Clinical Movement Analysis Society (CMAS) UK & Ireland

Clinical Movement Analysis Society (CMAS) – UK & Ireland

15th Annual Meeting

Belfast 14th - 15th April 2016

CMAS 2016 Sponsors

Thursday 14th

April Programme

Venue: Conference Centre, Riddel Hall, Stranmillis Road, Belfast

10.00-11.45 CMAS Committee & DELPHI consensus meetings

12.00-13.00 CMAS Registration opens

13.00-14.00 CMAS Standards and Education Consensus Meeting

Damien Kiernan & Adam Shortland

14.00-14.30 The Shed Project Caroline Stewart

14.30-15.00 Tea/Coffee & Exhibitors/Posters

15.00-16.30 Workshop - Complex motor presentations in ambulant children

(case studies & discussion) Terry Sanger

16.30-17.30 Vicon User Group Meeting

19.00 CMAS Dinner @19.30

Ten Square- Belfast City Centre

Friday 15th

April Programme


8.15 Registration opens

8.50 Welcome Address

9.00-9.45 Keynote lecture: ‘Risk, Reflexes, and the Kinematics of Self-

Preservation’ Dr. Terence Sanger

9.45-10.25 Free Papers (4 presentations)

10.25-10.45 Exhibitor Presentations


11.15-11.45 Invited Speaker: ‘Holistic management in complex motor

presentation’ Dr. Claire Lundy

11.45-12.30 Keynote Lecture: ‘Locomotor control and navigation in typical

development and in children with brain lesions’ Dr. Vittorio Belmonti

12.30-13.00 CMAS AGM (Members only)

12.30-13.45 Lunch & Exhibitors

13.45-14.15 Invited Speaker: Orthopaedics

‘External fixators in management of ankle joint deformity’ Mr. Michael McMullan

14.15-14.45 Invited Speaker: ‘Cerebral Palsy Integrated Pathway, Scotland

(CPIPS)’ Mr. Mark Gaston

14.45-15.35 Free Papers (5 presentations)


15.55-16.25 Invited Speaker: ‘Managing Expectation in Paediatric

Orthopaedics’ Mr. Aidan Cosgrove

16.25-16.45 Close of Meeting

Best paper VICON/Shed competition

Keynote Speaker

Dr Terence Sanger MD PhD Associate Professor of Biomedical Engineering, Biokinesiology,

and Child Neurology

Dr. Sanger is an Electrical Engineer, Computational Neuroscientist, and Child Neurologist specializing

in research and treatment of movement disorders in children. His NIH-funded research includes

work on understanding motor learning in children, the use of kinematic measurements to design

assistive communication interfaces, and multiscale modeling of large-scale neural systems for

control, with particular application to understanding the development of spasticity and

dystonia. Techniques in his laboratory include repetitive transcranial magnetic stimulation (rTMS),

transcranial direct-current stimulation (TDCS), mathematical modeling, and the use of field-

programmable gate arrays (FPGA) to perform high-speed simulations of neural development. He is

the director of the Child Movement Disorders Clinic at Children’s Hospital of Los Angeles. His

laboratory at USC has made important recent discoveries on the role of long-latency stretch reflexes

in the genesis of childhood secondary dystonia. Dr. Sanger received the PhD degree in Electrical

Engineering and Computer Science from MIT, the MD from Harvard Medical School, and an SM in

Applied Mathematics from Harvard University. He studied Pediatrics at Los Angeles County Medical

Center, Child Neurology at Boston Children’s Hospital, and Movement Disorders at Toronto Western

Hospital and the Hospital for Sick Children.

Topic: Risk, Reflexes, and the Kinematics of Self-Preservation

Keynote Speaker

Dr. Vittorio Belmonti MD, PhD Child Neurologist

Dr. Vittorio Belmonti works as a developmental neuropsychiatrist at Fondazione Stella Maris, Italy,

since 2014 and is now director of a residential rehabilitation unit for children and adolescents with

psychiatric disorders. He is Ph.D. laureate of La Fondation Motrice (Paris). From 2012 to 2014 he

conducted a post-doc research project under the supervision of Prof. Giovanni Cioni and Prof. Alain

Berthoz of the Collège de France. In his research career, he developed novel paradigms for the

assessment of the perceptual and cognitive processes underlying locomotor control in children and

adults, both with a typical development and with cerebral palsy. In particular, he studied the

formation of visually-guided locomotor trajectories, visual-spatial memory and navigation. Dr.

Belmonti is also official tutor of the General Movement Trust (Graz) and collaborated with Prof.

Heinz Prechtl. His long-dating research interests are: infant neurodevelopment, early brain lesions,

cerebral palsy, visual-spatial disorders, executive functions, and navigation through typical and

atypical development.

Title: Locomotor Control and Navigation in Typical Development and in Children with Brain

Lesions (abstract at end of booklet)

Guest Speakers

Dr Claire Lundy, Paediatric Consultant in Neurology & Neurorehabilitation, Belfast HSC Trust

Claire trained in children’s neurology, neuro disability and rehabilitation at Guys and St Thomas’ and

King’s in London. This was followed by a consultant post, split between Evelina Children’s and King’s.

During this time she developed expertise in the assessment and management of children with

movement disorders and acquired brain injury. Her research interests are pain management in

cerebral palsy, visual impairment in children with complex neurological disability and treatments for

movement disorders including botulinum toxin, intrathecal baclofen and deep brain stimulation.

Claire’s current post in Belfast as regional consultant for neuro disability has involved service

development work and has led to the development of a new neurodisability multidisciplinary team.

Topic: Holistic management in complex motor disorders patients

Mr Michael McMullan, Paediatric Orthopaedic Consultant, Belfast HSC Trust

Michael McMullan graduated from Queen’s University Belfast in 1995. He trained in Trauma and

Orthopaedics in the Northern Ireland Higher Surgical Training Programme for 6 years. He spent 1

year in full time research, sponsored by the Royal College of Surgeons England, investigating

infection in fracture healing. He successfully completed the FRCS (Trauma & Orthopaedics)

examination in 2005. He had the opportunity to work from 2006 – 2007 in the Royal Children’s

Hospital and the Royal Melbourne Hospital in Melbourne, Australia with Professor Leo Donnan and

Professor Kerr Graham. Michael McMullan was appointed as Consultant Trauma and Orthopaedic

Surgeon in the Royal Victoria Hospital and Musgrave Park Hospital in 2007. He is an Honorary

Lecturer in Queen’s University Belfast in Trauma Surgery. His main specialist interests include

complex fractures and injuries, adult and paediatric deformities and all aspects of foot and ankle

surgery.

Topic: Complex Orthopaedics – External Fixators in Foot Surgery

Mr Mark Gaston MBBChir MA FRCS(Orth) PhD Paediatric Orthopaedic Consultant,

Mark is a consultant orthopaedic surgeon based at the Royal Hospital for Sick Children in Edinburgh.

He provides the clinical input to the Anderson Gait Lab, Edinburgh and a substantial proportion of his

clinical practice is aimed at optimising gait in patients with neuromuscular conditions. He publishes

regularly in the area of gait and paediatric orthopaedics. Since 2013 he has been involved, with

colleagues across Scotland, in establishing the Cerebral Palsy Integrated Pathway Scotland (CPIPS), a

national surveillance programme aimed at optimising musculoskeletal management and monitoring

for hip dislocation in all children and adolescents with CP in Scotland.

Topic: Cerebral Palsy Integrated Pathway, Scotland (CPIPS)

Mr Aidan Cosgrove FRCS(Orth) Paediatric Orthopaedic Consultant Surgeon

Mr. Cosgrove trained in Belfast, Great Ormond Street, London and Minnesota, USA and has been a

Consultant Paediatric Orthopaedic Surgeon since 1997. He works in the Royal Belfast Hospital For

Sick Children, Musgrave Park Hospital and the Ulster Independent Clinic.

Mr. Cosgrove qualified from Queen’s University of Belfast Medical School in 1985 and undertook his

training in orthopaedic surgery in Belfast. He spent time in research, developing the use of

Botulinum toxin in Cerebral Palsy. For this work he was awarded his doctorate and also won the

prestigious Richmond Prize of the American Academy of Cerebral Palsy and Developmental Medicine

for the best research paper presented in 1994.

He is active in research and audit to ensure outcomes are as good as possible, in particular

Developmental Dysplasia of Hip, Perthes disease and Slipped upper femoral epiphysis. In addition he

is the clinical lead for the Gait analysis laboratory in Musgrave Park Hospital which deals extensively

with the effects on function of conditions such as Cerebral Palsy, Spina Bifida and other

neuromuscular conditions.

Topic: Managing Expectation in Paediatric Orthopaedics

Free Papers Timetable: Friday 15th April 2016


Morning Session 9.45-10.25

Chairs: Aidan Cosgrove & Jan Herman

9:45 Exploring free living physical activity profiles: Beyond step count.

Rafferty D, Wyke S, Brewster S, Sattar N, Gill J, Alexander G, McFadyen A, Ramsay A, Dybus A and Paul L

9:55 Are paediatric cerebral palsy subjects more susceptible to greater levels of loading at the low back during gait compared to healthy controls?

Kiernan D, Malone A, O’Brien T, Simms CK

10:05 Does crouch gait affect daily activity levels?

O’Sullivan R, French HP, Horgan NF and O’Brien T

10:15 Improving Movement Skills of Visually-Impaired Children Using interactive Sounds

Savage A, Rodger M and Walls M

Afternoon Session 14.45-15.35

Chairs: Gill Holmes & Neil Postans

14.45 Evaluation of Gait Data Presentation, Could It Affect our Judgement?

Koning BHW and Lewis A

14.55 The effects of Free Fibula Flap transfer on lower limb gait

Greene, AJ, Frew Q, Dziewulski, P and Tzafetta, K

15.05 Validation of the rules for the Functional Movement Systems (FMS) screening test against a quantitative, 3D motion capture system

Philp F, Blana D, Stewart C, Chadwick E and Pandyan A

15.15 Repeatability of The Oxford Foot Model in Children with Foot Deformity

McCahill J, Stebbins J, Koning B, Harlaar J and Theologis T

15.25 Psychometric properties of outcomes of gait characteristics and walking performance in young people with Cerebral Palsy: A systematic review

Zanudin A, Van der Linden M, Jagadamma K and Mercer K

Exploring free living physical activity profiles: Beyond step count.

Danny Raffertyf HD, Sally Wyke PhD b , Stephen Brewster PhD c , Naveed Sattar PhDd , Jason M.R. Gill PhD d , Gillian Alexandere , Angus K McFadyen PhD g, Andrew Ramsayc, Aleksandra Dybus PhD a ,

Lorna Paul PhD a

a School of Medicine, b Institute of Health and Wellbeing, c School of Computing Science, d Institute of Cardiovascular and Medical Sciences, All the University of Glasgow, UK, e NHS Greater Glasgow & Clyde, Glasgow, UK, f Glasgow Caledonian University, UK, g AKM Statistics, Glasgow

Introduction: It is common in the literature to describe physical activity (PA) as the number of steps taken in an average day. When using accelerometers to objectively measuring free living PA a rich data set is available that goes beyond a simple volume count, allowing a more detailed exploration of PA patterns. Understanding these patterns of PA potentially allows the development of targeted treatment strategies and/or a more detailed exploration of the effects of interventions.

Methods: 22 stroke survivors (10 men, age 55.3 ± 9.9 years; 4.2 ± 4.0 years since their stroke) were recruited from local stroke support groups, and 22 controls were matched for sex, age and body mass index. All participants wore an ActivPALTM physical activity monitor for seven days and from these data activity profiles, including the number of steps per day, time spent sedentary and time in different cadence bands, were recorded.

Results: Stroke survivors took significantly fewer steps per day than controls (4035 ± 2830 steps/day vs 8394 ± 2941 steps/day, p<0.001) and sedentary time (including sleep time) was significantly higher for stroke participants compared to controls (20.4 ± 2.7 hours vs 17.5 ± 3.8 hours, p<0.001). People living with stroke spent similar amounts of time with cadences between 20 – 79 steps per minute (Sporadic through to slow walking) but significantly less time making incidental movement i.e. with cadences between 1 – 19 steps per minute.(Figure 1).

Figure 1

Discussion & Conclusion: These results suggest that specifically targeting incidental movements in this patient group may have merit to increase the amounts of PA undertaken and reduce the amount of sedentary time. Objectively measured PA should be more fully explored to help understand PA behaviours and effectiveness of interventions.

“Are paediatric cerebral palsy subjects more susceptible to greater levels of loading at the low back during gait compared to healthy controls?”

Kiernan D1, 2, Malone A1, O’Brien T1, Simms CK2.

1 Gait Laboratory, Central Remedial Clinic, Clontarf, Dublin 3, Ireland.

2 Trinity Centre for Bioengineering, Parsons Building, Trinity College Dublin, Dublin 2, Ireland.

Introduction: Increased trunk movements particularly in the sagittal and coronal planes are characteristic of CP gait1, 2. The consequences of these excessive movements on lower limb kinetics have been examined3. However, the effect to which this excessive trunk movement influences the lower spine is unclear. This study investigated the impact of excessive trunk movements on the 3-d reactive forces and moments at the lower back in paediatric CP subjects compared to Typically Developed (TD) controls. The effect of functional level of impairment was also considered. Methods: Full trunk and lower limb 3-d gait analysis was performed on 52 children with CP (26 GMFCS I & 26 GMFCS II) and 26 TD control children. Reactive forces and moments at the L5/S1 joint space were predicted using a “bottom-up” inverse dynamics approach. Results: Increased RoM was evident for the trunk for CP children in all 3 planes. GMFCS II demonstrated increased RoM for ant/pos force. For med/lat force, GMFCS II showed increased ipsilateral peak while both GMFCS I & II showed increased contralateral peak. For L5/S1 moments, increased peaks in stance and swing and increased RMS were evident for GMFCS I & II compared to TD in the sagittal plane. In the coronal plane, GMFCS II children showed a significantly increased contralateral peak compared to GMFCS I and TD while both GMFCS groups were increased for ipsilateral peak. RoM of axial twist moments for both GMFCS levels were significantly increased compared to TD. In addition, a number of significant positive correlations were present between thorax kinematics and L5/S1 reactive forces and moments.

References:

[1] Romkes et al. JPO B, 16: 175-180

[2] Heyrman et al. Gait Post,38(4): 770-776.

[3] Ounpuu et al. Gait Post 4(1): p. 62-78.

Discussion and Conclusions:

Children with CP demonstrated increased

reactive forces and moments at the lower

spine, most evident in the coronal plane.

The increase in kinetics was also strongly

linked to increased motion of the trunk

and level of functional impairment. It is

important that the effects of excessive

trunk motion on spinal loading during CP

gait are considered in the clinical decision

making process. Fig.1 L5/S1 Ensemble average profiles

(Grey: TD, Black: GMFCS I, Dots: GMFCSII)

Does crouch gait affect daily activity levels?

O’Sullivan R1, 2, French HP2, Horgan NF2, O’Brien T1

1 Central Remedial Clinic 2 Royal College of Surgeons in Ireland. Introduction: Crouch gait is one of the most common gait patterns in Cerebral Palsy (CP) and is defined as excessive knee flexion throughout stance which increases both the forces on the knee [1] and the energy cost of gait [2]. This might be expected to impact negatively on daily mobility. However, it has also been suggested that crouch gait may in fact be advantageous in maximising the ground reaction forces generated by the muscles [3]. The purpose of this study was to examine the impact of crouch gait on daily activity levels in children with CP. Methods: Following a standard gait analysis, 32 subjects with diplegic CP (mean age 9.66±4.02; GMFCS I-III) in crouch (mean mid-stance knee flexion 22.55º±9.35º) wore an ActivPal activity monitor for 5 consecutive days. The average of 3 days (2 weekdays/1 weekend day) was used for analysis. Time spent in sedentary, standing, and walking activities and frequency of walking steps and transitions were correlated with kinematic indicators of crouch gait using Pearson’s correlation co-efficients.

Results:

Time Sitting/Lying

Time Standing

Time Stepping

Steps/Day Transitions/Day

GDI1 -0.239 0.183 0.262 0.422* 0.088

Knee Ground-Contact(o) -0.133 0.188 0.039 -0.092 0.112

Knee Mid-stance(o) 0.425* -0.485** -0.256 -0.205 -0.192

Knee return to extension(o)2 -0.530** 0.466** 0.446* 0.338 0.323

Normalised Speed -0.488** 0.339 0.548** 0.559** 0.331

Normalised Step Length -0.213 0.074 0.325 0.433* 0.095

Age (years) 0.559** -0.560** -0.432* -0.227 -0.623**

*Significant at p<0.05; **Significant at p<0.01; 1GDI=Gait Deviation Index

2Knee return to extension = knee flexion at shock absorption-knee flexion at mid-stance[4]

Discussion: Consistent with previous studies in CP, GDI correlated with daily step count [5] and age was associated with reduced activity levels [6]. Mid-stance crouch correlated with increased time sitting/lying and reduced time standing. Function of the knee extensor mechanism as measured by knee return to extension correlated with increased time sitting/lying and reduced time stepping and standing. Knee ground contact position did not impact on activity levels.

Conclusion: There were significant correlations between kinematic indicators of crouch gait and activity levels, suggesting that crouch results in reduced activity and increased sedentary time. This is possibly due to the increased energy cost and forces on the knee reported in crouch gait.

References: 1.Steele KM et al. Journal of biomechanics. 2012 Oct 11;45(15):2564-9. 2.Rose J et al. Journal of pediatric orthopedics. 1989 May-Jun;9(3):276-9. 3.Hoang HX. Gait & posture. 2012 Jul;36(3):405-8. 4.O'Sullivan R et al. Clinical anatomy. 2010 Jul;23(5):586-92. 5.Wilson NC et al. Archives of physical medicine and rehabilitation. 2015 Oct;96(10):1924-7. 6.Stevens SL et al. Archives of physical medicine and rehabilitation. 2010 Dec;91(12):1891-6.

Improving Movement Skills of Visually-Impaired Children Using Interactive Sounds Authors: Alannah Savage1, Dr Matthew Rodger1 and Martin Walls2

1 School of Psychology, Queen’s University Belfast 2 Blind Children UK Corresponding author email: [email protected] Introduction: The ability to make accurately controlled movement is important for everyday life. An infant learns simple motor tasks, like grasping an object while adults perform skilled movements daily, like driving a car. Visually-impaired (V.I) children often experience challenges in motor development, performing substantially worse on tasks measuring fine and gross motor skills compared to age-matched controls (Wagner, Haibach, & Lieberman, 2013).

Motor skills are important for social and cognitive development. Gross motor delays can discourage or restrict participation in physical or social activities like ball games. This project will therefore develop interventions to improve the motor skills of V.I children. The starting point is to identify and define key movement challenges.

Method: Previous research has relied on existing movement test batteries and adapted these for V.I participants (e.g. Wagner et al., 2013). These tests outline specific criteria and operate on a pass or fail basis, comparing performance to standardised age norms. This project will take a novel approach using motion capture analysis to precisely analyse the movement of V.I children. This will allow detailed investigation of kinematic variables relating to quality of movement to evaluate what the performance differences are between V.I and sighted children.

Motor tasks common to both the MABC-2 and the Oregon Project (assessment for V.I children) have been selected: balls skills and jumping. These involve fine and gross motor skills, they are transferable and competence in these skills can aid participation in social activities and exercise. Visually-impaired children and age-matched sighted controls (with and without a blindfold) will perform a series of ball tasks (throwing, rolling and intercepting) and jumping tasks (jumping over different heights, jumping in 180º rotation and jumping with awareness of distance).

Results: Performance will be compared against the MABC-2 published norms and with that of sighted age-matched controls. Initial collected data will be presented.

Discussion: This phase of the project will identify specific differences in movement kinematics to allow future interventions to be designed focusing on improving these components. Augmented auditory feedback (AF), most likely sonification, will be applied to enhance performance and training by providing spatial or timing information. This technique has been used successfully in motor learning (Konttinen, Mononen, Viitasalo, & Mets, 2004). Studies involving AF and V.I participants tend to focus on orientation and designing an aid that is worn daily (Lahav, Schloerb & Kumar, 2012).

Conclusion: This project aims to apply sonification to the learning of motor kinematics, which is a goal of enhancing basic movement skills.

Bibliography

Konttinen, N., Mononen, K., Viitasalo, J., & Mets, T. (2004). The Effects of Augmented Auditory Feedback on Psychomotor Skill Learning in Precision Shooting. Journal of Sport & Exercise Psychology, 26, 306–316.

Wagner, M. O., Haibach, P. S., & Lieberman, L. J. (2013). Gross motor skill performance in children with and without visual impairments-research to practice. Research in Developmental Disabilities, 34(10), 3246–52.

Lahav, Schloerb, Kumar, S. (2012). A Virtual Environment for People Who Are Blind. A Usuability Study. Journal of Assistive Technologies, 6(1), 38–52.

EVALUATION OF GAIT DATA PRESENTATION, COULD IT AFFECT OUR JUDGEMENT? Koning B.H.W. MSc1, Lewis A. PhD1 1Oxford Gait Laboratory, Nuffield Orthopaedic Centre, Oxford, UK. INTRODUCTION: Currently, the Oxford Gait Lab (OGL) compares joint angles between visits and/or conditions using example curves (Figure 1A). We recently started investigating alternative means to present our data and how this might influence our interpretation. Our current focus is using mean curves with 95% confidence or prediction intervals (CI and PI, respectively). Both the mean curves and intervals can be based on a point-by-point analysis (i.e. evaluate each time frame separately) or based on Fourier series to analyse each curve as a whole, using either statistical inference or bootstrapping [1,2]. METHODS & RESULTS: We tried three different presentation formats for individual visits, with 6 trials per visit, and used these to identify (statistically significant) differences between visits for one single patient (Figure 1): trials of the two visits are not overlapping (B); no overlap of point-by-point CI’s (using student‘s t-distribution, C); and no overlap of Fourier bootstrap CI’s (D). Additionally, we created 36 difference curves from the two visits and assessed whether their intervals crossed zero: point-by-point CI (E top); bootstrap CI (E middle); and bootstrap CI (E bottom). This resulted in six indications of between visit differences along the gait cycle.

Figure 1 - Sagittal left knee joint curves (A-D) and 6 presentation methods (B-E) to help identify differences (as indicated by the shaded bars above each graph) between visits. Green bands show average normal knee curves +/- 1SD.

DISCUSSION & CONCLUSIONS: To our knowledge, bootstrapping with as few as 6 sample curves has not been previously reported. In contrast to point-by-point analysis, the use of Fourier curves has the benefit of analysing the gait cycle as a whole. However, when applied as suggested it forces cyclic behaviour on each single curve, i.e. having the same angle at 0 and 100%, affecting the curves for loading response and terminal swing. To avoid near-zero SD vectors we used the original sample SD vector instead of the bootstrap SD vector during bootstrap iterations, resulting in smaller bootstrap intervals. These intervals, and those calculated using the student’s t-distribution, need to be cross-validated using additional trials and subjects before final conclusions can be drawn. A potential variation to the current bootstrap approach for constructing the intervals would be to not use absolute differences, which would result in non-symmetric intervals. A similar study is currently ongoing aimed at the presentation of individual session data against control data. In conclusion, results show a great diversity in identified (statistical) differences between visits. This is caused by a difference in method: point-by-point vs Fourier; using statistical assumptions vs bootstrapping; and potential invalidity of the applied method (i.e. are we allowed to use the 36 difference curves in this manner?). Additionally, it is important to consider the meaning of the two intervals (CI - how accurate is my mean? - versus PI - how likely is the next individual curve to be inside these bounds?) and which one applies best in any given situation? These are questions we are interested in raising and discussing at CMAS 2016. REFERENCES [1]Ohlsen 1989, Annals of Statistics 17:4, 1419-1440] [2] Lenhoff 1999, Gait Posture 9, 10–17.

The effects of Free Fibula Flap transfer on lower limb gait

Greene, A.J.(1), Frew, Q. (2) and Dziewulski, P.(2)

(1) Faculty of Medical Science, Anglia Ruskin University, Chelmsford, UK (2) St Andrews Centre for Plastic Surgery and Burns, Broomfield Hospital, Chelmsford, UK

Introduction: The fibula is one of the most suitable bones for oral and maxillofacial reconstructive surgery, as sufficient length can be harvested whilst preserving the fibula distally and proximally to maintain integrity of the knee and ankle joints. Previous studies have concluded that gait is expected to return to normal three months post operatively and with no significant changes to ankle kinematics or temporal spatial parameters [1]. Despite this, patients often complain of subjective symptoms of gait disturbance and changed gait pattern in the follow-up period.

Methods: Seven patients post unilateral free fibula flap transfer underwent three-dimensional gait analysis using an eight-camera VICON motion analysis system and two ground-embedded AMTI force plates. 46 lightweight passive reflective markers (12 mm diameter) were attached to the pelvis and both legs to track and model the lower limbs. Gait outcome measures included temporal spatial walking parameters and lower limb joint kinematics. A One-Way Analysis of Variance was used to compare differences between post-operative patients and normal controls, as well as between affected (operated) and non-affected (non-operated) limbs.

Results: After reconstructive fibula flap surgery, patients walked slower compared to controls as a result of reduced step length and increased step time (p < 0.05). Patients step length was significantly shorter for affected to unaffected limb stepping as opposed to unaffected to affected limb stepping. No significant kinematics differences were seen at the ankle joint however trends towards increased external rotation at the hip and increase knee valgus throughout stance exist (Figure 1).

Discussion: It is important to preserve the peroneal muscle attachment during the free fibula flap transfer [2]. Post-operative patients display reduced step length from the affected to the non-affected limb during gait. This may indicate that propulsion from the affected limb is compromised as a result of the fibula flap surgery without causing changes to the ankle kinematics. The resulting trend towards increased external rotation at the hip joint in the non- affected limb may occur in an attempt to recover lost step length. Further investigation is required to determine the effects of the fibula flap surgery on the joints further up the kinematic chain and the disturbances to gait patterns that may occur as a result.

[1] Maurer-Ertl et al (2012) Microsurgery 32:364–369

[2] Lee JH et al (2008) Int J Oral Maxillofac Surg; 37: 625–629

Validation of the rules for the Functional Movement Systems (FMS) screening test against

a quantitative, 3D motion capture system

F. Philp, Dr D. Blana, Dr C. Stewart, Dr E. Chadwick, Prof A. Pandyan

Aim: The aim of this study is to validate the rules for the FMS screening test against a quantitative,

3D motion capture system (Vicon, Oxford Metrics Ltd).

Introduction: The FMS (comprised of 7 exercise tests and 3 clearing tests) is used routinely in

competitive sports. It is used in an attempt to identify movement patterns predisposing athletes to

injury. A maximum of three attempts per test is allowed. The exercise tests and associated scoring

criteria of the FMS are yet to be validated using a quantitative motion analysis system.

Methods: Twenty four male footballers (aged between 19 - 22), competing in the British University

and College Sports leagues, volunteered to participate in the study. The FMS was carried out as per

instruction, whilst simultaneous capture of performance was carried out using the Vicon System. The

Plug-in gait marker set was used, with additional placement of two pelvic and four thorax markers to

compensate for marker occlusion. The dynamic Plug-in gait model was used for joint kinematics.

Results: Preliminary results for peak knee flexion (PKF) for 10 participants in the FMS subtest of the

overhead squat (no heel raise) are shown in Table 1.

Table 1. Peak Knee flexion (PKF) angle during the FMS subtest overhead Squat

Discussion: These results show substantial variation between attempts as well as marked asymmetry in some individuals. This suggests the FMS method of assessment for complex movements may not be adequate in describing the variations and combinations of movement parameters. Additionally, errors may arise from the assessors' 2-dimensional interpretation of a 3-dimensional movement. The next steps of this analysis will be to compare these results to ordinal FMS scores and criteria.

Conclusion: The approach being used has the potential to help confirm or refute the validity of the FMS and describe the normative values associated with the FMS. Further analysis of these results alongside the FMS scores and criteria is required for validation of the FMS rules.

Attempt 1 Attempt 2 Attempt 3

Participant Number Left Right Left Right Left Right

1 101 111 107 114 110 117

2 89.3 89.5 91.5 90.6 94.7 93.3

3 88.8 87.7 89.5 89 91.4 88.1

4 84 85.6 83.4 85.2 89.9 89.3

5 127 130 133 131 139 137

6 89.8 79 95.6 84.3 94.3 82.3

7 100 100 107 107 111 110

8 97.1 97.8 99.2 99.9 95.7 97.8

9 100 102 92.1 94.6 92 94.5

10 119 118 118 117 119 118

Mean PKF angle 99.6 100.06 101.63 101.26 103.7 102.73

Min. PKF angle 84 79 83.4 84.3 89.9 82.3

Max. PKF angle 127 130 133 131 139 137

Standard Deviation 13.74 15.859 15 15.575 15.93 17.182

REPEATABILITY OF THE OXFORD FOOT MODEL IN CHILDREN WITH FOOT DEFORMITY McCahill J. MPhysio1,2, Stebbins J. DPhil1, Koning B. MSc1, Harlaar J. PhD2, Theologis T. PhD1 1Oxford Gait Laboratory, Nuffield Orthopaedic Centre, Oxford, UK 2MOVE Research Institute, VU University, Amsterdam, Netherlands SUMMARY: Repeatability of multi-segment foot kinematics was measured for children with a pathological condition. Children previously treated for clubfoot deformity were tested for intra-rater repeatability with a mean difference between visits of 2.9 degrees and inter-rater repeatability with a mean difference between raters of 3.6 degrees. INTRODUCTION: The OFM is a multi-segment, kinematic model that has been developed to assess dynamic motion of the foot. It has previously been assessed for repeatability in healthy populations (adults and children) [1,2]. In order to determine the efficacy of the model for detecting foot deformity, it is important to know repeatability in pathological conditions. The aim of the study was to assess the within-tester and between-tester repeatability of the OFM in children previously treated for clubfoot deformity. PATIENTS/MATERIALS and METHODS: Fifteen children with clubfoot were assessed (mean age 8.8 years, range 4-14 years; 8 male, 7 female; 9 bilateral, 2 left, 4 right side affected). For the bilateral subjects- we randomly chose 1 side resulting in 8 left and 7 right feet for analysis. OFM data [1] were collected during level walking using a 16 camera Vicon MX/T-series system. Each child was measured on 2 occasions by the same tester, and once by a second tester. The data was processed by a single engineer. The mean absolute differences between testers and sessions were calculated for each of 15 clinically relevant, kinematic variables and compared to 15 healthy children previously collected in the same laboratory (mean age 9.5 years, range 6-14 years; 10 female and 5 male) (Figure 1). RESULTS:

Figure 1: Inter and intra-rater repeatability for foot model kinematic variables in children with clubfoot. HF = hindfoot relative to tibia angles, FF = forefoot relative to hindfoot angles, FF/Tib = forefoot relative to tibia angles, df = dorsiflexion, avg=average.

DISCUSSION: In order to distinguish real change from measurement artifact, it is important to know the inherent repeatability of the measurement system. The results of this study show the variability in multi-segment foot kinematics within tester and between testers in a pathological population. For a change in kinematics to be deemed important clinically, the difference in measured values between visits would need to exceed the repeatability values reported here. CONCLUSIONS: The Oxford Foot Model (OFM) has been designed to be adaptable in its application to measure different types of foot deformity. The results of this study show that it provides repeatable results in children with residual clubfoot deformity. To be distinguished from measurement artifact, changes in foot kinematics, as a result of intervention or as natural progression over time, must be greater than the repeatability reported here. REFERENCES [1] Stebbins, J et al. (2006). Gait & Posture, 23, 401-10. [2] Carson, M et al. (2001). J Biomech 34, 1299–307.

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Comparison Oxford Foot Model Variability

Clubfoot - Intra

Clubfoot - Inter

Healthy

Mean absolute differences

were within a degree for

the intra and inter-rater

reliability in 12/15

variables. Average

hindfoot rotation, forefoot

/tibia abduction and

forefoot supination were

more variable between

testers. Overall the

clubfoot reliability data

were less variable than the

healthy population.

Psychometric properties of outcomes of gait characteristics and walking performance in young people with Cerebral Palsy: A systematic review

Asfarina Zanudin, Marietta van der Linden, Kavi Jagadamma, Tom Mercer

School of Health Sciences, Queen Margaret University

Background: Robust psychometric properties of outcome measures (OMs) are important when assessing outcomes of an intervention. Several systematic reviews of psychometric properties of tools that measure different aspects of function Cerebral Palsy (CP) have been published. However, so far no systematic review on the psychometric properties of measures of gait characteristics and walking performance has been conducted.

Purpose: The aim of this study is to systematically review the psychometric properties of the OMs of gait characteristics and walking performance in young people with CP.

Method: The MEDLINE, CINAHL, EBSCOhost, Pubmed and Scopus databases were searched up to 14th January 2016. Studies evaluating reliability, validity, measurement error and responsiveness OMs of gait characteristics and walking performance of young people with CP and with at least one participant aged 12-20 were included. Methodological quality of studies were independently rated by two raters using a modified COnsensus-based Standard for the selection of health status Measurement INstruments (COSMIN) checklist. Quality of the results was rated using the Terwee and colleagues (2007) criteria. Best evidence synthesis was scored according to Cochrane criteria.

Results: Forty five out of 3313 studies on 18 OMs were finally included. For the methodological quality, the majority of the studies scored ‘good’ with only seven rated as ‘excellent’. Best evidence synthesis showed ‘limited’ (n= 9) to ‘strong’ (n=2 ) evidence for (part of) OMs included. Kinematics and spatial temporal gait parameters (derived from instrumented gait analysis) and Functional Mobility Scale were found to have a ‘strong’ level of evidence regarding their test retest and inter-rater reliability, respectively. This review revealed a lack of evidence regarding the responsiveness of the majority of OMs.

Conclusion: Future studies of high methodological quality are needed to explore the responsiveness of OMs assessing the gait and walking performance in young people with CP.

Title: Locomotor Control and Navigation in Typical Development and in

Children with Brain Lesions

Dr. Vittorio Belmonti

In this lecture, I will summarise recent behavioural evidence on anticipatory locomotor control and

navigation, both in typical development and in children with brain lesions. That evidence supports a

new developmental model of locomotor control based on the increasing neural integration of

different spatial reference frames.

Two consistent adult locomotor behaviours are head stabilisation and head anticipation: the head is

stabilised to gravity and leads walking direction. This cephalocaudal orienting organisation aligns

gaze and vestibula with a reference frame centred on the upcoming walking direction, allowing

anticipatory control on body kinematics. Head stabilisation and anticipation are not fully developed

until 11-13 years of age, i.e. well beyond the age of rectilinear gait maturation.

The adult brain can code trajectory geometry in an allocentric reference frame, irrespective of the

end effector, regulating body kinematics thereafter. The formation of locomotor trajectories in

allocentric space, like head anticipation, matures in early adolescence, indicating common

neurocomputational substrates.

These late-developing anticipatory control mechanisms can be distinguished from biomechanical

problems in children with cerebral palsy due to congenital brain lesions.

The Magic Carpet is a novel navigation task. Children's performance on the Magic Carpet indicates

that typical navigation development consists in the increasing integration of egocentric and

allocentric reference frames. In cerebral palsy, right-brain impairment seems to reduce navigation

performance due to a maladaptive left-brain sequential egocentric strategy.

In summary, anticipatory control and allocentric navigation are related to each other and are

hallmarks of mature locomotor behaviour. This is an original perspective, linking motor behaviour to

spatial cognition, kinematic data to neural modelling, and going beyond the traditional divide

between motion and cognition.

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Clinical Movement Analysis Society (CMAS) UK & Ireland