Gait & Posture 103 (2023) 1–5

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Gait & Posture

journal homepage: www.elsevier.com/locate/gaitpost

Single-leg vertical jumping in young adults with spastic cerebral palsy

Meta N. Eek a, *, Jesper Augustsson b, Roland Zügner c, Roy Tranberg c
a
Department of Health and Rehabilitation, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
b
Department of Sport Science at the Faculty of Social Sciences, Linnaeus University, Kalmar, Sweden
c
Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden

A R T I C L E I N F O A B S T R A C T

Keywords: Background: Maximum-strength tests are commonly used to detect muscle weakness in persons with cerebral
Cerebral palsy palsy (CP). Tests of explosive strength (power) in the lower extremities, such as vertical jump tests, are more
Vertical jump uncommon but might supplement maximum-strength testing by providing additional information about motor
Muscle power
function.
Research question: Is it feasible and useful to measure single-leg vertical jumping in young adults with CP?
Methods: Eleven persons with spastic CP (18–30 years), able to walk without support, were compared with a
reference group. Jump height and power generation in jumping were measured using a 3D motion-analysis
system and force plates. Maximum strength in plantarflexors was measured on the same occasion. Data were
analysed using non-parametric statistics.
Results: Jump height was significantly greater in the reference group than in the group with CP, both relative to
the less-involved leg of the participants with CP (p = .007) and relative to their more-involved leg (p < .001). In
the group with CP, jump height was twice as great for the less-involved leg than for the more-involved leg (p =
.008). Power generation at the hip joint was similar between the groups but differed for the knee and ankle joints
(p = .001–.033). In the reference group, most of the power was generated at the ankle joint, while the hip was the
dominant power generator for the more-involved leg in the group with CP.
Muscle strength in the group with CP showed a high correlation with jump height (rho = .745, p < .001) and
power generation at the ankle (rho = .780, p = .001).
Significance: The single-leg vertical jump test proved capable of measuring jump height and power generation in
participants with CP. It also identified explosive muscle weakness both relative to a reference group and between
legs. Hence the jump test may provide information additional to common tests of maximal muscle strength in
persons with CP.

1. Background
Cerebral palsy (CP) is a lifelong condition affecting motor ability. It is
a permanent injury inflicted upon an immature brain, but its symptoms
may change over time [1]. The typical pattern of motor ability is an
improvement until the age of seven, followed by a plateau phase and a
risk of deterioration as an adult [2–4]. CP affects approximately 2 in
1000 live-born children in the Western world [5]. It is divided into three
sub-types – spastic, dyskinetic and ataxic, where the spastic type is the
most common (80 %). The spastic type is subdivided into unilateral
spastic CP (USCP), where only one side of the body is involved, and
bilateral spastic CP (BSCP), where both sides are involved. However,
persons with a diagnosis of unilateral CP many times show symptoms
from the opposite side and in persons with BSCP functional impairment
can be either symmetrical or predominant on one side [1]. CP severity
can be classified using the Gross Motor Function Classification System
(GMFCS) [6], a five-level system where levels I–II correspond to the
ability to walk without support. For persons at levels I–II, motor prob­
lems typically manifest themselves as slow walking speed and diffi­
culties mastering uneven terrain and obstacles, which can affect daily
activities.
There may be several reasons for those motor problems, including
increased muscle tone, impaired motor control and muscle weakness
[7], all of which can make it difficult to perform rapid movements. It has
been shown that muscle weakness is common and correlates with
walking ability [8,9]. This weakness is often the most pronounced in the

* Correspondence to: Institute of Neuroscience and Physiology, P.B. 430, SE-405 30 Gothenburg, Sweden.
E-mail address: meta.nystrom.eek@gu.se (M.N. Eek).

https://doi.org/10.1016/j.gaitpost.2023.04.013
Received 17 January 2022; Received in revised form 10 April 2023; Accepted 13 April 2023
Available online 14 April 2023
0966-6362/© 2023 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
M.N. Eek et al. Gait & Posture 103 (2023) 1–5

plantar flexors [9,10]. Although the ability to activate muscles fast and dislodged a particular test weight [22].
make rapid movements (explosive strength, or the ability to produce Muscle tone assessment was made in supine position for the plantar
high power quickly) could be considered at least as important as flexors, hamstring muscles and hip adductors using the modified Ash­
maximum muscle strength for overall motor function, it is more com­ worth scale [23].
mon to measure the latter than the former in persons with CP [9]. In the Passive range of motion (ROM) was measured in the hip, knee and
sports world, explosive strength is considered to be the most important ankle joints using a plastic goniometer.
factor determining performance [11]. And even in everyday activities, Muscle strength, muscle tone and ROM was tested in participants
much muscle activity is short and rapid. For example, it usually takes with CP only.
about one second to take a step – and this involves eight different phases
with distinctly different muscle activation [12]. 1.3. Statistical methods
The vertical jump test is a method for measuring rapid movements
and explosive strength in the lower extremities. The height of a vertical As the groups were small and some variables were not normally
jump is considered one of the most important indicators of athletic distributed, data were analysed using non-parametric methods: the
performance [13], and a significant correlation between muscle strength Mann–Whitney U-test for comparisons between groups and Spearman’s
and jump height has been noted in athletes [14–16]. However, there are rho for correlations. The correlations found were graded as < 0.3 =
only a few studies of jump strength that include persons with CP – negligible, 0.3–0.5 = low, 0.5–0.7 = moderate, 0.7–0.9 = high and >
athletes [17–19] and children [20]. 0.90 = very high [24]. The level of significance was set to p < 0.05.
The primary purpose of the present study was to measure rapid Analyses were performed using IBM SPSS Statistics version 26 (IBM
movement in terms of a single-leg vertical jump in young adults with SPSS New York, NY, United States).
spastic CP affected by increased muscle tone and muscle weakness in the
legs, compared with an age-matched reference sample. A second aim 2. Results
was to investigate the correlation between maximum muscle strength
and jump height in persons with CP. Eleven persons with spastic CP aged 18–30 years were recruited. Ten
of them has USCP and one had BSCP. There were five women and six
1.1. Participants men. Ten were classified at GMFCS level I and one at level II. One
participant had a subtalar fusion in the more-involved leg; that leg was
Potential participants were identified through the CP register of excluded from testing. Data on the participants are presented in Table 1.
Western Sweden [21] and invited by means of a letter and a telephone Jumping data were compared with those of a reference group consisting
call. Inclusion criteria were a diagnosis of spastic CP (USCP or BSCP), of ten persons in the same age range. There were no differences between
age 18–30 years, GMFCS level I–II and the ability to follow instructions. the groups regarding age, height or weight (p = .595–.731).
The members of a reference group with volunteers in the same age In the group with CP, increased muscle tone was found for the
range, with no known conditions affecting jumping performance, were plantar flexors in all participants’ more-involved leg and in nine par­
recruited through the staff at the gait laboratory. All participants gave ticipants’ less-involved leg, ranging from a grade of 2 in one participant
their written consent to participate after receiving oral and written over 1 + in five to 1 in five participants. For the hamstrings, muscle tone
information. was increased in six participants on the more-involved side and in two
The study was approved by the Central Ethical Review Board at the on the less-involved side, all with a grading of 1 or 1 +. There were no
University of Gothenburg, Sweden; Ref. nos. 975-12 2013-03-14 and signs of increased muscle tone in the hip-adductor muscles. In regards to
153-16 2016-08-04. the ROM, it was considered limited for the plantar flexors in six par­
ticipants, while seven participants had a knee-extension deficit and two
1.2. Methods had a hip-extension deficit. However, those restrictions were small and
did not interfere with the ability to perform the test.
For data acquisition, a 12-camera motion-capture system with a
sampling rate of 240 Hz (Oqus 4, Qualisys AB, Gothenburg, Sweden) was
used together with two force plates (Kistler 9182C, Kistler Group,
Winterthur, Switzerland). Prior to the test, a static recording was made
of each participant standing in an upright position in the calibrated Table 1
volume, aligned to the global coordinate system. All marker data Characteristics of participants, mean (SD). Increased muscle tone and ROM are
collected from the recordings were filtered using a Butterworth 4th indicated as numbers for those exhibiting signs, for the less- and more-involved
order filter with a cut-off frequency of 6 Hz. Visual 3D™ software (C- leg, respectively.
Motion, Inc., Germantown, MD, United States) was used for calculations Reference CP
of kinematic and kinetic variables. Women/men 5/5 5/6
Jump assessment was made on the basis of a single-leg vertical jump
Age 25.2 25.8 (2.88)
where jump height was recorded along with power generation at the (3.57)
hip, knee and ankle joints. The participants were instructed to use the Height, cm 172 (9.07) 174 (13.6)
jump technique they preferred, swinging their arms if they so desired, Weight, kg 70.1 74.0 (19.1)
and were given an opportunity to practise before the assessment. Three (13.6)
Less-involved leg n More-involved leg n
attempts were captured for each leg and the highest jump was selected = 11 = 10
for analysis. Jump height was calculated as the difference between the Increased muscle
position of the pelvic segment in the static recording and at the maximal tone
height in the jump. Jump height was normalised to body height, and Plantar flexors 9 10
Hamstrings 2 6
power generated was normalised to body weight.
ROM
Maximal strength in plantar flexors was measured using a standing Hip-extensor 2 2
calf-raise machine with a stack of 5 kg plates. Tests were performed deficit
unilaterally, with left and right sides in random order. An attempt was Knee-extensor 2 7
deemed successful when a rope attached to a free 2.5-kg plate fell out of deficit
Ankle dorsiflexion 1 6
the weight stack when the participant performed a muscle action that

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M.N. Eek et al. Gait & Posture 103 (2023) 1–5

2.1. Jump height and peak power generation legs), respectively. The patterns found differed. In the reference group,
jump power correlated positively with peak hip power (rho = 498,
There was a variation in body height and weight in the groups, and to p = .026) and with peak knee power (rho = .726, p < .001). In the
make data more comparable we normalised jump height to body height group with CP, jump height correlated positively with peak knee power
and power generation to body weight. Two participants with CP were (rho=.688, p = .003) and with peak ankle power (rho = .818, p < .001).
not able to jump on their more-involved leg. Comparison of normalised
values between men and women showed that values were higher for 2.2. Muscle strength
men in the reference group for jump height and for power generation at
the hip and knee joints (jump height: p = .019; hip power: p = .001; knee Muscle strength in the plantar flexors was assessed using a standing
power: p < .001; ankle power: p = .174) but that there were no gender calf-raise machine in 21 legs in the group with CP. For three legs, the
differences in the group with CP (jump height: p = .440; hip power: p = maximum load for the machine (135 kg) was reached; that value was
.396; knee power: p = .777; ankle power: p = .692). As both groups were used in analyses. The mean value was 112 kg (SD = 30) for the less-
small and did not differ with regard to age, height and weight, further involved leg and 76 kg (SD = 36) for the more-involved leg; that dif­
comparisons were made between the full groups including both men and ference is statistically significant (p = .009). Muscle strength was found
women. Data on jump height and peak power generation are presented to have a high correlation with normalised jump height (n = 20,
in Table 2 and Fig. 1. rho = .745, p < .001) and peak generating power in the ankle (n = 16,
Jump height was significantly greater in the reference group than for rho = .780, p = .001), and a moderate correlation with peak generating
both the less-involved and the more-involved leg in the CP group, and in power in the knee (n = 16, rho = .693, p = .003).
the group with CP there was a statistically significant difference between
the less-involved and the more-involved leg, with jump height twice as 3. Discussion
great for the less-involved leg (p = .008). There was a large variation in
jump height in the less-involved leg in participants with CP, with one To our knowledge, this is the first study of single-leg vertical jumping
participant reaching the top quartile of the reference group. ability in young adults with CP using a 3D motion-capture system
Kinetic data was only available in 16 legs in the group with CP, due synchronised with force plates. The results showed that it was feasible to
to technical problems with the force plates. There was no difference in measure jumping with this type of measurement system. Further, jump
peak power generation between the groups at the hip joint, but it was height and power generation at the knee and ankle joints were signifi­
significantly lower at the knee and ankle joints in the group with CP. cantly lower in the group with CP, for both the less-involved and the
There was also a statistically significant difference between the less- and more-involved leg, than in the reference group, and there was also a
more-involved sides at the knee and ankle joints in the group with CP difference between the less-involved and the more-involved leg in the
(p = .028). The combination of similar hip-joint values and different group with CP. Finally, in the group with CP, plantar flexor weakness
knee- and ankle-joint values yielded different patterns of power gener­ correlated with a reduced jump height and reduced power generation at
ation in terms of each joint’s contribution to total generating power; see the ankle and knee joints.
Table 3 and Fig. 1. In the reference group, most of the power was In the present study, ten out of eleven participants with CP were
generated at the ankle joint, followed by the knee and hip joints. The diagnosed as having the unilateral subtype. Even so, a difference in
participants with CP had fairly equal values for all joints in the less- jumping ability compared with the reference group was found not only
involved leg whereas the hip joint was the dominant power generator for the more-involved leg but also for the less-involved one. In addition,
in the more-involved leg. the clinical examination identified increased muscle tone and a
Correlations between jump height and peak power generation were decreased ROM in the less-involved leg as well. Both of these findings
calculated in the group with CP (16 legs) and the reference group (20 underline the fact that persons diagnosed with unilateral CP may well
have motor involvement on both sides [1], which is something you need
to be aware of in clinical practice, and thoroughly test both sides. The
Table 2 variation in the amount of difference between legs in the individual
Data on single-leg vertical jump height and power generation at the hip, knee participant may be large.
and ankle joints. Jump height is presented both as measured and as normalised The calf-raise machine used in this study did not have sufficient
to body height. Median values and inter-quartile ranges (IQRs) are given. Sta­ weights to measure muscle strength in the reference group, and with a
tistically significant differences are in boldface. For the group with CP, “less” ceiling effect for the less-involved leg in the group with CP. Thus, it was
refers to the less-involved leg and “more” to the more-involved leg. not possible to assess if muscle strength was within normal ranges in the
Reference CP Comparison Ref- group with CP. Muscle strength was found to have a high correlation
CP with jump height and peak generating power in the ankle. There was no
Median Median p values
(IQR) (IQR)
difference in power generation at the hip joint between groups, indi­
cating that muscle strength at this level was not affected. As persons with
Jump height, cm n = 20 legs less: n = 11
CP often have both muscle weakness [9] and difficulties with fast
more: n = 9
30.4 (8.5) less 21.5 (8.3) .007 movements, jumping and testing of maximal muscle strength may both
more 10.5 (5.0) < .001 be valuable to test as supplementary aspects of muscle performance.
Normalised to body height In many sports, athletes aim to increase their jumping performance,
17.4 (4.8) less 11.2 (5.1) .007 which is considered a key factor for athletic improvement [25]. Various
more 5.7 (2.9) < .001
Power generation, n = 20 n=8
jump tests are used to evaluate muscular power and functional perfor­
W/kg mance in athletes, to spot talents and to monitor the impact of different
Hip training and rehabilitation interventions [26,27]. Jumping could also be
7.66 (4.17) less 7.33 (4.35) .839 appropriate as exercise for persons with CP, especially considering that
more 7.45 (3.20) .760
it can be performed without special equipment or premises and is also
Knee
10.44 (4.63) less 7.01 (3.10) .025 time efficient. In this study, jump height was measured using 3D
more 3.73 (3.02) < .001 motion-analysis, which is an expensive system rarely used outside the
Ankle laboratory setting. There exist, however, several more clinician-friendly
12.60 (5.39) less 9.55 (4.26) .033 methods that reliably measure jump ability at a relatively low cost, such
more 5.55 (3.31) < .001
as for example contact mats.

3
M.N. Eek et al.
Fig. 1. Box plots of single-leg vertical jump height and peak generating power in the reference group and in the less- and more-involved leg, respectively, in the
group with CP. Jump height is normalised to body height and peak generating power is normalised to body weight.
Table 3
Contribution of each joint as a percentage of total generating power for a single-
leg vertical jump, mean (SD).
Ref CP less CP more
n = 10 n=8 n=8
Hip % 24.2 (5.3) 30.5 (8.0) 48.1 (18.3)
Knee % 33.5 (6.2) 30.4 (4.5) 22.9 (10.7)
Ankle % 42.3 (8.7) 39.1 (5.4) 29.1 (10.3)
Two-leg jumping measured using a force plate has been reported to
yield a reliable measure in football players with CP [17]. However, we
found no directly comparable studies on single-leg jumping. A review of
119 articles on jump testing in adolescents reports a vast variety of
methods used in terms of both jumping technique and measurement
devices, the conclusion drawn being that there is no consensus today
regarding how to perform a jump test – including as to whether par­
ticipants should be allowed to swing their arms freely or should perform
the jump with their hands on their hips [28]. However, persons with CP
often find it difficult to co-ordinate a jump with their hands on their hips,
which strongly affects overall jumping ability. Further, in everyday life
it is rare that you have to jump with your hands on your hips. For this
reason, we instructed the present participants to try to jump as high as
possible using the jumping technique of their choice.
Two studies of single-leg vertical jumping in healthy adults found
jump heights that were lower than those of the reference group in the
present study. In those studies, jump height was calculated on the basis
of flight time and body weight, and arm swinging was not permitted [29,
30]. A third study, using 3D motion analysis and force-plate measure­
ments, presented data from single-leg vertical jumps performed with
hands-on-hips by males engaging habitually in sports [31]. Its results
were comparable to those of the present study regarding the fact that
peak power was generated at the ankle joint, but with values somewhat
higher. That the hip joint – rather than the ankle joint, as in the reference
group and in the above-mentioned study – was found to be the main
power generator in single-leg jumping by participants with CP may be
due to the fact that, as distal-muscle weakness is common in persons
with spastic CP, the hip joint, with better rapid motor control, may step
in as the main power generator [9,32]. A similar shift to the hip joint as
the main power generator has also been reported with regard to the gait
of children with hemiplegic CP [33]. The clinical implications include
the importance of a thorough examination and, subsequently, to focus
the training based on the findings (e.g., training of stability/coordina­
tion, maximal muscle strength and/or explosive capacity). For example,
in gait the hip joint needs to act more as a stabiliser to the pelvis and
trunk, enabling the plantar flexors to act as the main power generators.
4
Gait & Posture 103 (2023) 1–5
Future studies with more subjects are needed to improve our un­
derstanding of explosive motor control, such as e.g. the relation to gait
and timing of peak power generation.
3.1. Limitations
The present study has some limitations that may affect its general­
isability. Above all, the sample used is rather small and includes both
men and women. Previous studies have reported differences in jumping
performance between healthy males and females. We have tried to
compensate for this by having groups that are similar in gender distri­
bution, age and weight, and by normalising values to body height and
weight. Comparison of male and female jumping in the present study
showed that there was no difference in the group with CP. In fact, muscle
weakness, increased muscle tone and limitations in ROM probably had a
greater impact on performance than gender.
Declaration of Competing Interest
The authors attest that they have no conflicts of interest to disclose.
Acknowledgements
This work was supported by grants from the Norrbacka-Eugenia
Foundation, the Promobilia Foundation, the Neuro Foundation and the
Royal Wedding Foundation. The funding sources had no involvement in
any process of the research.
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