Abstract
Walking is a primary human motor function which normally develops in the first 18 months of life. Children with cerebral palsy have impairments that interfere with their walking ability. The International Classification of Functioning, Disability and Health (ICF) defines participation as involvement in a life situation. Limitations in walking ability contribute to decreased levels of participation. Participatory environments are complex, unique to the participant, and often include unpredictable circumstances. For example, an unexpected change of direction eliminates the ability to make a pre-planned motor adjustment, requiring compensatory movement adaptation. Little is known about motor response to unpredictability, particularly in children. Measurement of response to unpredictability and the relationship to participation levels requires availability of relevant measurement tools. The overall aim of this thesis is to understand children’s responses to unpredictability while walking and how those responses may be related to mobility-based participation.
Methods:
This thesis involved four processes to better understand motor response to unpredictability and participation: 1) a literature review led to the development of a framework to conceptualize the impact of unpredictability while walking; 2) an empirical study to determine response to unpredictability in children who are typically developing; 3) a scoping review to survey the literature for Clinical Gait Assessment Tools (CGAT) that measure unpredictability and participation; and, 4) a survey of practicing physiotherapists to investigate how CGATs are being used.
A novel model, the Context of Walking (CoW), was developed to conceptualize the impact of unpredictability. Two methodological studies informed the main empirical study that investigated the impact of mid-gait unpredictability on children who are typically developing (n=13). The scoping review of nearly 500 articles identified CGATs used in research studies. An electronic survey of paediatric physiotherapists was conducted to understand clinicians’ priorities for usage of CGATs.
Results:
When exposed to unpredictable circumstances, children demonstrate alterations in gait biomechanics: decreased gait speed, decreased step length, increased double limb support time, increased stance time and increased turn velocity. Over 80 CGATs were identified by the scoping review; 72% measured the ICF domain activity and 12% measured participation. Utilization of CGATs in the research literature was centered on those that measure activity. The survey study of 101 clinicians found that only three of the thirteen most commonly used CGATs have a measure of participation, and all but one measured the activity domain. The study also found that many clinicians have awareness of the large number of available CGATs but have never used them.
Conclusions:
Unpredictability requires gait adaptations that are like those of people at risk for fall. It is possible that children with cerebral palsy may limit exposure to participatory environments to avoid gait requirements that they cannot efficiently or safely manage. Available CGATs are limited in their measure of participation and do not measure response to unpredictability. To address the problem of unpredictability, it is necessary to develop targeted intervention programs and appropriate measurement tools to determine if response to unpredictability improves with intervention, and whether such improvement results in a higher level of participation.