Gait & Posture 38 (2013) 1038–1043

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Gait & Posture

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

The relationship between clinical measurements and gait analysis data

in children with cerebral palsy
Małgorzata Domagalska a,*, Andrzej Szopa a, Małgorzata Syczewska b,
Stanisław Pietraszek c, Zenon Kidoń c, Grzegorz Onik a
a
Faculty of Health Sciences, Medical University of Silesia, Katowice, Poland
b
Paediatric Rehabilitation Department, The Children’s Memorial Health Institute, Warszawa, Poland
c
Institute of Electronics, Silesian University of Technology, Gliwice, Poland

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

Article history: Spasticity is a common impairment that interferes with motor function (particularly gait pattern) in
Received 7 December 2012 children with cerebral palsy (CP). Gait analysis and clinical measurements are equally important in
Received in revised form 20 May 2013 evaluating and treating gait disorders in children with CP. This study aimed to explore the relationship
Accepted 27 May 2013
between the spasticity of lower extremity muscles and deviations from the normal gait pattern in
children with CP. Thirty-six children with spastic CP (18 with spastic hemiplegia [HS] and 18 with spastic
Keywords: diplegia [DS]), ranging in age from 7 to 12 years, participated in the study. The children were classified as
Cerebral Palsy
level I (n = 24) or level II (n = 12) according to the Gross Motor Function Classification System. Spasticity
Clinical assessment of spasticity
Accelerometer
levels were evaluated with the Dynamic Evaluation of Range of Motion (DAROM) using the
Gait accelerometer-based system, and gait patterns were evaluated with a three dimensional gait analysis
Gillette Gait Index using the Zebris system (Isny, Germany). The Gillette Gait Index (GGI) was calculated from the gait data.
The results show that gait pathology in children with CP does not depend on the static and dynamic
contractures of hip and knee flexors. Although significant correlations were observed for a few clinical
measures with the gait data (GGI), the correlation coefficients were low. Only the spasticity of rectus
femoris showed a fair to moderate correlation with GGI. In conclusion, the results indicate the
independence of the clinical evaluation and gait pattern and support the view that both factors provide
important information about the functional problems of children with CP.
ß 2013 Elsevier B.V. All rights reserved.

1. Introduction The Dynamic Evaluation of Range of Movement (DAROM) is an

Various treatment strategies are used to improve motor
function in children with cerebral palsy (CP). Clinical examination
combined with gait analysis is often used to assess the effective-
ness of various treatment methods [1–8]. The most popular
methods of clinical muscle tone assessment are subjective scales,
including the Ashworth Scale (AS), the Modified Ashworth Scale
(MAS), the Tardieu Scale (TS), and the Modified Tardieu Scale (MTS)
[2,8]. In children with spastic CP, there is a strong correlation
between the range of motion (ROM), the velocity of movement,
and the position in which the tested muscle reacts to stretching
[2,9–13].
* Corresponding author at: Faculty of Health Sciences, Medical University of
Silesia, Medyków 12, 40-752, Katowice, Poland. Tel.: +48 601 516 725;
fax: +48 322088712.
E-mail addresses: mdomagalska@sum.edu.pl (M. Domagalska),
aszopa@sum.edu.pl (A. Szopa).
assessment that considers spasticity, dependence on movement
velocity, and the position of adjacent joints. The instrument was
introduced by Reimers and Jóźwiak [9–11]. The reliability of the
Ashworth Scale has been questioned [8]. The MTS and the DAROM
(a simplification of the MTS), which uses at least 2 different
velocities of passive muscle stretching, have reported satisfactory
intra- and inter-rater reliability [2,8]. However, these assessments
are not objective tests. The DAROM, similar to the MTS, defines the
ROM as slow and fast passive stretching to determine a dynamic
component of muscle contracture [2,10,11]. In contrast with a
standard clinical examination, the DAROM identifies a ‘‘range of
motion deficit’’ (DROM), defined as a value from the minimal
muscle stretch position. In this test, two joint angles are measured:
DROM I, defined as the PROM deficit following a slow velocity
stretch, and DROM II, defined as the angle of catch (AOC) after a fast
velocity stretch. The difference between DROM II and DROM I
indicates the examined muscle group’s level of contracture and is
called the angle of spasticity (ASO) [2,10–13]. The DAROM, again
like the MTS, specifies three velocities that can be applied to the

0966-6362/$ – see front matter ß 2013 Elsevier B.V. All rights reserved.
http://dx.doi.org/10.1016/j.gaitpost.2013.05.031
 M. Domagalska et al. / Gait & Posture 38 (2013) 1038–1043
muscle [12]: V1, as slow as possible; V2, the speed of the body
segment falling freely under gravity; and V3, as fast as possible. In
the DAROM, the precise measurement of a limb’s position during
testing is essential [9–11].
Currently, one of the most commonly used methods for
assessing motor deficits in children with CP is objective,
instrumented gait analysis. An algorithm called bridge therapy
is often used: in this algorithm, spasticity and contracture are
managed simultaneously using orthotic devices [3–7,13–16].
However, while most gait analysis reports are based on selected
gait parameters [3–7], many gait parameters are interdependent.
Moreover, improvements in selected gait parameters are not
always equal to global gait pattern enhancement. To overcome
these problems, an index for quantifying deviations from normal
gait, called the Gillette Gait Index (GGI) and, previously, the
Normalcy Index (NI) [17], was introduced. This index is a global
measure of gait pattern based on 16 selected gait parameters taken
from objective gait analysis. However, data comparing the
spasticity determined via quantitative clinical examination with
the results of objective gait analysis are scarce in the literature.
Therefore, the purpose of this study was to explore the
relationship between spasticity in the muscles of the lower
extremities, assessed with the DAROM method, and deviations
from normal gait in children with CP.
2. Methods
The research protocol was approved by the Bioethics Commit-
tee of the Medical University of Silesia in Katowice, Poland. The
parents/guardians signed an informed consent form prior to the
subjects’ enrolment into the study.
2.1. Subjects
Thirty-six children with CP, 18 with hemiplegia (HS) and 18
with diplegia (DS), were included in the study. All of the
participants were independently functioning outpatients (Level I
or II of the Gross Motor Function Classification System [GMFCS])
[18] at local paediatric rehabilitation centres. The inclusion criteria
were a diagnosis of the predominantly spastic type of CP, the
ability to walk without assistive devices, age 7 to 12 years,
sufficient cooperation to enable accurate clinical assessment and
three-dimensional gait analysis, no surgeries within 18 months,
and no inhibiting casts or botulinum toxin treatment 6 months
before the evaluation. The HS group consisted of 6 girls and 12
boys; deficits occurred on the right side in 12 patients and on the
left side in 6, and the mean age was 8 years and 2 months (range: 7
years, 4 months to 12 years, 2 months). The DS group consisted of 8
girls and 10 boys; the mean age was 10 years and 4 months (range:
8 years, 3 months to 12 years, 2 months). A group of 18 healthy
children (6 girls and 12 boys) with no known neurological or
Table 1
Accelerometer placement and stabilisation for dynamic assessment of range of motion (DAROM tests).
Test Testing position
T1 Deficit of hip extension Supine, the contralateral extended leg resting
in the Thomas test on a support
T2 Pelvis elevation angle in Prone, both lower limbs extended resting on a support
the Duncan-Ely test
T3 Popliteal angle Supine, hip and knee of tested leg flexed 908, ankle in
neutral position, contralateral flexion leg resting on
support
T4 Deficit of knee extension Supine, hip of tested leg in neutral position in all planes
and knee flexed 908, off the table with the ankle in a
neutral position contralateral extended leg resting on
support
1039
orthopaedic problems and mean age of 8 years and 8 months
(range: 7 years, 5 months to 12 years, 3 months) was recruited as a
reference group (Ref). These children underwent only gait analysis.
2.2. Testing procedure
Each child with CP underwent a clinical examination, including
DAROM, of the four muscle groups in each leg. The testing positions
and standardisation procedures for all measurements are shown in
Table 1. All of the measurements were performed at the functional
testing lab of the University of Silesia. All of the participants were
examined three times (on consecutive days) by the same well-
trained physiotherapist. The child was instructed to hold onto a
couch in both sitting and lying positions, and the pelvis was
stabilised to minimise compensatory movements. The therapist
moved the segment of the lower limb from the starting position
towards the final position at two velocities (V1 and V3), holding the
limb at the end of the available range while testing with the slow
velocity (DROM I) or at the position of the AOC (DROM II) while
testing with the fast velocity.
2.3. Data collection and analysis
The DROM I and DROM II angles were measured (in degrees)
using an accelerometer-based system with ZK software (Institute
of Electronics of Silesian University of Technology) [19]. The limb
segment coordinates were defined by external markers. The results
from the three trials were averaged to obtain the DROM I and
DROM II values. The ASO value was calculated as the difference of
DROM II DROM I [3]. Angular velocity was measured using an
accelerometer system.
2.4. Three-dimensional instrumented gait analysis
After clinical examination, objective gait analysis was per-
formed using the Compact Measuring System for 3D Real-Time
Motion Analysis (CMS- HS 3D) with WinGait software (Zebris
Medizintechnik GmbH, Germany). The CMS HS 3D system is based
on 15 active ultrasonic markers (five triplets of ultrasound
markers).[20]
Before gait analysis, the following anatomic landmarks were
identified with an instrumented pointer: hip joint centre, knee
rotation centre (internal and external), ankle rotation centre
(internal and external), forefoot landmark (between the second
and third metatarsals), and rear foot (heel). Gait data were
recorded while the subjects walked on an Alfa XL treadmill
(Kettler, Germany). Prior to data collection, all subjects had the
opportunity to practice walking on the treadmill. The children
walked without shoes and without assistive devices. Markers were
attached to the skin with double-sided adhesive tape and placed
bilaterally. Depending on each subject’s walking abilities, five to
Position of accelerometer Stabilisation
10 cm proximal to the lateral epicondyle femur, parallel Pelvis
to the long axis of the femur
10 cm distal to the trochanter major, parallel to the long Without
axis of the femur stabilisation
Anterior, 5 cm proximal to the lateral malleolus, parallel Pelvis
to the long axis of the fibula
Anterior, 5 cm proximal to the lateral malleolus, parallel Pelvis
to the long axis of the fibula
1040 M. Domagalska et al. / Gait & Posture 38 (2013) 1038–1043
eight gait cycles were recorded for further analysis. The GGI was
calculated separately for each leg using the procedure described by
Schutte.[17]
2.5. Statistical analysis
The normality of the distribution of the analysed parameters
was assessed using skewness and kurtosis and Shapiro–Wilk’s test.
Normally distributed variables were summarised as the means and
standard deviations; non-normally distributed variables are
presented as median and range. The DROM results were compared
using a three-way repeated measure ANOVA. An alpha level of 0.05
was chosen as a cut-off for all statistical comparisons, and
Bonferroni post hoc comparisons were performed when necessary.
ASO and GGI were compared using a one-way repeated measure
ANOVA (for the different types of lower limbs). The biomechanical
parameters and GGI for hemiplegic patients were evaluated for the
affected and unaffected sides separately; however, for the diplegic
and control subjects, the data from the left and right legs were
pooled together. The correlation between GGI and all biomechani-
cal parameters (DROM I, DROM II, ASO) was tested using a
Spearman rank correlation coefficient. The software package
Statistica (Version 9.0 PL) was used for statistical analysis.
3. Results
3.1. Data analysis of angular velocity measurements
The median and range of slow (V1) and fast (V3) angular
velocity applied during DAROM depended on the test time point
(T1, T2, T3, T4) and the type of lower limb tested (unaffected and
affected in children with HS and the affected legs of children with
DS). The fastest angular velocity (V3) was observed at T3 for the
unaffected hemiplegic leg (147.24  37.968/s), while the slowest
angular velocity (V1) was observed in T2 in children with DS
(24.14  7.348/s). The differences between the V1 and V3 velocities in
children with CP in each test were statistically significant (each p-
value < 0.001).
3.2. Data analysis of clinical measurements
The descriptive statistics for DROM I, DROM II and ASO for the
unaffected and affected lower limbs of children with spastic
hemiplegia and the affected lower limbs of children with spastic
diplegia are presented in Table 2. Fig. 1 shows the effect of two
different angular velocities, slow (V1) and fast (V3), on DROM, as
measured in the four DAROM tests (T1–T4) of unaffected (n = 18;
1A) and affected (n = 18; 1B) lower limbs in children with
hemiplegia (HS) and the affected lower limbs of children with
diplegia (DS; n = 36; 1C).
A main effect of the level of involvement was found in testing
the lower limbs of children with HS (F(1, 34) = 16.54 p < .001),
indicating that the average DROM of the affected leg was
Table 2
Summary of clinical measurements (DROM I, DROM II, ASO) for unaffected (n = 18) and affected (n = 18) lower limbs in children with hemiplegia and affected (n = 36) lower
limbs in children with diplegia (as shown in Table 2). Normally distributed variables are summarised as the means and standard deviations, and non-normally distributed
variables are presented as the median and range. Non-parametric ANOVA test.
Hemiplegia
Unaffected Affected
Tests DROM I (8) DROM II (8) ASO (8) DROM I (8) DROM II (8)
T1 49.9  12.4 51.1  11.5 0.1 < -2–16> 49.6  7.4
T2 13.6 < 7–32.1> 15.3  6.3 0.8  2 15  4.5
T3 10  4.1 10.2  3.4 0.2  5.3 11.2  5.3
T4 4.2  2.1 8.2 < 0.1–17.3> 4.8 < -8.2–10.6> 5.1  1.3
significantly larger in each test than the average DROM of the
unaffected leg was. A main effect of muscle group was significant in
both groups of CP children, in HS F(3, 102) = 2.20, p = .001 and in DS
F(3, 105) = 10.48, p = .001. Each DAROM test (T1, T2, T3, T4)
differed in the reported DROM (Table 2). A main effect of applied
velocity (V1, V3) was found in the HS (F(3, 102) = 12.53, p < .001)
and DS groups (F(1, 35) = 90.80, p < 001), with significantly larger
DROM values in both groups when V3 was applied (Fig. 1). A main
effect of level of involvement was found for the lower limbs of
children with HS (F(2, 99) = 16.54 p < .001), indicating that the
average DROM of the affected leg was significantly greater than
that of the unaffected leg in each test. There was a significant
interaction between main factors (F(3, 51) = 34.30, p < .001). Post
hoc analysis showed that DROM applied with V3 (DROM II) to the
unaffected hemiplegic leg was not different from DROM I (applied
with V1) in each DAROM test. There was a significant interaction
between main factors (F(2, 99) = 21.17, p < .001). The DROM
measured in the affected hemiplegic leg with V3 (DROM II) was
significantly larger than the DROM measured with V1 (DROMI),
but only in T3 and T4. In the diplegic legs, DROM II did not differ
from DROM I in T3 and T4; however, in T1 and T2, DROM II was
significant larger (Fig. 2A–C). A two-way analysis of variance
yielded a main effect of lower limb involvement level (F(1,
34) = 91.70, p < .001), such that the average ASO was significantly
larger for the affected hemiplegic leg than for the unaffected leg in
each DAROM test, excluding T2. Additionally, the ASO for the
affected hemiplegic leg was significantly larger than the ASO of the
diplegic leg in the first and second DAROM test (F(1, 52) = 5.07,
p = .001), but it was not significantly larger in the third and fourth
(Table 1). The interaction of main factors was significant
(F(3,156) = 21.17, p = .001).
3.3. Gillette Gait Index (GGI)
The level of lower limb involvement for the GGI is shown in
Fig. 2. Statistically significant differences were found between the
GGI of healthy children (Ref) and the GGIs of children with CP. The
differences between unaffected and affected hemiplegic lower
limbs and affected diplegic limbs were confirmed by post hoc
analysis (each p-value <0.001).
3.4. Correlation between GGI and DROM I, DROM II, ASO data
Table 3 summarises the correlation coefficients between
clinical measures and GGI. The statistically significant correlations
are printed in bold and marked with an asterisk. There were only
fair (0.21–0.40) and moderate (0.41–0.60) correlations.
4. Discussion
Spasticity is a common impairment that interferes with motor
function in children with CP.[12] The relationship between clinical
assessments of spasticity and gait analysis in patients with CP has
Diplegia
Affected
ASO (8) DROM I (8) DROM II (8) ASO (8)
56.3  8.1 6.7  3.9 50.8 < 35.5–59.9> 59.3  6.3 9.9  5.4
17  4.5 1.6 < 0.2–6.5> 14.2  2.3 23.5  3.5 10.6 < 1.8–14>
24.9  5.7 13.6  5.2 30.6  13.6 32.3 < 18.2–59.5> 5.2 < -16–46.8>
16.9 < 9.1–19.9> 12.7 < 3.7–15.8> 2.5 < 0.4–7.8> 4.3 < -7.8–23.3> 1.5  7.1
 M. Domagalska et al. / Gait & Posture 38 (2013) 1038–1043 1041

Fig. 1. The effects of the angular velocities (slow, V1, and fast, V3) applied in the DAROM tests (T1–T4) to measure the deficit of ROM (DROM) in the unaffected lower limbs of
children with HS hemiplegia (n = 18; 1A), the affected lower limbs of children with HS hemiplegia (n = 18; 1B) and the affected lower limbs of children with DS diplegia (n = 36; 1C).
The angle of spasticity (ASO) in the unaffected and affected hemiplegic lower limbs (1D), the affected lower limbs of children with hemiplegia (HS; n = 18) and the affected lower
limbs of children with diplegia (DS; n = 36; 1E) are shown. Nonparametric ANOVA tests were used for comparisons. Vertical lines indicate the levels of confidence.

been described in several studies. Damiano and Abel [21] reported
a significant correlation between the knee extensor Ashworth
score and gait impairment. Spasticity of the rectus femoris was
reported as the primary cause of a stiff knee gait.[22,23] These
findings are in agreement with Kerrigan et al. [24], who also
reported other causes of a stiff knee gait, including impaired
dynamic hip flexion and poor ankle mechanics.
The results of this study show that deviations from normal gait
in patients with CP generally do not depend on the static and/or
dynamic contractures of hip and knee flexors. Although the GGI
detected statistically significant correlations for a few clinical
measures, the majority of correlation coefficients were low. Our

Table 3
Correlation coefficients. Statistically significant correlations between clinical and
GGI scores are indicated in bold.

Tests Spearman’s R p-Level

T1 GGI & DROM I 0.053 0.6590

GGI & DROM II 0.131 0.2741
GGI & ASO 0.216 0.0687
T2 GGI & DROM I 0.054 0.6519
GGI & DROM II 0.158 0.1837
GGI & ASO 0.493 0.0006
T3 GGI & DROM I 0.481 0.0000
GGI & DROM II 0.381 0.0009
GGI & ASO 0.143 0.2323
T4 GGI & DROM I 0.234 0.0481
GGI & DROM II 0.269 0.0223
GGI & ASO 0.209 0.0783
Fig. 2. The effect of lower limb involvement level on GGI.
1042 M. Domagalska et al. / Gait & Posture 38 (2013) 1038–1043
results were consistent with those reported by Orendurff et al. [25]
and McMulkin et al. [26], who found only weak correlations
between gait analysis and clinical examination measures, includ-
ing ROM, in children with CP. Desloovere et al. [27] also explored
the relationship between gait analysis and clinical examination
parameters. She found poor correlations between spasticity of the
hip flexors and adductors, the hamstrings, the rectus femoris, the
gastrocnemius, and gait parameters.
Our results, which found the highest correlation between GGI
scores and rectus femoris spasticity, are consistent with the results
presented by Desloovere et al., who reported fair to moderate
correlations between rectus femoris scores (assessed using MAS
and MTS) and gait data [27]. Desloovere et al. evaluated spasticity
using MA and MT scores and investigated these scores’ dependence
on separate gait kinematic parameters; in contrast, our study was
based on the DAROM method, objective accelerometric measure-
ments and a global index for quantifying deviations from normal
gait. In children with CP, spasticity is commonly assessed with the
MTS, using goniometric measurements of ROM while applying
three different velocities [3,28,29]. Many authors report that the
MTS correlates poorly with the degree and type of muscle tone
disorders in children with CP because of a strong relationship
between ROM and adjacent joint position.[2,8,28] Additionally,
goniometric measurements do not allow for simultaneously
measuring the applied velocity of passive movement and
corresponding ROM.
The DAROM test is a simultaneous accelerometric measure-
ment of the ROM deficit and the corresponding passive movement
angular velocity, enabling the assessment of static contractures
and dynamic spastic components. Another positive feature of
DAROM is the precise localisation of muscle contractures
permitted by the different testing positions.
This study is the first paper to provide spasticity measurements
using DAROM. The results provide objective values for the fixed
(DROM I) and dynamic (DROM II) contractures in the lower limbs
muscles in children with CP, along with the ASO. A small difference
between DROM II and DROM I indicates a predominantly fixed
contracture with a weak spasticity component of the ROM deficit.
A large difference between DROM II & DROM I values indicates a
high spasticity component.
Although knee and hip extension deficits occurred in both
groups of children with CP, the nature of these deficits differed in
the two groups, as indicated by the DROM and ASO values. In HS
children, the difference resulted from static contracture of the hip
flexors and clear indicators of hamstring spasticity, which can be
defined as ‘‘combined static contracture of the hip flexors and
hamstring dynamics’’. In DS children, hip and knee deficits resulted
from rectus femoris muscle dynamic contracture and static
contracture of the hamstrings, which may be defined as ‘‘combined
static contracture of the hamstrings and dynamic contracture of
the rectus femoris’’.
According to our results, hip and knee flexor contractures in
children with spastic CP are heterogeneous and require different
therapeutic strategies. The great diversity of the muscle contrac-
ture scope (isolated contracture of the hip flexors: iliopsoas and
rectus femoris; isolated contracture of the knee flexors: ham-
strings and triceps surae; combined contracture of hip and knee
flexors; and different types of contractures, static contractures, or
dynamic limitations) indicates that therapy for children with CP
should be based on detailed knowledge of the individual’s specific
type of contractures [3–7,9,12,30]. In this context, it is extremely
important to differentiate between myostatic contractures and
dynamic limitations and choose the proper treatment option, i.e.,
either contracture management or spasticity management [6].
This study shows that separate use of either the DAROM or gait
analysis may be less valuable for clinical decision making in
children with CP. However, the weak relationship between clinical
examination and the index for quantifying deviations from normal
gait does not indicate the superiority of either method. Rather, it
indicates their complementary nature. Moreover, clinical exami-
nation focuses on the primary abnormalities of children with CP,
which arise directly from the damage to the CNS (e.g., abnormal
muscle tone, abnormal reflex activity, loss of selective muscle
control, spasticity) and from secondary effects (contracture and
deformations), resulting from abnormal bone and muscle growth.
The pathological gait is characterised not only by primary and
secondary problems but also by compensatory mechanisms
(tertiary effects). The lack of correlation between the two
measurements supports the view that both data sets are critical
for interpretation and treatment decision-making in children with
CP. A shortcoming of this study was the spasticity measurement in
the proximal muscles of the lower extremities. In many CP
children, distal muscles are more severely affected, and this is
especially true of hemiplegic children. In future work, the
spasticity assessment of the calf muscles will be added to
investigate the association between the DAROM of all lower limb
muscles and their activity in the relative gait phase.
Conflict of interest statement
The authors declare that they have no conflict of interest.
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