Kinematic Motion Analysis in Upper Extremity Cerebral Palsy

Special Article – Cerebral Palsy

Phys Med Rehabil Int. 2016; 3(5): 1097.

Kinematic Motion Analysis in Upper Extremity Cerebral Palsy

Scallon G and Van Heest A*

Department of Orthopaedic Surgery, University of Minnesota, USA

*Corresponding author: Ann Van Heest, MD, Department of Orthopaedic Surgery, University of Minnesota, Administrative Offices 2512 South 7th Street, Suite R200, Minneapolis, MN 55454, USA

Received: August 31, 2016; Accepted: September 23, 2016; Published: September 26, 2016


Management of physical impairment in children with upper extremity cerebral palsy is complex and multifaceted. In this patient population, clinical presentation and neurologic involvement is widely variable. Management decision making, particularly with respect to surgical and invasive interventions, is built on comprehensive history, physical examination, and assessment of function. In that cerebral palsy is a disorder of movement and posture, additional methods of assessment of the movement disorder have been developed and validated. Historically, kinematic data in the lower extremities has preceded advancements in the upper extremities due to complexity of motion and multiple body segments. In the upper extremity, motion assessment has been validated for rating videos for joint positioning and functional impairment. Kinematic data collected during functional tasks assesses deficiency. Kinematic data has involved video capture and review, electromyography, and fixed marker tracking. Sophisticated software and technological advancements are promising to aid upper extremity kinematic assessment in children with cerebral palsy. Ultimately, these technologies may play a significant role navigating complex treatment algorithms.

Keywords: Cerebral palsy; Video; Motion analysis; Kinematics; Upper extremity


CP: Cerebral Palsy; EMG: Electromyography; ROM: Range of Motion; FCU: Flexor Carpi Ulnaris; PT: Pronator Teres; ECU: Extensor Carpi Ulnaris; SHUEE: Shriners Hospital for Children Upper Extremity Evaluation; ECRL: Extensor Carpi Radialis Longus; ECRB: Extensor Carpi Radialis Brevis; BR: Brachioradialis, ECRB: Extensor Carpi Radialis Brevis.


Cerebral palsy (CP) is a disorder of development of movement and posture causing activity limitations that are attributed to nonprogressive disturbances the occurred in the developing fetal or infant brain. Wide variability in the manifestation of impairment exists depending on the extent and location of the central nervous system lesion. Abnormal innervation ultimately results in imbalance of muscle forces across multiple joints, affecting different muscles and different joints to varying degrees. The most common manifestations in the upper extremity include shoulder adduction with internal rotation, elbow flexion, forearm pronation, wrist flexion and ulnar deviation, finger flexion, and thumb in palm deformities.

Patient evaluation in the upper extremity includes a careful history and physical examination. History includes a subjective patient and parent assessment of functional limitations. Physical examination includes active and passive range of motion of all joints, as well as assessment of muscle tone and control. Sensibility of the hand with assessment of stereo gnosis function helps understand functional use patterns, as the sensory cortex, as well as the motor cortex, of the brain is commonly affected. Historically, classification of upper extremity involvement in CP has been subjectively based on examiner interpretation, functional tests, and physical examination [1-4].

In that cerebral palsy is a disorder of movement and posture, additional methods of assessment of the movement disorder are necessary. Static and dynamic assessment of limb mechanics informs therapeutic decision making [1]. Analysis of motion in the upper extremity is integral to guiding rehabilitation and management of individuals with CP. Techniques for analysis static and dynamic upper extremity mechanics can include electromyography (EMG), wearable marker kinematic measurement, and motion capture. This review investigates how motion analysis is being used for assessment of upper extremity dysfunction due to CP, as an adjunct for decision making in this complex patient population.

Upper Extremity Cerebral Palsy

Upper extremity involvement in children with CP is pervasive and is commonly assessed by the Manual Ability Classification System (MACS), which describes how children (4-18 years) with cerebral palsy use their hands to handle objects in daily activities. . Of children with CP ages 4-14, approximately 64% are independent with activities of daily living in the upper extremity (MACS I-II) and 14% are completely dependent (MACS V). Thumb-in-palm deformity was noted in 41% of children, with a predilection for those with spastic quadriplegia [3-6]. No or minimal digital flexor spasticity was reported in 69%, moderate spasticity in 23%, and no active wrist or finger extension in 2%. Typical imbalance results in elbow flexion, forearm pronation, wrist flexion, ulnar deviation, finger flexion, and thumb-in-palm deformity. There is some evidence that correction of distal impairments in the upper extremity may improve proximal kinematics [7].

The paradigm for management of upper extremity involvement in children with CP is broad. Non-operative interventions include tone management with medications including botulinum toxin A injections,; therapies including constraint-induced movement therapy, bimanual training, mirror therapy, hand therapy, Kinesio tape, or somatosensory training; as well as splinting, , and electrical stimulation [8]. Surgical intervention has been shown to improve static and dynamic limb positioning as well as improvement on functional testing [4,9-13]. Guidance of surgical intervention in upper extremity procedures relies on careful examination and assessment of muscle imbalance, abnormal limb positioning, and functional impairment [9,11].

Motion Analysis

Delineation of upper extremity kinematics has evolved substantially over the last century. At one end of the spectrum is qualitative description of during routine daily activities. Kinematics of the upper extremity tasks have been assessed since the 1960’s using rudimentary electrogoniometers to measure joint motion and angular velocity [14]. More recent studies have integrated video recordings, EMG, optoelectric and ultrasound tracking, and most recently 3-D pattern recognition. The use of these technologies and the findings in the literature are summarized.

Video Recordings

For many years, video recordings have been used to supplement the evaluation of upper and lower extremity kinematics. Historically, the bulk of this literature has quantified anthropomorphic norms. It has been widely used in sports and assessing repetitive workplace trauma [14]. Video recording of children, particularly in the home environment, has been used to develop several classification systems of upper extremity and hand dysfunction [15,16].

One example of goniometric data extracted from video recordings is demonstrated by Kruelen et al [17,18]. Video recording data is collected from bi-planar cameras on a global coordinate system (Figure 1). Synchronized data is collected of subjects maximally pronating and supinating forearms and lifting a class and a wooden disk at shoulder height. Angular measurements are manually calculated from isolated video frames, which are translated into angular velocity and range of motion (ROM) data. Accuracy of the model is predicted within 5 mm. Ink markings were made over bony prominences about the elbow, wrist, acromion, and sternum. In the first study, the authors examine a cohort of patients with CP and pronation and wrist flexion deformities. They had spasticity of the flexor carpi ulnaris (FCU) and pronator teres (PT) with poor active but good passive ROM. These patients were indicated for PT rerouting and FCU to extensor carpi ulnaris (ECU) transfer. Examination preand postoperatively demonstrates a mean supination increase of 63°, active ROM increase of 23°, and active pronation decrease 40° [17]. The second study using this technique compared 10 patients with hemiplegic CP with impaired supination of the forearm to 10 control subjects. They demonstrate increased lateral and anterior trunk bend as a compensatory mechanism for elbow flexion and pronation deformities.