Modelling Gait Abnormalities and Bone Deformities in Children With Cerebral Palsy

Cerebral palsy (CP) is a neuromuscular disorder that affects the motor control of muscles. CP children exhibit abnormal walking patterns and frequently develop lower limb, long bone deformities. To improve functionality and guide orthopaedic treatments effectively, it is critical to elucidate the relationship existing between bone morphology and movement of the lower limbs CP children.

The hypothesis of this study is that gait abnormalities result in bone deformities. The investigation of this complex relationship represents the core of this thesis.

The examination of magnetic resonance images and gait analysis of healthy and CP children showed different development in femoral and tibial morphology and varied gait characteristics between them. Similarly, different correlations between bone morphology and gait characteristics resulted in healthy and CP children.

Gait characteristics also varied between CP children. An objective and quantitative graphical classification method of CP gait patterns was developed. This classified the CP children in overlapping clusters according to their gait patterns, confirming the presence of multiple gait abnormalities on the same lower limb for CP children.

With the intention to define the effect of the walking characteristics on the bone structure, femoral muscle and hip contact forces in healthy and CP children with different walking strategies were estimated by using inverse dynamic analysis. The different gait styles resulted in different loadings on the developing femur bone. These constituted the loading conditions for bone growth analysis.

A three-dimensional finite element model for femoral growth was developed and mechanobiological theories applied in order to predict femur changes over time in healthy and CP children. The models predicted higher femoral anteversion and neck-shaft angle formation in children with CP, emphasizing how different gait characteristics can influence bone morphology.

This information has potential to explain and eventually prevent or treat the development of bone deformities in CP children.

Year	Entry
2001	Anderson FC, Pandy MG. Static and dynamic optimization solutions for gait are practically equivalent. J Biomech. February 2001;34(2):153-161.
1996	Piazza SJ, Delp SL. The influence of muscles on knee flexion during the swing phase of gait. J Biomech. June 1996;29(6):723-733.
1990	Komi PV. Relevance of in vivo force measurements to human biomechanics. J Biomech. 1990;23(suppl 1):23-34.
2001	Bergmann G, Deuretzbacher G, Heller M, Graichen F, Rohlmann A, Strauss J, Duda GN. Hip contact forces and gait patterns from routine activities. J Biomech. July 2001;34(7):859-871.
1982	Procter P, Paul P J. Ankle joint biomechanics. J Biomech. 1982;15(9):627-634.
2008	Hicks JL, Schwartz MH, Arnold AS, Delp SL. Crouched postures reduce the capacity of muscles to extend the hip and knee during the single-limb stance phase of gait. J Biomech. 2008;41(5):960-967.
1973	Seireg A, Arvikar RJ. A mathematical model for evaluation of forces in lower extremeties of the musculo-skeletal system. J Biomech. May 1973;6(3):313-326.
2005	Arnold AS, Anderson FC, Pandy MG, Delp SL. Muscular contributions to hip and knee extension during the single limb stance phase of normal gait: a framework for investigating the causes of crouch gait. J Biomech. November 2005;38(11):2181-2189.
1970	Morrison JB. The mechanics of the knee joint in relation to normal walking. J Biomech. January 1970;3(1):51-61.
2004	Goldberg SR, Anderson FC, Pandy MG, Delp SL. Muscles that influence knee flexion velocity in double support: implications for stiff-knee gait. J Biomech. August 2004;37(8):1189-1196.
2001	Neptune RR, Kautz SA, Zajac FE. Contributions of the individual ankle plantar flexors to support, forward progression and swing initiation during walking. J Biomech. November 2001;34(11):1387-1398.
1997	Glitsch U, Baumann W. The three-dimensional determination of internal loads in the lower extremity. J Biomech. November–December 1997;30(11-12):1123-1131.
2002	Wu G, Siegler S, Allard P, Kirtley C, Leardini A, Rosenbaum D, Whittle M, D'Lima DD, Cristofolini L, Witte H, Schmid O, Stokes I. ISB recommendation on definitions of joint coordinate system of various joints for the reporting of human joint motion, I: ankle, hip, and spine. J Biomech. 2002;35(4):543-548.
1988	Carter DR, Wong M. Mechanical stresses and endochondral ossification in the chondroepiphysis. J Orthop Res. January 1988;6(1):148-154.
1997	Pedersen DR, Brand RA, Davy DT. Pelvic muscle and acetabular contact forces during gait. J Biomech. September 1997;30(9):959-965.
1982	Brand RA, Crowninshield RD, Wittstock CE, Pedersen DR, Clark CR, van Krieken FM. A model of lower extremity muscular anatomy. J Biomech Eng. November 1982;104(4):304-310.
1978	Crowninshield RD. Use of optimization techniques to predict muscle forces. J Biomech Eng. May 1978;100(2):88-92.
1984	Röhrle H, Scholten R, Sigolotto C, Sollbach W, Kellner H. Joint forces in the human pelvis-leg skeleton during walking. J Biomech. 1984;17(6):409-424.
1977	Carter DR, Hayes WC. The compressive behavior of bone as a two-phase porous structure. J Bone Joint Surg. 1977;59A(7):954-962.
1984	Armstrong CG, Lai WM, Mow VC. An analysis of the unconfined compression of articular cartilage. J Biomech Eng. May 1984;106(2):165-173.
1975	Seireg A, Arvikar RJ. The prediction of muscular load sharing and joint forces in the lower extremities during walking. J Biomech. March 1975;8(2):89-102.
1981	Patriarco AG, Mann RW, Simon SR, Mansour JM. An evaluation of the approaches of optimization models in the prediction of muscle forces during human gait. J Biomech. 1981;14(8):513-525.
2006	Miyanishi K, Trindade MCD, Lindsey DP, Beaupré GS, Carter DR, Goodman SB, Schurman DJ, Smith RL. Effects of hydrostatic pressure and transforming growth factor-β3 on adult human mesenchymal stem cell chondrogenesis in vitro. Tissue Eng. June 2006;12(6):1419-1428.
1998	Soltz MA, Ateshian GA. Experimental verification and theoretical prediction of cartilage interstitial fluid pressurization at an impermeable contact interface in confined compression. J Biomech. October 1998;31(10):927-934.
1984	Dul J, Townsend MA, Shiavi R, Johnson GE. Muscular synergism, I: on criteria for load sharing between synergistic muscles. J Biomech. 1984;17(8):663-673.
1989	Yamaguchi GT, Zajac FE. A planar model of the knee joint to characterize the knee extensor mechanism. J Biomech. 1989;22(1):1-10.
1980	Mow VC, Kuei SC, Lai WM, Armstrong CG. Biphasic creep and stress relaxation of articular cartilage in compression: theory and experiments. J Biomech Eng. February 1980;102(1):73-84.
1996	Carter DR, Van der Meulen MCH, Beaupré GS. Mechanical factors in bone growth and development. Bone. January 1996;18(1)(suppl 1):S5-S10.
1978	Pedotti A, Krishnan VV, Stark L. Optimization of muscle-force sequencing in human locomotion. Math Biosci. 1978;38(1-2):57-76.
1998	Duda GN, Heller M, Albinger J, Schulz O, Schneider E, Claes L. Influence of muscle forces on femoral strain distribution. J Biomech. September 1998;31(9):841-846.
1988	Carter DR, Wong M. The role of mechanical loading histories in the development of diarthrodial joints. J Orthop Res. 1988;6(6):804-816.
1986	Hodge WA, Fijan RS, Carlson KL, Burgess RG, Harris WH, Mann RW. Contact pressures in the human hip joint measured in vivo. Proc Natl Acad Sci USA. May 1986;83(9):2879-2883.
1990	Wong M, Carter DR. A theoretical model of endochondral ossification and bone architectural construction in long bone ontogeny. Anat Embryol. July 1990;181(6):523-532.
2003	Zajac FE, Neptune RR, Kautz SA. Biomechanics and muscle coordination of human walking, II: lessons from dynamical simulations and clinical implications. Gait Post. February 2003;17(1):1-17.
1996	Lloyd DG, Buchanan TS. A model of load sharing between muscles and soft tissues at the human knee during static tasks. J Biomech Eng. August 1996;118(3):367-376.
1997	Duda GN, Schneider E, Chao EY. Internal forces and moments in the femur during walking. J Biomech. September 1997;30(9):933-941.
1978	Hardt DE. Determining muscle forces in the leg during normal human walking: an application and evaluation of optimization methods. J Biomech Eng. May 1978;100(2):72-78.
2006	Thelen DG, Anderson FC. Using computed muscle control to generate forward dynamic simulations of human walking from experimental data. J Biomech. 2006;39(6):1107-1115.
1987	Carter DR, Orr TE, Fyhrie DP, Schurmant DJ. Influences of mechanical stress on prenatal and postnatal skeletal development. Clin Orthop Relat Res. June 1987;219:237-250.
1981	Crowninshield RD, Brand RA. A physiologically based criterion of muscle force prediction in locomotion. J Biomech. 1981;14(11):793-801.
1984	Dul J, Johnson GE, Shiavi R, Townsend MA. Muscular synergism, II: a minimum-fatigue criterion for load sharing between synergistic muscles. J Biomech. 1984;17(9):675-684.
1995	Collins JJ. The redundant nature of locomotor optimization laws. J Biomech. March 1995;28(3):251-267.
1987	Davy DT, Audu ML. A dynamic optimization technique for predicting muscle forces in the swing phase of gait. J Biomech. 1987;20(2):187-201.
1990	Delp SL, Loan JP, Hoy MG, Zajac FE, Topp EL, Rosen JM. An interactive graphics-based model of the lower extremity to study orthopaedic surgical procedures. IEEE Trans Biomed Eng. 1990;37(8):757-767.
1993	Bergmann G, Graichen F, Rohlmann A. Hip joint loading during walking and running, measured in two patients. J Biomech. August 1993;26(8):969-990.
1994	Delp SL, Ringwelski DA, Carroll NC. Transfer of the rectus femoris: effects of transfer site on moment arms about the knee and hip. J Biomech. October 1994;27(10):1201-1211.
2002	Shefelbine SJ. Mechanical Regulation of Bone Growth Fronts and Growth Plates [PhD thesis]. Stanford University; June 2002.

Year

Entry

2001

Anderson FC, Pandy MG. Static and dynamic optimization solutions for gait are practically equivalent. J Biomech. February 2001;34(2):153-161.

1996

Piazza SJ, Delp SL. The influence of muscles on knee flexion during the swing phase of gait. J Biomech. June 1996;29(6):723-733.

1990

Komi PV. Relevance of in vivo force measurements to human biomechanics. J Biomech. 1990;23(suppl 1):23-34.

2001

Bergmann G, Deuretzbacher G, Heller M, Graichen F, Rohlmann A, Strauss J, Duda GN. Hip contact forces and gait patterns from routine activities. J Biomech. July 2001;34(7):859-871.

1982

Procter P, Paul P J. Ankle joint biomechanics. J Biomech. 1982;15(9):627-634.

2008

Hicks JL, Schwartz MH, Arnold AS, Delp SL. Crouched postures reduce the capacity of muscles to extend the hip and knee during the single-limb stance phase of gait. J Biomech. 2008;41(5):960-967.

1973

Seireg A, Arvikar RJ. A mathematical model for evaluation of forces in lower extremeties of the musculo-skeletal system. J Biomech. May 1973;6(3):313-326.

2005

Arnold AS, Anderson FC, Pandy MG, Delp SL. Muscular contributions to hip and knee extension during the single limb stance phase of normal gait: a framework for investigating the causes of crouch gait. J Biomech. November 2005;38(11):2181-2189.

1970

Morrison JB. The mechanics of the knee joint in relation to normal walking. J Biomech. January 1970;3(1):51-61.

2004

Goldberg SR, Anderson FC, Pandy MG, Delp SL. Muscles that influence knee flexion velocity in double support: implications for stiff-knee gait. J Biomech. August 2004;37(8):1189-1196.

2001

Neptune RR, Kautz SA, Zajac FE. Contributions of the individual ankle plantar flexors to support, forward progression and swing initiation during walking. J Biomech. November 2001;34(11):1387-1398.

1997

Glitsch U, Baumann W. The three-dimensional determination of internal loads in the lower extremity. J Biomech. November–December 1997;30(11-12):1123-1131.

2002

Wu G, Siegler S, Allard P, Kirtley C, Leardini A, Rosenbaum D, Whittle M, D'Lima DD, Cristofolini L, Witte H, Schmid O, Stokes I. ISB recommendation on definitions of joint coordinate system of various joints for the reporting of human joint motion, I: ankle, hip, and spine. J Biomech. 2002;35(4):543-548.

1988

Carter DR, Wong M. Mechanical stresses and endochondral ossification in the chondroepiphysis. J Orthop Res. January 1988;6(1):148-154.

1997

Pedersen DR, Brand RA, Davy DT. Pelvic muscle and acetabular contact forces during gait. J Biomech. September 1997;30(9):959-965.

1982

Brand RA, Crowninshield RD, Wittstock CE, Pedersen DR, Clark CR, van Krieken FM. A model of lower extremity muscular anatomy. J Biomech Eng. November 1982;104(4):304-310.

1978

Crowninshield RD. Use of optimization techniques to predict muscle forces. J Biomech Eng. May 1978;100(2):88-92.

1984

Röhrle H, Scholten R, Sigolotto C, Sollbach W, Kellner H. Joint forces in the human pelvis-leg skeleton during walking. J Biomech. 1984;17(6):409-424.

1977

Carter DR, Hayes WC. The compressive behavior of bone as a two-phase porous structure. J Bone Joint Surg. 1977;59A(7):954-962.

1984

Armstrong CG, Lai WM, Mow VC. An analysis of the unconfined compression of articular cartilage. J Biomech Eng. May 1984;106(2):165-173.

1975

Seireg A, Arvikar RJ. The prediction of muscular load sharing and joint forces in the lower extremities during walking. J Biomech. March 1975;8(2):89-102.

1981

Patriarco AG, Mann RW, Simon SR, Mansour JM. An evaluation of the approaches of optimization models in the prediction of muscle forces during human gait. J Biomech. 1981;14(8):513-525.

2006

Miyanishi K, Trindade MCD, Lindsey DP, Beaupré GS, Carter DR, Goodman SB, Schurman DJ, Smith RL. Effects of hydrostatic pressure and transforming growth factor-β3 on adult human mesenchymal stem cell chondrogenesis in vitro. Tissue Eng. June 2006;12(6):1419-1428.

1998

Soltz MA, Ateshian GA. Experimental verification and theoretical prediction of cartilage interstitial fluid pressurization at an impermeable contact interface in confined compression. J Biomech. October 1998;31(10):927-934.

1984

Dul J, Townsend MA, Shiavi R, Johnson GE. Muscular synergism, I: on criteria for load sharing between synergistic muscles. J Biomech. 1984;17(8):663-673.

1989

Yamaguchi GT, Zajac FE. A planar model of the knee joint to characterize the knee extensor mechanism. J Biomech. 1989;22(1):1-10.

1980

Mow VC, Kuei SC, Lai WM, Armstrong CG. Biphasic creep and stress relaxation of articular cartilage in compression: theory and experiments. J Biomech Eng. February 1980;102(1):73-84.

1996

Carter DR, Van der Meulen MCH, Beaupré GS. Mechanical factors in bone growth and development. Bone. January 1996;18(1)(suppl 1):S5-S10.

1978

Pedotti A, Krishnan VV, Stark L. Optimization of muscle-force sequencing in human locomotion. Math Biosci. 1978;38(1-2):57-76.

1998

Duda GN, Heller M, Albinger J, Schulz O, Schneider E, Claes L. Influence of muscle forces on femoral strain distribution. J Biomech. September 1998;31(9):841-846.

1988

Carter DR, Wong M. The role of mechanical loading histories in the development of diarthrodial joints. J Orthop Res. 1988;6(6):804-816.

1986

Hodge WA, Fijan RS, Carlson KL, Burgess RG, Harris WH, Mann RW. Contact pressures in the human hip joint measured in vivo. Proc Natl Acad Sci USA. May 1986;83(9):2879-2883.

1990

Wong M, Carter DR. A theoretical model of endochondral ossification and bone architectural construction in long bone ontogeny. Anat Embryol. July 1990;181(6):523-532.

2003

Zajac FE, Neptune RR, Kautz SA. Biomechanics and muscle coordination of human walking, II: lessons from dynamical simulations and clinical implications. Gait Post. February 2003;17(1):1-17.

1996

Lloyd DG, Buchanan TS. A model of load sharing between muscles and soft tissues at the human knee during static tasks. J Biomech Eng. August 1996;118(3):367-376.

1997

Duda GN, Schneider E, Chao EY. Internal forces and moments in the femur during walking. J Biomech. September 1997;30(9):933-941.

1978

Hardt DE. Determining muscle forces in the leg during normal human walking: an application and evaluation of optimization methods. J Biomech Eng. May 1978;100(2):72-78.

2006

Thelen DG, Anderson FC. Using computed muscle control to generate forward dynamic simulations of human walking from experimental data. J Biomech. 2006;39(6):1107-1115.

1987

Carter DR, Orr TE, Fyhrie DP, Schurmant DJ. Influences of mechanical stress on prenatal and postnatal skeletal development. Clin Orthop Relat Res. June 1987;219:237-250.

1981

Crowninshield RD, Brand RA. A physiologically based criterion of muscle force prediction in locomotion. J Biomech. 1981;14(11):793-801.

1984

Dul J, Johnson GE, Shiavi R, Townsend MA. Muscular synergism, II: a minimum-fatigue criterion for load sharing between synergistic muscles. J Biomech. 1984;17(9):675-684.

1995

Collins JJ. The redundant nature of locomotor optimization laws. J Biomech. March 1995;28(3):251-267.

1987

Davy DT, Audu ML. A dynamic optimization technique for predicting muscle forces in the swing phase of gait. J Biomech. 1987;20(2):187-201.

1990

Delp SL, Loan JP, Hoy MG, Zajac FE, Topp EL, Rosen JM. An interactive graphics-based model of the lower extremity to study orthopaedic surgical procedures. IEEE Trans Biomed Eng. 1990;37(8):757-767.

1993

Bergmann G, Graichen F, Rohlmann A. Hip joint loading during walking and running, measured in two patients. J Biomech. August 1993;26(8):969-990.

1994

Delp SL, Ringwelski DA, Carroll NC. Transfer of the rectus femoris: effects of transfer site on moment arms about the knee and hip. J Biomech. October 1994;27(10):1201-1211.

2002

Shefelbine SJ. Mechanical Regulation of Bone Growth Fronts and Growth Plates [PhD thesis]. Stanford University; June 2002.

Year	Entry
2023	Sadeghian SM, Lewis CL, Shefelbine SJ. can pelvic tilt cause cam morphology? a computational model of proximal femur development mechanobiology. J Biomech. August 2023;157:111707.
2019	Merritt LE. Forelimb Unloading Impairs Glenohumeral Bone Development in Growing Rats [Master's thesis]. North Carolina State University; 2019.

Year

Entry

2023

Sadeghian SM, Lewis CL, Shefelbine SJ. can pelvic tilt cause cam morphology? a computational model of proximal femur development mechanobiology. J Biomech. August 2023;157:111707.

2019

Merritt LE. Forelimb Unloading Impairs Glenohumeral Bone Development in Growing Rats [Master's thesis]. North Carolina State University; 2019.