gait analysis
Gait analysis is a common process among ambulant people with the disease of cerebral palsy. It is used to assess specific problems with gait and provide insight as to how the abnormal gait may be ameliorated. In some cases, surgical interventions may be called for, and the results of gait analysis are useful in both preoperative surgical planning and postoperative evaluation of improvement. In less severe cases, physical therapy and orthopedic supports (i.e., orthotics) may be sufficient to improve gait.
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1. Gait analysis--a new diagnostic tool
Three-dimensional gait analysis is a systematic measurement, description, and assessment of human gait. Gait analysis is established as a useful diagnostic tool in patients with gait problems, as it is not possible to obtain an adequate and detailed understanding of such a complex mechanism as gait in a conventional clinical examination. The method has provided a better understanding of both normal gait and abnormal gait patterns; it is a suitable instrument for evaluation of treatment results as well as for scientific work. The first gait laboratory for clinical use in Norway was established in 2002 in the Section for child neurology at Rikshospitalet University Hospital in Oslo, Norway. In this article the procedure for gait analysis is described and the clinical value is indicated by a case record of a child with cerebral palsy. Gait analysis has entailed a change of policy with regard to surgical treatment in this patient group. Previously, operative intervention at a single level was usual, whereas current practice involves simultaneous interventions at several levels of both lower extremities. After three years' experience we recommend gait analysis in routine diagnostics, particularly as a preoperative evaluation, in all children with gait problems and in the follow up after surgery or other treatment.
[Lofterod, B., Terjesen, T. & Skaaret, I. (2005). Gait analysis--a new diagnostic tool [Norwegian]. Tidsskrift for den Norske Laegeforening, 125(15), 2014-6.]
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2. Determination of gait patterns in children with spastic diplegic cerebral palsy using principal components
This study developed an objective graphical classification method of spastic diplegic cerebral palsy (CP) gait patterns based on principal component analysis (PCA). Gait analyses of 20 healthy and 20 spastic diplegic CP children were examined to define gait characteristics. PCA was used to reduce the dimensionality of 27 parameters (26 selected kinematics variables and age of the children) for the 40 subjects in order to identify the dominant variability in the data. Fuzzy C-mean cluster analysis was performed plotting the first three principal components, which accounted for 61% of the total variability. Results indicated that only the healthy children formed a distinct cluster; however it was possible to recognise gait patterns in overlapping clusters in children with spastic diplegia. This study demonstrates that it is possible to quantitatively classify gait types in CP using PCA. Graphical classification of gait types could assist in clinical evaluation of the children and serve as a validation of clinical reports as well as aid treatment planning.
[Carriero, A., Zavataky, A., Stebbins, J., Theologis, T., & Shefelbine, S. J. (2008). Determination of gait patterns in children with spastic diplegic cerebral palsy using principal components. Gait & Posture [epublication ahead of print].]
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3. Intrasubject repeatability of gait analysis data in normal and spastic children
OBJECTIVE: To evaluate intrasubject repeatability of data obtained from computer-aided motion analysis in normal and spastic children. DESIGN: Prospective controlled study. BACKGROUND: Information from gait analysis is used in selecting therapeutic interventions for gait improvement in cerebral palsy. While there are several studies regarding repeatability of normal gait, there are no studies evaluating the repeatability of spastic gait. METHODS: Forty children (20 normal, 20 with diplegic type of cerebral palsy) were subjected to gait analysis. Kinematic, kinetic and time distance parameters obtained from gait analysis were studied for intrasubject variability within-day and between-day using statistical measures. RESULTS: Normal children had lower variability in time distance parameters than spastic children both within and between days. The repeatability of kinetics was better than those of kinematics, and values for normal children were better than those for spastic children. Within-day repeatability of kinematics and kinetics was better in normal children. Between-day repeatability of kinematics was better in normal children, while spastic children showed better repeatability for kinetics. CONCLUSIONS: We found lower repeatability of gait analysis data in spastic children compared to normal children. Restricted joint range of motion due to spasticity in the group of cerebral palsy patients may be responsible for the lower repeatability of data. Some errors due to marker placement are inadvertent and contribute to the lower between-day repeatability. RELEVANCE: The results of this study should be of interest to clinicians who make therapeutic decisions in patients with cerebral palsy using gait analysis data, and for scientists studying normal and pathological gait.
[Steinwender, G., Saraph, V., Scheiber, S., Zwick, E. B., Uitz, C. & Hackl, K. (2000). Intrasubject repeatability of gait analysis data in normal and spastic children. Clinical Biomechanics (Bristol, Avon), 15(2), 134-9.]
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4. Can clinical gait analysis guide the management of ambulant children with bilateral spastic cerebral palsy?
BACKGROUND: The role of clinical gait analysis in the management of ambulant children with bilateral spastic cerebral palsy (BSCP) is controversial. We hypothesized that gait analysis would allow us to differentiate between children with BSCP who would benefit from surgical intervention and those in whom surgery was not indicated. METHODS: We reviewed the outcome in 3 groups of children with BSCP referred for treatment recommendations based on gait analysis by looking at changes in the popliteal angle (PA), Gillette Gait Index (GGI), and minimum knee flexion in single support (MKFS) on a subsequent gait analysis. We identified 15 children in whom surgical intervention was not thought to be needed (SNR group) and 15 children who had multilevel surgery recommended but not performed (SND group). We randomly selected and reviewed 15 children referred during the study period who had multilevel surgery recommended and performed following gait analysis (OP group) for comparison. RESULTS: The initial PA, MKFS, and GGI were greater in the OP and SND groups compared with the SNR group. Popliteal angle did not change between analyses in the SNR and SND groups and decreased in the OP group (P = 0.004). Minimum knee flexion in single support remained similar between analyses in the SNR group, increased in the SND group (P < 0.0001), and decreased in the OP group (P < 0.0001). The GGI remained similar in the SNR and SND groups but decreased in the OP group (P = 0.0002). The number of children in the SND group showing an increase of more than 10% in the GGI between analyses (8/15) was greater than that in the OP group (0/15) (P = 0.0022). The PA, MKFS, and GGI contributed significantly to the treatment recommendations (P = 0.0013, P = 0.0045, P = 0.0054, respectively), which were not affected by age and Gross Motor Functional Classification System level. CONCLUSIONS: Gait analysis helped us to distinguish children with BSCP who would benefit from surgery from those in whom nonoperative management was appropriate, and its routine clinical use is encouraged in the management of these children. LEVEL OF EVIDENCE: Level III, retrospective comparative study.
[Gough, M. & Shortland, A. P. (2008). Can clinical gait analysis guide the management of ambulant children with bilateral spastic cerebral palsy? Journal of Pediatric Orthopedics, 28(8), 879-83.]
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5. Gait analysis outcomes of percutaneous medial hamstring tenotomies in children with cerebral palsy
BACKGROUND: Hamstring lengthening procedures are commonly performed on children with cerebral palsy (CP) to improve gait. The purpose of this study was to determine the efficacy of percutaneous hamstring tenotomy surgery for children with ambulatory CP. METHODS: In this retrospective study, subjects were included if they had a diagnosis of CP and had computerized gait analysis data collected before and after surgery. Subjects were not included in the study if they had any open hamstring lengthening on the same side. Other concomitant lower extremity surgeries were not exclusionary. Short- and long-term follow-up groups were established: if the time from their surgery to their gait laboratory was less than 18 months, they were placed in the short-term follow-up group, and if the time from their surgery to their gait laboratory was greater than 18 months, they were placed in the long-term follow-up group. RESULTS: The results demonstrated that for short- and long-term groups on preoperative to postoperative analysis, there was significantly improved knee extension at initial contact, increased velocity, increased stride length, improved overall gait as indicated by a decrease in a 16 variable multivariate index (Gillette Gait Index), and a decreased popliteal angle. For the short-term group only, additional significant findings included increased peak knee extension in stance and reduced plantar flexion at initial contact. The absolute values of peak knee extension in stance and plantar flexion at initial contact were equivalent at follow-up for the short- and long-term groups. Increased anterior pelvic tilt was also significant for the short-term follow-up group only. CONCLUSIONS: The findings of this study demonstrate that the minimally invasive technique of percutaneous hamstring tenotomy is effective in improving key dynamic gait parameters for individuals with CP for a short period, and these benefits are maintained in the long term. LEVEL OF EVIDENCE: Level IV.
[Gordon, A. B., Baird, G. O., McMulkin, M. L., Caskey, P. M. & Ferguson, R. L. (2008). Gait analysis outcomes of percutaneous medial hamstring tenotomies in children with cerebral palsy. Journal of Pediatric Orthopedics, 28(3), 324-9.]
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6. Gillette Gait Index as a gait analysis summary measure: Comparison with qualitative visual assessments of overall gait
BACKGROUND: The Gillette Gait Index (GGI) is a summary measure incorporating 16 clinically important kinematic and temporal parameters. The purpose of this study was to compare GGI scores from computerized gait analysis versus qualitative visual assessments of overall gait to assess the validity of the GGI as a summary score for gait analysis. METHODS: The GGI was calculated for 25 children with cerebral palsy who underwent computerized gait analysis before and 1 year after lower extremity surgery to correct gait problems. Twelve observers reviewed video recordings from the gait analysis to assess the severity of each patient's gait impairment preoperatively and postoperatively and the amount of preoperative to postoperative change. Variability of the video ratings was assessed, and GGI scores were compared with the mean video ratings. RESULTS: The individual ratings showed some variability, with moderate intrarater agreement (weighted kappa = 0.49-0.56) and slight to fair interrater agreement (kappa = 0.11-0.25). However, the mean scores from all raters were much more consistent, as demonstrated by a highly significant relationship in preoperative to postoperative change viewing the videos separately versus together (r2 = 0.62; P = 0.0001). GGI scores were correlated with these mean scores preoperatively (r2 = 0.34; P = 0.003), postoperatively (r2 = 0.30; P= 0.005), and in preoperative to postoperative change (r2 = 0.30, P = 0.006 for absolute change; r2 = 0.22, P = 0.02 for percentage change). CONCLUSIONS: These results support the validity of GGI as a gait analysis summary score and suggest that GGI may be a useful outcome measure in patients undergoing gait analysis. CLINICAL RELEVANCE: Clinicians and researchers should consider using the GGI as a quantitative outcome measure for assessing overall gait.
[Wren, T. A., Do, K. P., Hara, R., Dorey, F. J., Kay, R. M. & Otsuka, N. Y. (2007). Gillette Gait Index as a gait analysis summary measure: Comparison with qualitative visual assessments of overall gait. Journal of Pediatric Orthopedics, 27(7), 765-8.]
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7. Preoperative gait analysis has a substantial effect on orthopedic decision making in children with cerebral palsy: Comparison between clinical evaluation and gait analysis in 60 patients
BACKGROUND: There is still some debate regarding the role of 3-dimensional gait analysis in routine preoperative evaluation of children with cerebral palsy. The aim of this prospective study was to evaluate to what extent introduction of 3-D gait analysis changes preoperative surgical planning. METHOD: Before gait analysis, 60 ambulatory children aged 10 (4-18) years with spastic cerebral palsy had a specific surgical plan outlined, based on clinical examination by orthopedic surgeons. After gait analysis, the proposed surgical procedures were reviewed to determine the frequency with which the treatment plans changed. A multidisciplinary team assessed the gait analysis. RESULTS: Treatment plans for 42 of the 60 patients were altered after gait analysis. Surgical treatment was recommended for 49 patients whereas 11 were recommended non-surgical treatment. Of the 253 specific surgical procedures proposed, 97 procedures were not recommended after gait analysis and 65 additional procedures were recommended after the analysis. Thus, the number of procedures proposed was reduced by 13%. A total of 318 specific surgical procedures were proposed either clinically, by gait analysis, or both. There was overall agreement between the referring orthopedic surgeons and gait analysis in 156 of these 318 procedures (49%). Gait analysis proposed more surgery for psoas tenotomy and rectus femoris transfer, whereas less surgery was proposed for other soft tissue and bony procedures. There was good accordance between gait analysis recommendations and the surgery performed subsequently (92%). INTERPRETATION: Gait analysis provided important additional information that modified preoperative surgical planning to a high degree. The high accordance between recommendations and surgery performed suggests that surgeons seriously consider the gait data and treatment recommendations.
[Lofterod, B., Terjesen, T., Skaaret, I., Huse, A. B. & Jahnsen, R. (2007). Preoperative gait analysis has a substantial effect on orthopedic decision making in children with cerebral palsy: Comparison between clinical evaluation and gait analysis in 60 patients. Acta Orthopaedic, 78(1), 74-80.]
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8. A clinical gait analysis. A survey of usefulness of a gait laboratory
Advanced equipment for objective, quantitative 3-D locomotion analysis has been developed and has resulted in setting up clinical gait and locomotion laboratories connected to hospitals in USA and Europe. Before treatment of sufferings related to the locomotive system, the pathological movements can be objectified, and by repeating a gait analysis, the effect of treatment can be read. In treatment of cerebral palsy the method is used routinely, but influences of traumatic brain damage and apoplexy, as well as the effect of artificial joints in the body's locomotive patterns, can profitably be analysed.
[Sonne-Holm, S., Bencke, J. & Jacobsen, S. (2007). A clinical gait analysis. A survey of usefulness of a gait laboratory [Danish]. Ugeskrist for Laeger, 169(4), 304-7.]
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9. The role of gait analysis in the orthopaedic management of ambulatory cerebral palsy
PURPOSE OF REVIEW: The literature was reviewed to describe the role of gait analysis in the orthopaedic management of ambulatory children with cerebral palsy and examine the current best evidence to support these roles. RECENT FINDINGS: Gait laboratory analysis is superior to visual or observational analysis of gait because it provides an objective record of gait that is able to quantify the magnitude of deviations of pathologic gait from normal and also explain these abnormalities. Recognizable gait patterns can be classified and used for making treatment decisions, the effectiveness of which can be assessed using gait analysis as a measure of gait outcomes. There are many sources of variability, however, including patients themselves, the gait laboratories and testing processes, interpretation of data and surgeons' surgical recommendations. SUMMARY: Although gait analysis has been shown to alter decision making, there is little evidence that the decisions based on gait analysis lead to better outcomes. Consequently, clinical gait analysis remains controversial, with wide variation in the rates of utilization of gait analysis in the management of children with ambulatory cerebral palsy. The time is ripe for clinical trials and cohort studies to provide the evidence to establish the appropriate utilization of this technology.
[Narayanan, U. G. (2007). The role of gait analysis in the orthopaedic management of ambulatory cerebral palsy. Current Opinions in Pediatrics, 19(1), 38-43.]
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10. Correlation between physical functioning and gait measures in children with cerebral palsy
The primary aim of this investigation was to assess the correlation between the POSNA Musculoskeletal Functional Health Questionnaire (POSNA) and gait analysis in children with cerebral palsy (CP). POSNA and computerized gait analysis were used to evaluate individuals with CP. Correlations were investigated between POSNA scales, gait parameters, and the Gillette Functional Assessment Questionnaire (FAQ) in 63 children (31 males, 32 females; mean age 9.17 years [SD 3.06], age range 3.75 to 16.44 years) with spastic CP. Twelve participants had hemiplegia, 29 diplegia, 12 quadriplegia, and 10 triplegia. The result of backwards stepwise multiple regression analysis indicated that the Log normalcy index (NI) was a significant predictor of the POSNA Global Function and Comfort scale. Energy expenditure (EE) did not add significantly to the prediction. The POSNA scales differentiated between the different topographical types of CP. The POSNA scale is a valid and useful clinical measure. Used in conjunction with the NI, EE, and FAQ, the POSNA scale provides a more complete appraisal of change in functioning.
[Tervo, R. C., Azuma, S., Stout, J. & Novacheck, T. (2002). Correlation between physical functioning and gait measures in children with cerebral palsy. Developmental Medicine and Child Neurology, 44(3), 185-90.]
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11. Gait analysis. An essential tool in the treatment of cerebral palsy
Gait analysis has radically changed the treatment of cerebral palsy. Preoperatively, it allows critical assessment of the specific pathologies of the patient. Postoperatively, it provides an accurate assessment of outcome. This assessment of outcome has in turn allowed the accurate critique of surgeries and has made it possible to discard treatments that are not useful or are perhaps even injurious. As a result of this continual reassessment of surgical techniques, several principles and insights regarding the treatment of cerebral palsy have been learned. These include (1) the importance of reestablishing normal gait prerequisites, (2) the methods of reducing the energy expenditure of the pathologic gait, (3) the importance of skeletal structures in providing the lever arm by which muscles produce moments around joints, (4) the role and importance of two joint muscles, and (5) the importance of separating abnormalities, which are emanating from the neurologic lesion, from secondary ("coping") responses. Through gait analysis, it has become apparent that diplegia and hemiplegia are noninclusive terms, each of which contain a variety of homogeneous patterns of gait. Eventually these patterns may be separated and identified and optimal treatment protocols for each pattern type developed.
[Gage, J. R. (1993). Gait analysis. An essential tool in the treatment of cerebral palsy. Clinical Orthopaedics and Related Research, 288, 126-34.]
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12. Gait analysis in cerebral palsy
Ambulation problems in cerebral palsy have been very difficult to analyse because it is the central control system rather than the motor system that is at fault. Until recently, decisions regarding surgical management has been made on clinical grounds, which by and large, have been subjective. Attempts to remedy this situation has resulted in the setting up of Gait Analysis Laboratories to provide a more objective method of evaluation of disorders of human motion. We have recently been using an opto-electronic computer-based gait analysis system to analyse normal as well as abnormal gait. Gait analysis can provide information regarding movements of both lower limbs in three planes, ground reaction forces, joint torque and dynamic electromyography. Children with various types of Cerebral Palsy have been assessed. The results of four clinical gait assessment cases are presented and discussed. Information provided by the Gait Analysis Laboratory has introduced more objectivity in pre-operative planning for these children.
[Lee, E. H., Nather, A., Goh, J., Teng, B. & Bose, K. (1985). Gait analysis in cerebral palsy. Annals of the Academy of Medicine, Singapore, 14(1), 37-43.]
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12. Pre- and postoperative gait analysis in patients with spastic diplegia: A preliminary report
The benefits of using computerized gait analysis to plan and evaluate operations were assessed by studying the data from 20 children with spastic diplegia and examining the changes in estimated external work of walking, stride length, walking velocity, and joint rotations pre- and postoperatively. Of the 20 patients, 13 improved, 6 were unchanged, and 1 was worse. None of the patients walked in a crouch postoperatively. By clinical evaluation, 19 of the 20 patients were better. Thus objective gait analysis imposed much more stringent criteria for improvement. Computerized gait analysis has enabled us to be more objective in the evaluation and documentation of outcome.
[Gage, J. R., Fabian, D., Hicks, R. & Tashman, S. (1984). Pre- and postoperative gait analysis in patients with spastic diplegia: A preliminary report. Journal of Pediatric Orthopedics, 4(6), 715-25.]
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