Ground reaction forces and control of centre of mass motion during gait : implications for intervention in cerebral palsy
A question which has arisen clinically is the inability to generate adequate vertical force during the second half of the stance phase in cerebral palsy gait. Neither the mechanism nor the consequences of this inability are understood. It implies that the centre of mass (CoM) is inadequately supported with the potential for collapse of the limb in single support. Normal walking is achieved by the sophisticated control of the neuromuscular and skeletal systems with the purpose of advancing the body with minimum energy expenditure. These control systems are affected by damage to the brain in children with cerebral palsy and result in a multitude of problems which affect their gait making it difficult to determine cause and effect. This study aimed to improve the understanding of the ground reaction forces and motion of the CoM. Objectives: The principle objectives were to analyse the supporting forces of the CoM during gait in normal adults, children, and children with diplegic cerebral palsy, by examining the inter-relationships of the vertical and horizontal components of the ground reaction force with the vertical component of motion and temporal parameters of the CoM. Design: The study of adults and children’s data was both prospective and retrospective. The study of cerebral palsy data was retrospective. A new software programme was developed to extract specific gait parameters from both normal and cerebral palsy gait patterns. A novel approach to analyse the interaction of motion and force data in normal walking was subsequently developed. Background: In normal gait, the vertical component of the ground reaction force forms a double hump where both humps are equal in magnitude and greater than body weight. It is widely accepted that the first hump (FZ1) is associated with deceleration of the downward motion of the CoM as the foot “impacts” the ground and the second hump (FZ2) is the action of “push off” as the body is propelled upwards and forwards. Walking requires force contributions from both legs but traditionally computed three-dimensional (3D) gait analysis packages presents the force data with both legs superimposed, rather than sequentially in time. This gives the impression that there is no period of overlap of the forces and thus ignores the critically important period where the CoM is transferred from one leg to the other during double support. By changing the presentation to view it sequentially in time, plus superimposing the CoM kinematics onto the same scale allowed their interactions to be observed and objectively measured. Methods: The kinematic and kinetic data of 53 normal adults, 33 normal children, and 57 diplegic cerebral palsy children were acquired for the study. A new gait cycle, based on CoM motion, was defined to allow analysis of the forces in relation to CoM motion. Software was developed to extract specified parameters from the gait data. Impulse calculations over specific periods (based on the vertical motion of the CoM) allowed analysis of the vertical force contribution of each leg to the vertical support of the CoM. Results: The results showed that inadequate generation of vertical force in children with diplegic cerebral palsy was widespread. In approximately 40% of such children there was a reduced ability to generate an adequate FZ2, which resulted in a reduced ability to control of the descent velocity of the CoM. The mean reduction in descent velocity in cerebral palsy was only 54% compared to 86% in adults. Integration of the vertical force and motion of the CoM showed that FZ2 was associated with controlling the descent velocity of the CoM. This reverses the traditionally accepted concept of “impact” and is contrary to the belief that FZ2 is associated with ‘push off’. Conclusions and Relevance: This study emphasises the importance of the role of the supporting leg in the second half of stance. Failure to generate an adequate FZ2, which is currently ignored in clinical practice, should be given priority in patient management. This new knowledge has significant implications from a clinical perspective, not only in diplegic cerebral palsy, but in pathologies such as amputees, spina-bifida, and other neuro-muscular conditions.
Gait, Cerebral palsy, Ground reaction force
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