LEG MOVEMENTS IN THE SUPINE POSITION OF INFANTS WITH SPASTIC DI PLEGlA

Kenji Yokochi Kazuhisa Inukai Akihiko Hosoe Satoshi Shirnabukuro Eiji Kitazurni Kazuo Kodama

Spastic diplegia is a common form of cerebral palsy, especially among preterm infants. It is characterized by bilateral hypertonic involvement, primarily of the lower extremities, and is generally accepted to be caused by periventricular infarction and/or haemorrhage in both hemispheres (Bennett et al. 1981, Veelken et al. 1983). The involvement of the lower limbs affects the development of locomotion (Crothers and Paine 1959, Ingram 1964, Bobath and Bobath 1975).

Diplegic infants have abnormal muscle tonus, primitive reflexes, automatic re- actions and volitional movements (Illingworth 1966; Drillien 1972; Capute 1979; Ellenberg and Nelson 1981; Harris 1987, 1989). However, the problem of accurately diagnosing spastic diplegia during infancy has not yet been fully resolved.

For adult patients with central motor disturbance, especially spasticity, assess- ment of voluntary motor function is part of the neurological assessment (DeJong 1979), and the importance of such assess- ment has been stressed in physical therapy (Twitchell 1951, Brunnstrom 1970).

Differentiation of the spontaneous movements of the lower extremities of diplegic infants from those of normal infants would be useful for detecting the early manifestation of spasticity, and also for diagnosing spastic diplegia in infancy.

In the present study we analysed the leg movements in the supine position of diplegic infants and compared them with those of preterm infants with a good neurodevelopmental outcome.

Material and method Videotape recordings of 49 infants with spastic diplegia (33 male, 16 female) were analysed retrospectively. The children were selected from outpatients attending the National Rehabilitation Centre for Disabled Children from 1981 to 1985, Kagawa Rehabilitation Centre from 1980 to 1983 and Seirei-Mikatabara General Hospital from 1984 to 1988 for problems in motor development: all were less than one year of (corrected) age. Videotape recordings were obtained for all infants visiting the three centres, and those for children who were followed to more than three years of age and who developed spastic diplegia were selected for this study.

Spastic diplegia was diagnosed by the presence of bilateral hypertonic involve- ment of the lower extremities, with lesser involvement of the upper extremities and absence of involuntary movements, and was confirmed at one year of age or more. At three years of age all the children could sit unsupported and could manipulate a small object with each hand, but none could walk stably or go up and down stairs without support.

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The severity of the children's motor disability was ranked according to their locomotion without bracing at three years corrected age. 16 were able to walk without support, 19 walked with support and 14 could not walk, even with support. All had had physical therapy since they were less than one year of age. None had undergone any surgical procedure before three years of age. The children's IQs were 250.

Three children's birthweights were > 25OOg, two were 2000 to 2500g, 19 were 1500 to 1999g,22 were 1000 to 14998 and three were < 1000g. Gestational ages were 237 weeks for three children; for the other 46 they were 1 3 6 weeks.

The diplegic infants, lying supine, were recorded on videotape for two to five minutes on their first visit at three to 11 months corrected age. From these record- ings, spontaneous movements of the lower extremities and movements of the hips and knees > 10" without rotation of the trunk were analysed. Movements of the ankles only were ignored. Continuous movement of the hips and/or knees without a pause of more than one second was regarded as one movement.

The leg movements were grouped according to flexion or extension of the hips and knees, as follows: (1) Simultaneous flexion of the hips and knees (leg flexion)-when the hips were flexed from a position of extension and the knees were flexed simultaneously. (2) Simultaneous extension of the hips and knees (leg extension)-when the hips were extended from a position of flexion and the knees were extended simultaneously. (3) Isolated hip movements-when the knees were kept in a fixed position, either flexed or extended, and the hips moved in any direction. When the leg appeared to move only because of truncal movement, the hips were not assessed as having moved. (4) Isolated knee movements-the hips remained fixed when the knees were flexed or extended. (5) Hip flexion combined with knee extension (leg elevation)-when the hips were flexed and the knees extended simultaneously, with the feet elevated. When the leg apparently moved because

of truncal movement, the hips and knees were not assessed as having moved. (6) Other movements. These movements were assessed for each infant and the movements were described.

The controls were 70 preterm infants with a good neurodevelopmental prognosis, selected from those followed up at the Seirei-Hamamatsu General Hospital in 1989 and 1990 and assessed as having normal development at 18 months corrected age or more. Their birthweights closely matched those of the diplegic infants: three were 2000 to 2500g, 29 were 1500 to 1999g, 33 were 1000 to 1499g and five were c 1000g. Their gestational ages ranged from 27 to 36 weeks. 34 infants had had mechanical ventilation. Bacterial infections occurred in 19. Subependymal haemorrhage occurred in five infants, but ultrasonography showed no penventricular area with abnormal intensity.

Spontaneous movements of the control infants while lying supine were recorded for two or three minutes with a video- camera, with the permission of their mothers. Movements of their lower extremities were analysed in the same way as those of the diplegic infants.

Determination of leg movements in the diplegic and control infants was made independently by two observers (K.Y., K.I.), and there was a 92 per cent rate of agreement.

Results The spontaneous movements of the lower extremities of the diplegic and control infants are summarised in Table I. At the times they were examined, only simul- taneous flexion and extension of the hips and knees were seen in the diplegic infants, with rare isolated hip movements; neither isolated knee movements nor hip flexion combined with knee extension were seen. When the hips and knees were flexed, the hips were more abducted and more externally rotated, and the ankles more dorsiflexed, than when the hips and knees were extended. When the hips and knees were extended, the hips were more adducted and more internally rotated and the ankles more plantar-flexed than when the hips and knees were flexed. In a small number of cases only the hips moved: they

TABLE I Leg movements in supine of 49 diplegic and 70 control infants Qess than one year corrected age)

~

Age N Leg Leg, Hip Knee Leg, (mths) flexion extension movement movement elevation

1

2

3

4

5

6

7

8 9

10 11

Diplegic Control Diplegic Control Diplegic Control Diplegic Control Diplegic Control Diplegic Control Diplegic Control Diplegic Diplegic Diplegic Diplegic

- - - - - 0

0 10 10 10 5 0 0

10 10 10 4 0 0 - - - - -

10 7 10 I 10 7 : ] ; < o . o ~ 2 ! ] ; < o . o ~ !];<0.01

3 3 3 10 10 10 9 4 4

10 10 6 6

10 10 7 7

10 10 5 5 5 5 6 6 6 6

4 10 6

10 I

10 5 5 6 6

0- 8 0

liJp<O*Mi 10 lo 10- 0

0 0 1 0 2 0 1 0

0- 10 0

0 10- 0 0 0 0

** p<O-Ool 10

** p<0-001

Hip movement was seen less frequently in diplegic than in control infants at three to four months (*) (x2 test) and five to seven months (**) (Fischer exact test). Knee movement and leg elevation were seen only in control infants, a significant difference from diplegic infants at three to four months (*) and five to seven months (**) (Fischer exact test).

were flexed, extended, abducted, adducted, or rotated internally or externally.

The control infants showed only simultaneous flexion and extension of the hips and knees and isolated hip move- ments at one and two months of age. Between three and five months of age, some showed isolated hip movements, knee movements, or hip flexion combined with knee extension, other than simul- taneous flexion and extension of the hips and knees. After six months of age, all showed all leg movements.

Isolated hip movements were signifi- cantly less frequently seen i n the diplegic infants than in the control infants between three and four months (p < 0.05, x2 test), and five and seven months @cO-001, Fischer exact test). Isolated knee movements and hip flexion combined with knee extension were seen only in the control group, differing significantly from the diplegic infants at three and four months (pc0-05 and p<O.Ol, Fischer exact test), and at five to seven months ( p < O . O O l and p<O.001, Fischer exact test).

Discussion Leg movements of the diplegic infants were found to be limited in the supine position. Only simultaneous flexion and extension of the hips and knees were seen, with occasional isolated hip movements. Leg elevation (hip flexion and knee exten- sion) and isolated knee movement were seen only in the preterm control infants.

In the control infants, isolated knee movements were seen between three and six months corrected age, and leg elevation between three and five months. In healthy term infants ‘leg lift, extension at knee’ (similar to leg elevation in this study) is known to occur after 15 weeks of age (Hopkins and Prechtl 1984), close to the corrected age at which leg elevation occurred in our control infants. Otherwise, preterm newborn infants are known to have variable postures, and to make many isolated arm or leg movements (Prechtl and Nolte 1984). At less than three months corrected age, leg elevation and isolated knee movements were not seen in the control infants. Developmental changes in spontaneous leg movements

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during early infancy need further study. The significant difference between the

leg movements of the diplegic infants and those of the controls, seen after three months corrected age, is useful for diagnosing spastic diplegia in infancy, in addition to the traditional neurological signs (Illingworth 1966; Drillien 1972; Capute 1979; Ellenberg and Nelson 1981; Harris 1987, 1989). Particularly after five months corrected age, the absence of either leg elevation or isolated knee mo-vements suggests spastic diplegia. However, the leg-movement patterns of infants with central motor disorders other than spastic diplegia have still to be determined.

Simultaneous flexion and extension of the hips and knees, seen mainly in the diplegic infants, was also the main leg movement of the control infants under three months corrected age; this move- ment may be interpreted as primitive or immature. The leg movements of the diplegic infants seemed to be synergistic: when the knees were flexed, the hips were flexed, abducted and externally rotated, and the ankles were dorsiflexed; when the knees were extended, the hips were extended, adducted and internally rotated, and the ankles were plantar-

SUMMARY

flexed. These movement patterns are the same as the flexor and extensor synergy of the lower extremities of hemiplegic adults described by Twitchell (195 1) and Brunnstrom (1970). The gross motor patterns of diplegic children are also partly regarded as synergistic movements (Yokochi et al. 1990). Thus the spastic extremities can be regarded as the cause of the difficulty in release from synergistic movement patterns, even in infancy. Release from synergistic movement patterns must be considered when planning physical therapy programmes for patients with spastic diplegia.

Accepted for publication 22nd May 1991.

Authors’ Appointments *Kenji Yokochi, M.D., Department of Pediatric Neurology, Seirei-Mikatabara General Hospital, Mikatabara 3453, Hamamatsu, Shizuoka 433, Japan. Kazuhisa Inukai, M.D., Department of Pediatrics, Seirei-Hamamatsu General Hospital, Hamamatsu, Shizuoka, Japan. Akihiko Hosoe, M.D., Department of Pediatrics, Kagawa Rehabilitation Center, Takamatsu, Kagawa, Japan. Satoshi Shimabukuro, M.D.; Eiji Kitazumi, M.D.; Kazuo Kodama, M.D.; Department of Pediatrics, National Rehabilitation Center for Disabled Children, Tokyo, Japan.

*Correspondence to first author.

Leg movements in the supine position of 4 9 infants with spastic diplegia (three to 11 months corrected age) were examined. Only simultaneous flexion and extension of the hips and knees were seen, with exceptional isolated hip movements; the simultaneous movements had synergic features. When the knees were flexed, the hips were flexed, abducted and externally rotated, and the ankles were dorsiflexed. When the knees were extended, the hips were extended, adducted and internally rotated and the ankles were plantar-flexed. Hip flexion combined with knee extension (leg elevation) and isolated knee movements were not seen in diplegic infants, but were seen in all control preterm infants with a good prognosis, after five and six months corrected age, respectively. The absence of these movements is a useful diagnostic item for spastic diplegia.

RBSUMB Mouvements des membres in fkrieurs en position dorsale chez Ies nourrissons prksentant une dipkgie spastique Les mouvements des membres infkrieurs en position dorsale ont CtC CtudiCs chez 4 9 nourrissons atteints de diplkgie spastique (ayant de trois B 11 mois d’fige corrigk). Seuls des mouvements spontanks de flexion et d’extension des hanches et des genoux ont ktk observb, avec d’exceptiQnnels mouvements isoKs des hanches; les mouvements simultanh 6taient synergiques. Quand les genoux Ctaient flkhis, les hanches 6taient en flexion, abduction et rotation externe, et les chevilles ktaient en flexion dorsale. Quand les genoux ktaient en extension, les hanches ktaient en extension, adduction et rotation interne, et les chevilles en flexion plantaire. La flexion des hanches a s s o d e ti une extension des genoux (klkvation des membres infkrieurs) et les mouvements isolks des genoux n’ktaient pas observks chez les nourrissons diplkgiques mais existaient chez tous les prkmaturks de bon pronostic, aprbs respectivement six et sept mois d’fige corrigk. L’absense de tels mouvements est un item diagnostique utile vis B vis de la diplkgie spastique.

ZUSAMMENFASSUNG Beinbewegungen in RiickenIage bei Kindern mit spastischer DipIegie Bei 49 Kindern mit spastischer Diplegie (im korrigierten Alter von drei bis 11 Monaten) wurden die

Beinbewegungen in Ruckenlage untersucht. Es wurde nur eine simultane Flexion und Extension der Huft- und Kniegelenke beobachtet, mit ungewohnlichen isolierten Huftbewegungen: die sirnultanen Bewegungen hatten synergistische Merkmale. Wenn die Kniegelenke gebeugt waren, waren die Hiiftgelenke gebeugt, abduziert und aunenrotiert und die FuDgelenke dorsiflektiert . Wenn die Kniegelenke ausgedehnt waren, waren die Huftbewegungen ausgedehnt, adduziert und innenrotiert, und die Knochel waren plantarflektiert. Huftbeugung kombiniert mit Kniestreckung (Beinhebung) und isolierte‘Kniebewegungen wurden bei Kindern rnit Diplegie nicht gesehen, fanden sich aber bei allen Fruhgeborenen mit guter Prognose nach sechs bzw. sieben Monaten (korrigiertes Alter). Das Fehlen dieser Bewegungen ist ein nutzlicher diagnostischer Parameter fur eine spastische Diplegie.

RESUMEN Movimientos de piernas en posicidn supina en niilos con diplejia espastica Se examinaron 10s movimientos de piernas en posicidn supina de 49 lactantes con diplejia esphstica (de tres a 11 meses de edad corregida). S610 se observo flexion y extensi6n simultaneas de caderas y rodillas con excepcionales movimientos aislados de la cadera; 10s movimientos simultheos tenian caracteristicas sinergicas. Cuando las rodillas se flexionaban, las caderas se flexionaban, abducian y giraban hacia fuera y 10s tobillos se tiraban para arriba. Cuando se extendian las rodillas, se extendian las caderas, y resultaban torcidas hacia dentro y 10s pies se flexionaban plantarmente. La flexi6n de la cadera en combinaci6n con la extensi6n de la rodilla (elevaci6n de la pierna), asi como movimientos aislados de la rodilla no fueron vistos en 10s lactantes diplkjicos, per0 si en lactantes preter mino con un buen pron6stic0, desputs de 10s seis y siete meses de edad corregida respectivamente. La ausencia de estos movimientos es un dato diagn6stico de utilidad en la diplejia esphtica.

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