Full course material can be downloaded from: … · Balance of Forces . a. External Forces (1) Stance Phase: Ground Reaction Force . AACPDM IC 9: Gait Analysis at Your Fingertips

IC 9:

Gait Analysis at your Fingertips : Enhancing Observational Gait Analysis using Mobile

Device Technology and the Edinburgh Visual Gait Scale

Jon R. Davids, MD Vedant A. Kulkarni, MD Suzanne Bratkovich, PT

Shriners Hospitals for Children – Northern California / University of California, Davis

Sacramento, CA USA

Full course material can be downloaded from: www.shrinerschildrens.org/aacpdm2017

http://www.shrinerschildrens.org/aacpdm2017

IC 9: Course Outline

• Introduction to Normal Gait • Introduction to the Edinburgh Visual Gait Scale. • Mobile Device Videography and App-Based Analysis • Break: (10 minutes) • Case-Based Audience Participation: Case examples for analysis of

gait using mobile device technology and the Edinburg Visual Gait Scale.

• Questions / Discussion

AACPDM IC 9: Gait Analysis at Your Fingertips

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NORMAL GAIT AND IDENTIFICATION OF COMMON GAIT DEVIATIONS IN CHILDREN WITH CEREBRAL PALSY

I. Normal Gait A. The Gait Cycle

B. Stance Phase

1. Loading Response

2. Mid Stance

3. Terminal Stance

4. Pre-Swing

C. Swing Phase

1. Initial Swing

2. Mid Swing

3. Terminal Swing

D. Biomechanics

1. Balance of Forces

a. External Forces

(1) Stance Phase: Ground Reaction Force


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(2) Swing Phase: Gravitational, Inertial Forces

b. Internal Forces

(1) Muscles

(2) Ligaments / Joint Capsule

(3) Skeletal Anatomy

2. Location of Ground Reaction Force to Joint Centers

a. Controlled by

(1) Muscle Activity

(2) Body Segmental Alignment

E. Pre-requisites of Normal Gait

1. Stability in Stance

2. Clearance in Swing

3. Effective Phase Shifts

a. Stance to Swing / Swing to Stance

4. Energy Efficiency

F. Terminology at the Ankle / Foot

1. First / Heel Rocker

a. Loading Response

2. Second / Ankle Rocker

a. Mid Stance

3. Third / Forefoot Rocker

a. Terminal Stance / Pre-Swing

II. Gait Disruption in Children with Cerebral Palsy

A, Task Analysis

1. Propulsion


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a. Temporo-spatial Parameters

2. Stability in Stance

a. Shock Absorption

b. Single Support

3. Clearance in Swing

a. Peak Knee Flexion

4. Effective Phase Shifts

a. Stance to Swing

(1) Power Generation

b. Swing to Stance

(1) Terminal Swing Alignment

5. Energy Efficiency

a. Increased Passenger Segment Deviations

b. Increased Use of “Active” Stabilization Mechanisms

c. Decreased Limb Segment Coordination

d. Biarticular Muscle Dysfunction

III. Classification of Gait Deviations

A. Primary Deviations / Deficits

1. Directly Related to Underlying Pathology (Spasticity)

B. Secondary Deviations / Deficits

1. Related to Growth and Development

(Muscle Contracture, Skeletal Malalignment)

C. Tertiary Deviations / Deficits

1. Obligatory, Detrimental (Knee Hyperextension)

2. Obligatory / Voluntary, Helpful (Forward Trunk Lean)


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D. Interventions

1. Address Primary Deviations / Deficits (Neurosurgery, Pharmacologic)

2. Address Secondary Deviations / Deficits (Musculoskeletal Surgery)

3. Tertiary Deviations / Deficits (Resolve Spontaneously)

IV. Common Gait Deviations

A. Common Deviations at the Hip

Deviation

Gait Cycle Cause Significance

Limited Flexion

Initial Contact / Loading Response

• Compensation for weak hip extensor muscle group

• Decreased shock absorption

Pre-swing • Weak hip flexor muscle group

• Diminished knee flexion in Swing

Mid-swing • Weak hip flexor muscle group

• Impaired motor control • Hip pain

• Poor foot clearance • Poor foot position for initial

contact

Excess Flexion


• Spasticity / Contracture of hip flexor muscle group

• Compensation for excess knee flexion / ankle dorsiflexion

• Increased demand on knee and hip extensor muscle groups

• Decreased limb stability

Mid-swing • Compensation for diminished knee flexion / ankle dorsiflexion

• Helps clearance

Internal Rotation

Mid-stance • Increased femoral anteversion

• Compensation for external pelvic rotation

• Intoeing gait pattern • Impaired forward

progression • Disrupts patellofemoral

tracking External Rotation

Mid-stance • Diminished femoral anteversion

• Increased thigh girth • Compensation for knee /

ankle / foot pain

• Outtoeing gait pattern • Increased base of support • Decreased foot lever arm • Excess loading of medial

knee and ankle ligaments


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Mid-swing • Compensation for weak hip flexor muscle group

• Helps clearance

Adduction Mid-stance • Adductor muscle group spasticity

• Secondary to weak hip abductor muscle group (contralateral pelvic drop)

• Apparent (combination of hip flexion and internal rotation)

• Decreased base of support • Decreased limb stability • Functional lengthening of

reference limb

Abduction Mid-stance • Compensation for long reference limb

• Increased base of support • Functional shortening of

reference limb Mid-swing • Compensation for long

reference limb • Compensation for weak

hip flexor muscle group

• Functional shortening of reference limb

• Helps reference limb advancement in Swing


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B. Common Deviations at the Knee

Deviation Gait Cycle Cause Significance Limited flexion Initial Contact /

Loading Response • Weak knee extensor

muscle group • Knee pain • Impaired proprioception


Mid-swing • Secondary to poor hip flexor function

• Rectus femoris spasticity

• Knee pain

• Poor foot clearance

• Poor foot position for initial contact

Excessive Flexion


• Knee flexion spasticity/contracture

• Impaired proprioception


Mid-stance • Knee flexion spasticity/contracture


• Increased demand on knee extensor muscle group

• Decreased stability

Terminal Swing • Knee flexion spasticity/contracture


• Poor foot position for initial contact

Hyperextension Mid-stance • Secondary to excessive ankle plantar flexion

• Impaired proprioception • Intentional to increase

limb stability

• Decreased forward progression

• Damage to knee ligaments


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C. Common Deviations at the Ankle / Foot

Deviation Gait Cycle Possible Causes Significance Toe Strike Initial

Contact • Inadequate knee extension

in TSw • Inadequate ankle

dorsiflexion in TSw • Compensation for knee

extensor weakness • Hindfoot pain

• Loss of first rocker

• Disruption of forward momentum

• Diminished shock absorption

Foot Slap Loading Response

• Weak ankle dorsiflexor muscles

• Disruption of forward momentum

• Diminished shock absorption

Excessive Plantar Flexion (Toe-walking)

Mid-stance • Plantar flexor muscle group spasticity / contracture

• Compensation for knee extensor weakness

• Ankle pain

• Disrupted second rocker

Excessive Plantar Flexion (Foot Drag)

Mid-swing / Terminal Swing

• Weak dorsi-flexor muscles • Plantar flexor muscle

group spasticity / contracture

• Limited voluntary motor control of dorsiflexor muscle group

• Poor foot clearance

• Poor foot position for subsequent initial contact

Early Heel Rise (Vaulting)

Mid-stance • Compensation for long (anatomic or functional) contralateral limb in swing phase

• Overload of ankle plantar flexor muscle group

Delayed/Absent Heel Rise

Terminal Stance

• Weak ankle plantar flexor muscles

• Mid- /Forefoot pain

• Disrupted third rocker

• Decreased step/stride length

In-toeing Mid-stance • Internal pelvic rotation • Increased femoral

anteversion • Internal tibial torsion • Varus foot malalignment

• Disruption of forward progression

Mid-swing • Internal pelvic rotation • Poor foot


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• Increased femoral anteversion

• Internal tibial torsion • Varus foot malalignment

clearance (hitting against opposite limb)

Out-toeing Mid-stance • External pelvic rotation • Diminished femoral

anteversion • External tibial torsion • Valgus foot malalignment

• Diminished stability

Terminal Stance

• External pelvic rotation • Diminished femoral

anteversion • External tibial torsion • Valgus foot malalignment

• Disrupted third rocker


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References1-15

1. Gage JR. An overview of normal walking. Instr Course Lect. 1990;39:291-303. Epub 1990/01/01.

2. Gage JR, DeLuca PA, Renshaw TS. Gait analysis: principle and applications with emphasis on its

use in cerebral palsy. Instr Course Lect. 1996;45:491-507. Epub 1996/01/01.

3. Gage JR, Schwartz MH. Normal Gait. In: Gage JR, Schwartz MH, Koop SE, Novacheck TF, editors.

The Identification and Treatment of Gait Problems in Cerebral Palsy. 2nd ed. London: MacKeith Press;

2009. p. 31-64.

4. Harvey A, Gorter JW. Video gait analysis for ambulatory children with cerebral palsy: Why,

when, where and how! Gait Posture. 2011;33(3):501-3. Epub 2010/12/24.

5. Kaufman KR, Sutherland DH. Kinematics Of Normal Human Walking. In: Rose J, Gamble JG,

editors. Human Walking. 3rd ed. Philadelphia: Lippincott Williams & Wilkins; 2006. p. 33-52.

6. Ounpuu S. Patterns of Gait Pathology. In: Gage JR, editor. The Treatment of Gait Problems in

Cerebral Palsy. London: Mac Keith Press; 2004. p. 217-37.

7. Perry J, Burnfield J. Gait Analysis: Normal and Pathologic Function. 2nd ed. Thorofare, N.J.: Slack

incorporated; 2010.

8. Rathinam C, Bateman A, Peirson J, Skinner J. Observational gait assessment tools in paediatrics--

a systematic review. Gait Posture. 2014;40(2):279-85. Epub 2014/05/07.

9. Rethlefsen SA, Healy BS, Wren TA, Skaggs DL, Kay RM. Causes of intoeing gait in children with

cerebral palsy. J Bone Joint Surg Am. 2006;88(10):2175-80. Epub 2006/10/04.

10. Rethlefsen SA, Kay RM. Transverse plane gait problems in children with cerebral palsy. J Pediatr

Orthop. 2013;33(4):422-30. Epub 2013/05/09.

11. Rodda JM, Graham HK, Carson L, Galea MP, Wolfe R. Sagittal gait patterns in spastic diplegia. J

Bone Joint Surg Br. 2004;86(2):251-8. Epub 2004/03/30.

12. Saunders JB, Inman VT, Eberhart HD. The major determinants in normal and pathological gait. J

Bone Joint Surg Am. 1953;35-A(3):543-58. Epub 1953/07/01.

13. Sutherland DH, Davids JR. Common gait abnormalities of the knee in cerebral palsy. Clin Orthop

Relat Res. 1993(288):139-47. Epub 1993/03/01.


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14. Todd FN, Lamoreux LW, Skinner SR, Johanson ME, St Helen R, Moran SA, et al. Variations in the

gait of normal children. A graph applicable to the documentation of abnormalities. J Bone Joint Surg Am.

1989;71(2):196-204. Epub 1989/02/01.

15. Wren TA, Rethlefsen S, Kay RM. Prevalence of specific gait abnormalities in children with

cerebral palsy: influence of cerebral palsy subtype, age, and previous surgery. J Pediatr Orthop.

2005;25(1):79-83. Epub 2004/12/23.

Mobile Device Videography and App-Based Analysis

• Principles of Gait Video Acquisition – Focus & Lighting – Proper Perspective – Subject clothing for Optimal Visualization – Skin Marking for Enhanced Landmark Visualization – Tracking the Subject – Minimizing Motion Artifact

• Low Cost Options for Mobile Videography – Hand-held – Selfie Stick – Gimbal

• Video Editing Options - Free and Low Cost Options – Built-in Video Editor on Device (free) – Huddl Technique (free) – Slowmo – Slow Motion Video Analysis (free) – Coach’s Eye – Video Analysis ($4.99) – Dartfish Express ($6.99)

Video-Based Gait Analysis using Huddl Technique

Download App from Apple App Store or Google Play

EVGS Scoring Worksheet

Terminal Swing/Initial Contact R

Terminal Swing/Initial Contact L

Peak Hip Flexion (EVGS #13) Markedly increased flxn (>60° ) 2 Increased flxn (46°-60°) 1 Normal flxn (25°-45°) 0 Reduced flxn (10 °-24 °) 1 Severely reduced flxn (<10 ° ) 2 Knee Position (EVGS #10) Severe flxn (>30 °) 2 Moderate flxn (16 ° -30 °) 1 Normal flxn (5 ° -15 °) 0 Moderate extn (4 ° flxn - 10 extn) 1 Severe hyperextn (>+10 ° extn) 2 Foot Position (EVGS #1) Heel Contact 0 Flatfoot Contact 1 Toe Contact 2

Peak Hip Flexion (EVGS #13) Markedly increased flxn (>60° ) 2 Increased flxn (46°-60°) 1 Normal flxn (25°-45°) 0 Reduced flxn (10 °-24 °) 1 Severely reduced flxn (<10 ° ) 2 Knee Position (EVGS #10) Severe flxn (>30 °) 2 Moderate flxn (16 ° -30 °) 1 Normal flxn (5 ° -15 °) 0 Moderate extn (4 ° flxn - 10 extn) 1 Severe hyperextn (>+10 ° extn) 2 Foot Position (EVGS #1) Heel Contact 0 Flatfoot Contact 1 Toe Contact 2

Mid-Stance Right

Mid-Stance Left

Peak Sagittal Position of Trunk in Stance (EVGS #16) Normal (vertical to 5° fwd or bkwd) 0 Moderate (> 5° bkwd or 6° - 15° fwd) 1 Marked (> 15° fwd lean) 2 Pelvic Rotation Mid-Stance (EVGS #15) Marked retraction (> 15°) 2 Mod retraction (6° - 15°) 1 Normal (5° retr - 10° pro) 0 Mod protraction (11°- 20°) 1 Marked protraction (>20°) 2 Heel Lift in Stance (EVGS #2) No forefoot contact 2 Delayed (with or after contralat foot contact) 1 Normal (between contralat foot level and IC) 0 Early (before opp foot level) 1 No heel contact 2

Peak Sagittal Position of Trunk in Stance (EVGS #16) Normal (vertical to 5° fwd or bkwd) 0 Moderate (> 5° bkwd or 6° - 15° fwd) 1 Marked (> 15° fwd lean) 2 Pelvic Rotation Mid-Stance (EVGS #15) Marked retraction (>15°) 2 Mod retraction (6° - 15°) 1 Normal (5° retr - 10° pro) 0 Mod protraction (11°- 20°) 1 Marked protraction (>20°) 2 Heel Lift in Stance (EVGS #2) No forefoot contact 2 Delayed (with or after contralat foot contact) 1 Normal (between contralat foot level and IC) 0 Early (before opp foot level) 1 No heel contact 2


Terminal Stance R

Terminal Stance L

Peak Hip Extension in Stance (EVGS #12) Severe flxn (>15°) 2 Moderate flxn (1 ° -15°) 1 Normal (0 ° -20° extn) 0 Mod hyperextn (21 ° -35°) 1 Severe hyperextn (> 35°) 2 Peak Knee Extension in Stance (EVGS #9) Severe flxn (>25°) 2 Mod flxn (16° – 25°) 1 Normal (0° - 15° flxn) 0 Moderate hyperextn (1° - 10°) 1 Severe hyperextn (>10°) 2 Max Ankle Dorsiflexion in Stance (EVGS # 3) Excessive df (>40°) 2 Increased df (26° - 40°) 1 Normal (5° - 25° df) 0 Reduced df (10° pf - 4° df) 1 Marked pf (>10°) 2

Peak Hip Extension in Stance (EVGS #12) Severe flxn (>15°) 2 Moderate flxn (1 ° -15°) 1 Normal (0 ° - 20° extn) 0 Mod hyperextn (21° - 35°) 1 Severe hyperextn (> 35°) 2 Peak Knee Extension in Stance (EVGS #9) Severe flxn (>25°) 2 Mod flxn (16° – 25°) 1 Normal (0° - 15° flxn) 0 Moderate hyperextn (1° - 10°) 1 Severe hyperextn (>10°) 2 Max Ankle Dorsiflexion in Stance (EVGS # 3) Excessive df (>40°) 2 Increased df (26° - 40°) 1 Normal (5° - 25° df) 0 Reduced df (10° pf - 4° df) 1 Marked pf (>10°) 2


Mid-Swing R

Mid-Swing L

Peak Knee Flexion in Swing (EVGS #11) Severely increased (>85° flxn) 2 Mod increased (71° -85° flxn) 1 Normal flxn (50° -70°) 0 Mod reduced (35° -49° flxn) 1 Severely reduced (<35° flxn) 2 Maximum Ankle Dorsiflexion in Swing (EVGS #7) Excessive df (>30° df) 2 Increased df (16° -30° df) 1 Normal (15° df – 5° pf) 0 Moderate pf (6° -20° pf) 1 Marked pf (>20° pf) 2 Foot Clearance in Swing (EVGS #6) High steps 1 Full clearance 0 Reduced clearance 1 None 2

Peak Knee Flexion in Swing (EVGS #11) Severely increased (>85° flxn) 2 Mod increased (71° -85° flxn) 1 Normal flxn (50° -70°) 0 Mod reduced (35° -49° flxn) 1 Severely reduced (<35° flxn) 2 Maximum Ankle Dorsiflexion in Swing (EVGS #7) Excessive df (>30° df) 2 Increased df (16° -30° df) 1 Normal (15° df – 5° pf) 0 Moderate pf (6° -20° pf) 1 Marked pf (>20° pf) 2 Foot Clearance in Swing (EVGS #6) High steps 1 Full clearance 0 Reduced clearance 1 None 2


Mid-Stance Front View R

Mid-Stance Front View L

Maximum Lateral Trunk Shift (EVGS #17) Reduced lat shift of trunk 1 Normal (approx 25 mm shift over stance leg) 0 Moderate inc lat shift 1 Severely inc lateral shift 2 Pelvic Obliquity (EVGS #14) Marked down (>10°) 2 Mod down (1°- 10°) 1 Normal (0°- 5° up) 0 Mod up (6° - 15°) 1 Marked up (>15°) 2 Knee Progression Angle (EVGS #8) External (part knee cap visible) 2 External (all knee cap visible) 1 Normal/Neutral (knee cap midline) 0 Internal (all knee cap visible) 1 Internal (part knee cap visible) 2 Foot Rotation/Progression Angle (EVGS #5) Marked ext > KPA (by > 40°) 2 Mod ext > KPA (by 21° - 40°) 1 Normal/ Sl more ext than KPA (0° - 20°) 0 Mod int > KPA (by 1° - 25°) 1 Marked int > KPA (by > 25°) 2

Maximum Lateral Trunk Shift (EVGS #17) Reduced lat shift of trunk 1 Normal (approx 25 mm shift over stance leg) 0 Moderate inc lat shift 1 Severely inc lateral shift 2 Pelvic Obliquity (EVGS #14) Marked down (>10°) 2 Mod down (1° - 10°) 1 Normal (0° - 5° up) 0 Mod up (6° - 15°) 1 Marked up ( >15°) 2 Knee Progression Angle (EVGS #8) External (part knee cap visible) 2 External (all knee cap visible) 1 Normal/Neutral (knee cap midline) 0 Internal (all knee cap visible) 1 Internal (part knee cap visible) 2 Foot Rotation/Progression Angle (EVGS #5) Marked ext > KPA (by > 40°) 2 Mod ext > KPA (by 21° - 40°) 1 Normal/ Sl more ext than KPA (0° - 20°) 0 Mod int > KPA (by 1° - 25°) 1 Marked int > KPA (by > 25°) 2


Mid-Stance Rear View R

Mid-Stance Rear View L

Hindfoot Valgus/Varus (EVGS #4) Severe valgus ( > 15°) 2 Moderate valgus (6 ° - 15°) 1 Normal (0 ° - 5° valgus) 0 Moderate Varus (1° - 10 °) 1 Severe Varus ( > 10 ° ) 2

Hindfoot Valgus/Varus (EVGS #4) Severe valgus ( > 15°) 2 Moderate valgus (6 ° - 15°) 1 Normal (0° - 5 ° valgus) 0 Moderate Varus (1° - 10°) 1 Severe Varus ( > 10° ) 2


Client Name: Date of Video: DOB/Age: Initial/Pre-op/Post-op/Follow-up (circle) MRN: Person scoring: Diagnosis/GMFCS: Background/Date of Surgery/Procedures:

Edinburgh Visual Gait Score: Summary Score Grid

Phases of Gait Cycle

Joint/Segment Trunk Pelvis Hip Knee Ankle Foot

Right Left Right Left Right Left Right Left Right Left Right Left Sagittal

Initial Contact

(13, 10, 1)

EVGS # 13 EVGS # 10 EVGS # 1

Mid Stance (16, 15, 2)


Terminal Stance

(12, 9, 3)


Mid Swing (11, 7, 6)


Coronal Mid Stance

front (17,14,8,5)

EVGS # 17 EVGS # 14 EVGS # 8 EVGS # 5

Mid Stance Back (4)

EVGS # 4

Segment Totals

0-4 0-4 0-4 0-8 0-6 0-8

Right LE Total

34

Left LE Total

34

Documents

Full course material can be downloaded from: … · Balance of Forces . a. External Forces (1) Stance Phase: Ground Reaction Force . AACPDM IC 9: Gait Analysis at Your Fingertips