position as close to static standing with minimal muscle
activation, baseline EMG will be recorded in supine after attaching the electrodes 15. Baseline
noise will be removed from the EMG signals recorded during GI, as it has been found that
individuals with CP have higher baseline muscle activity in a static upright position
compared to a normal population 14. Prior to A/D conversion, EMG data will be band pass
filtered 20-600Hz to remove electrode noise <20 Hz 10,11. A notch filter at 60Hz will be used
to remove noise from electrical components 10. Full wave rectification and a low-pass second
order Butterworth filter will then be applied 14. EMG amplitude will be obtained by
calculating root mean square of the rectified signal 11.

COP displacement in the anteroposterior direction will be normalized to foot length, while
COP displacement in the mediolateral direction will be normalized to stance width 9. COP
trajectory (AP/ML) will be calculated from each trial and down sampled to 100Hz 15.

The start of the anticipatory phase will be defined from the start of COP displacement in the
anteroposterior or mediolateral directions, as COP displacement occurs prior to visible
movement 15. The timing of heel off (H0) will be defined as the moment when the the force
vector in the direction of gravity (Fz) of the leading limb becomes 0N 9. The anticipatory
phase will be from the start of COP displacement up to the moment just before Fz reaches
zero.

EMG data and COP trajectory will be normalized to 100% of the anticipatory phase. This
will allow for comparison of individual muscle activation timing, EMG amplitude and COP
trajectory to be compared between trials. Change over time in normalized EMG data and
COP trajectory from baseline to 2 years follow up will be compared in each individual
subject. This will potentially show the development of APA in gait initiation over gait
acquisition in a child with spastic diplegic cerebral palsy. This approach will be used in
subjects who are not included in the group analysis due to surgical or botox interventions.
This is also to avoid having confounding effects of these interventions on the group data
analysis.

A group analysis will be applied to subjects that did not undergo any botox or surgical
interventions. EMG data and COP trajectory will be compared at each time point (baseline, 6
months, 1 year, 1.5 years, 2 years) to describe the change in EMG activation patterns, timing
and amplitude, as well as COP trajectory across gait development.

References
1. Aruin A, Latash M. The role of motor action in anticipatory postural adjustments
studied with self-induced and externally triggered perturbations. Exp Brain Res.
1995;106(2). doi:10.1007/BF00241125

2. Assaiante C, Woollacott M, Amblard B. Development of Postural Adjustment During

Gait Initiation: Kinematic and EMG Analysis. Journal of Motor Behavior.
2000;32(3):211-226. doi:10.1080/00222890009601373

3. Brenière Y, Cuong Do M, Bouisset S. Are Dynamic Phenomena Prior to Stepping

Essential to Walking? Journal of Motor Behavior. 1987;19(1):62-76.
doi:10.1080/00222895.1987.10735400

4. Girolami GL, Shiratori T, Aruin AS. Anticipatory postural adjustments in children

with hemiplegia and diplegia. Journal of Electromyography and Kinesiology.
2011;21(6):988-997. doi:10.1016/j.jelekin.2011.08.013

5. Ledebt A, Bril B, Brenière Y. The build-up of anticipatory behaviour. Experimental

Brain Research. 1998;120(1):9-17. doi:10.1007/s002210050372

6. Ledebt A, Brenière Y. Dynamical implication of anatomical and mechanical

parameters in gait initiation process in children. Human Movement Science.
1994;13(6):801-815. doi:10.1016/0167-9457(94)90019-1

7. Liu WY, Zaino CA, McCoy SW. Anticipatory Postural Adjustments in Children with
Cerebral Palsy and Children with Typical Development. Pediatric Physical Therapy.
2007;19(3):188-195. doi:10.1097/PEP.0b013e31812574a9

8. Malouin F, Richards CL. Preparatory adjustments during gait initiation in 4–6-year-

old children. Gait & Posture. 2000;11(3):239-253. doi:10.1016/S0966-
6362(00)00051-5

9. Mani H, Miyagishima S, Kozuka N, et al. Development of temporal and spatial

characteristics of anticipatory postural adjustments during gait initiation in children
aged 3–10 years. Human Movement Science. 2021;75:102736.
doi:10.1016/j.humov.2020.102736

10. McManus L, De Vito G, Lowery MM. Analysis and Biophysics of Surface EMG for
Physiotherapists and Kinesiologists: Toward a Common Language With
Rehabilitation Engineers. Front Neurol. 2020;11:576729.
doi:10.3389/fneur.2020.576729

11. Merlo A, Campanini I. Technical Aspects of Surface Electromyography for

Clinicians. TOREHJ. 2010;3(1):98-109. doi:10.2174/1874943701003010098

12. Rosenbaum P, Paneth N, Leviton A, Goldstein M, Bax M. A report: the definition and
classification of cerebral palsy April 2006. Developmental Medicine & Child
Neurology. 2007;49:8-14. doi:10.1111/j.1469-8749.2007.tb12610.x

13. Sensor Location. The SENIAM Project (Surface Electromyography for the Non-
Invasive Assessment of Muscles) Accessed 2 December 2021,
 http://seniam.org/sensor_location.htm

14. Shiratori T, Girolami GL, Aruin AS. Anticipatory postural adjustments associated
with a loading perturbation in children with hemiplegic and diplegic cerebral palsy.
Exp Brain Res. 2016;234(10):2967-2978. doi:10.1007/s00221-016-4699-0

15. Stackhouse C, Shewokis PA, Pierce SR, Smith B, McCarthy J, Tucker C. Gait
initiation in children with cerebral palsy. Gait & Posture. 2007;26(2):301-308.
doi:10.1016/j.gaitpost.2006.09.076

16. Tomita H, Fukaya Y, Honma S, Ueda T, Yamamoto Y, Shionoya K. Anticipatory

postural muscle activity associated with bilateral arm flexion while standing in
individuals with spastic diplegic cerebral palsy: A pilot study. Neuroscience Letters.
2010;479(2):166-170. doi:10.1016/j.neulet.2010.05.059

17. Vieira MF, Sacco I de CN, Nora FG da SA, Rosenbaum D, Lobo da Costa PH.
Footwear and Foam Surface Alter Gait Initiation of Typical Subjects. Hug F, ed.
PLoS ONE. 2015;10(8):e0135821. doi:10.1371/journal.pone.0135821