Muscle Synergies in Response to Biofeedback-Driven Gait Adaptations in Children With Cerebral Palsy

Adam T. C. Booth, Marjolein M. van der Krogt, Jaap Harlaar, Nadia Dominici, Annemieke, I Buizer

Research output: Contribution to JournalArticleAcademicpeer-review


Background: Children with cerebral palsy (CP) often show impaired selective motor control (SMC) that induces limitations in motor function. Children with CP can improve aspects of pathological gait in an immediate response to visual biofeedback. It is not known, however, how these gait adaptations are achieved at the neural level, nor do we know the extent of SMC plasticity in CP. Aim: Investigate the underlying SMC and changes that may occur when gait is adapted with biofeedback. Methods: Twenty-three ambulatory children with CP and related (hereditary) forms of spastic paresis (Aged: 10.4 ± 3.1, 6–16 years, M: 16/F: 9) were challenged with real-time biofeedback to improve step length, knee extension, and ankle power while walking on an instrumented treadmill in a virtual reality environment. The electromyograms of eight superficial muscles of the leg were analyzed and synergies were further decomposed using non-negative matrix factorization (NNMF) using 1 to 5 synergies, to quantify SMC. Total variance accounted for (tVAF) was used as a measure of synergy complexity. An imposed four synergy solution was investigated further to compare similarity in weightings and timing patterns of matched paired synergies between baseline and biofeedback trials. Results: Despite changes in walking pattern, changes in synergies were limited. The number of synergies required to explain at least 90% of muscle activation increased significantly, however, the change in measures of tVAF 1 from baseline (0.75 ± 0.08) were less than ±2% between trials. In addition, within-subject similarity of synergies to baseline walking was high (>0.8) across all biofeedback trials. Conclusion: These results suggest that while gait may be adapted in an immediate response, SMC as quantified by synergy analysis is perhaps more rigidly impaired in CP. Subtle changes in synergies were identified; however, it is questionable if these are clinically meaningful at the level of an individual. Adaptations may be limited in the short term, and further investigation is essential to establish if long term training using biofeedback leads to adapted SMC.

Original languageEnglish
Article number1208
JournalFrontiers in Physiology
Issue numberSEP
Publication statusPublished - 27 Sept 2019


This project was made possible by funding from the PACE ITN, under the European Union’s Horizon 2020 Research and Innovation Program, Marie Skłodowska-Curie grant agreement number 642961. ND was supported by the Dutch Organisation for Scientific Research (NWO) VIDI grant (016.156.346 FirSTeps) and the European Research Council (ERC) under the European Union’s Horizon 2020 Research and Innovation Program (grant agreement number 715945 Learn2Walk).. We would like to express our sincere thanks to Denise Smit and Helen van Galen for all their work during the collection of data for this study. We would also like to thank all who participated in this study.

FundersFunder number
Horizon 2020 Framework Programme715945
H2020 Marie Skłodowska-Curie Actions642961
European Research Council
Nederlandse Organisatie voor Wetenschappelijk Onderzoek016.156.346


    • EMG
    • feedback
    • motor control
    • rehabilitation
    • virtual reality


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