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Evaluation of rotational gait abnormality in the patients with cerebral palsy
Abstracis EVALUATION OF ROTATIONAL WITB CEREBRAL PALSY
GAIT ABNORMALITY
I Gait & Posture
7 (1998)
144490
IN THE PATIENTS
Seref Aktas, MD, Michael D Aiona. MD, Michael OrendurE, MS Shriners Hospital For Childrm Portland, Dregon 97201
Ambulatory patients with Cerebral Palsy (CP) may present with complex 3-D gait abnormalities.Many studies have described the segittal plane gait deviations in this patient population. However, transverse plane deviations can be present with the intental rotation of the femur commottly seen. These gait deviations can be identitied by observation and quantified by 3-D instrumented gait analysis. The purpose of this study is to detamine if static physical exam measures and /or computed axial tomography (CT) radiologic evaluation of torsional deformities CM quantitatively predict the amount of gait deviation present
Evaluation of 13 ambulatory CP patients consisted of static physical exam (FE) measures of the femoral arc of rotation in hip eaemion, thigh-foot aegJeand tmesmalleoler axis in prone position. Radiognpbic assessment included stattdard CT scan -rements of frmorai anteversion &l tibiel torsion. I of the 13 patients did not bwe a tibial CT scan Gait data was u&cted wins . Ccamen VICON 370 system with two AMTI force plates, and subsequently pro&d wing VICON Clitti&l Manager s&ware (&ford Metrics, oxford, Englettd). Gait analysis data of the shtdy gmttp was reviewed and average hip rotation and average tibial rotation were calatlated for each limb during gait The data gathered from PE and CT 8cans were analyzed stUistically with linear regression analysis to the average rotation of each segmentdwitt8 geit
On PE of 26 hips, the PE wera8zehip intental rotation wu 63. I’=*1 I .9Owith average hip extetnel rotetion of 23.3“+14.6“. The wemae thiab foot attule of 24 leas was 13.8°*Z0.20. with en everqe tmnsmdlleolx tis of 185°~18.80. Gai~attalysis d& documeeted an average internal hip rotation of lS.0°i13.P and an average extental tibial rotation of 24.0%24.6. CT evektetion revealed fwml anteversion angles benveee -9 P and 60’ with e man of 30.3*+16 3Oend external tibial torsion between -8 9 and 62’ with the mean of 35 I”*18 8” Lii rqlrrssion enslysis reveekd no reledonship behveett the varisbles for the hips. PE intent& external hio rotation as well as CT femoral anteversion failed to quantitatively predii j, medial hip rotation in gait (T&k I). The relationship between transmalleoler axis, thigh-foot angle, CT tibia1 torsion nteasuremettt and gait analysis tibial rotation were statistic& significant The best predictor of gait tibial rotation was CT tibial rotation meawement followed by thigh foot angle and transmalle&r axis respectively (Table 2)
Discussion Excessive femoral anteversion and increased static internal bip rotation are commonly present in the patient with cerebral palsy. Though many patients may have these identified abnortttalities, the e&t of femoral anteversion on gait is variable and unpredictable In CP. spastic muscles contribute to dynamic defomtify. For example, we b&l two patients with almost same CT femoral anteversion values (20’ and 20.97: Whik the one with 20’ femoral anteversion walked with 60.3” internal hip rotation, the’other with 20.9’ femoral etttwtion wdked with 12.6Ointernal hip rotation. Hip mtation during the gait is subject to both dynamic forces and anatomic variations In our study, the static measurements failed to predict the gait hip rotation but did predict the tibial rotation during gait. Tibial rotation can not be a&ted by abnotnul muscle forces As such CT scan correlated well with the tibial rotation seen in gait. Based cm this study, CT ecaes are no longer obtained on the CP patients to quantify femoral anteversion for evaluation of rotational ebncmdities es its contribution is variable patient to patient. The question remains whether the amowt of rotetionnl correction paformed in surgery should be based on quantified amaunt of deviation meawred on gait enaJy& or bucd on nomulization of the phyajcal exam or anwersion mew.& radiogmpbicdlly es the static and dynamic cmnponutts cmtrib4on veties in each patient Acknowledgment: We would like to thank Roseamy Pierce. PT and Linda Smith Portland Sbrie-em Hospital For Cbildme Gait Amdwis Laboratorv for their e%brt in suppat of this study.
Wellding Punctiost in Children with Cerebral P&y : Stride AdeptehiIity end Gross Motor Skills Nencv Lennon PT’, Freeman Miller, M.D.‘, Patrick Castagna, M S ’ * lames Richards. Ph.D l Memo Orlin. PT. M.S .** *The duPont Hospital For Children~ Wilmbtgb&, DE’19899 l *Alleghmty University of the Health Sciences, Philadelphia,PA 19102 Iatmduetion: The sophisticated and adaptablenature of human walking emerges in the early childhood years as multiple body systems organize propulsive forces and balance requirements for gait In the child with cerebral palsy (C P ). impaimtents in muscle tone.
upright locomotion. The abtmdaw of deb on tcmpoml-epetial gait patterm children with C.P supports this observuion. Sludii that exetnined stride diannsions st differeet walking spuds bwe shown that children with C.P. have e limited ability to vaty walking speed,and we different stntegies than able-bodied peers to increase walking speed The goals of this project were to examine the strategies uwd to adapt stride dimensions, and to describe the relationship of stride pattans to gross motor abilitieu in children with cerebral Palsy Methoddog: Thirty children, ranging in agefrom six to fourken, with a diagwsis of spastic cerebral palsy were tested for this pmject All children were able to walk a mimmum of thiny meters without an usistive device Physical examination included lower extremity goiniometry, ettthropmxeaiw, snd muscle tone usasmmt Motor ability wss evaluated by sdminismtiott of the Gross Motor Function Measure. Fxb child wre his or her usual footwear for the gmsa motor and wlking test collection. A tbrc+ dimensional high-resolution video system was used for collection of the gait data Retroreflective markers were tapedto the subjects’ sneakem at the first metatarsal head, posterior cakanmus, and superior aspect of the sacrum. Children were asked to walk a minimum of three time8 along a twelve meter walkway in each of four conditions Selfselected speed and fart walking conditions were collected first. The child’s natural cadence was calctdued fmm e self-selected speal trial Next. the child practiced walking in rhythm to a metmnonte set first at this n&al cadence, then set at a &dence IS-2O!hlower and I5-20% hiaha than natural. Followina the twactice session. three walkinn trials at lower and at three G higher cadexe were c&&d ‘This method ofmutipulsting~peed and step frequency pmdwed s wide range of temporal-spstial datafor each subject Gait cycle evarts were idmtified from toe and heel msrkers using s projkt specific pmgmm Each subjects’ ability to walk et the expected low and high cadence wea examined by comparing the achieved to the expected cadence Mean values for velocity, stride and step lengths, cadence, and support times were calculated for each walking wndltion The percent change (from natural) for each vanable in each condition was generated Preliminary analysis on this data w.w initiated using descriptive stetistics to Identify the strategies used to adapt stride dimensions and the relationship between adaptive patents and gross motor ability Results: Preliminary analysis includes data from twenty five subjeas Natural or selfselectedwalking speed, fast walking speed,and percmtt increase in speed were all found to be positively correlated with GMFM t&al wxe Strategiesused by those subjects who were able to increase walking speedranged from elewting cadettec only to increasing stride length and cadencein prop&ion. The letter p&tent was adopted by the highest functioning children. The youngest subjects relied on elevating cadence alone to achieve faster speeds. With r@rd to the conditions of high and low imposed c&we, 76% of subjects successfully walked at the low cedettce, and 88% walked et the expecied high cadence. Failure to achieve a de&d cadencewas ietluettced by age;the younga subjects had difficulty with dtc low cadence.and subjects who failed the high cadence condition were older Adaptations to the high cadence condition were similar to those made in the fast condition for the majority of subjects h4ost ntbjecta append to achieve their maximum cadence during the fast walking trials. Subjects with the mc+t limited motor function decreasedboth walking speedand step length to achieve the imposed high cadence Adaptations to the low cadencealso appearal to be related to motor function Subjects with the highest motor function tendedto maintain a velocity similar to their self selected condition, and so ittcredsed their stride length to achieve the imposed low cadence A secmtd strategy observed in the high motor timctioning subjects wss to maintain their natural stride length, and slightly reduce walking speed Finally, the lowest motor functioning subjects achieved the low cadence by dmmatically reducing velocity, using a proportional decrease in both stride ler& and cadence Discussion: Preliminary findings from this study sre cm&tent with thme of Abel and Drouin (1996) with regard to the stride patterns of children with cerebal palsy. Walking speed in self-selected and fast conditions is relatedto the extent of motor impairment in this population As Abel and colleagues found, there is a strong preference in children with C P to elevatecadence over stride length to walk at fasta speeds This is most evident in young children, evm those with minimal nunor impaimtenb. The expected normal trend in fast walhng is to achieve higher maximum cadencevalue8 with increasmg The reverse wes observed in our sample. At older ages.differences in the strategies used to increase speedwere ntost apparent, and were related to motor function Perhaps the higher functioning children leareednew and more dficient walking strategieswith age Additionally, the observation in certain subjects of lengthening strides at reduced cadence values suppottt the idea that children with C P can learn to adopt a more eff~cwnt stride panem Some of the strategies identified in this study may be effective in teaching younger patients with C P to overcome velocity-induced spasticity during gait
age
Referettces Abel MF et al Jowml ofPtx6aIric Ord~~pae&s, 16 753-758, 1996 Drouin LM et al Dew/opmenra/~&inr ondChi/dNeuro/o~. 38 1007-1019, Holt KG et al Medicine and Science in Sports andFxercire, 23 491-498, 1991 Norlin R et al Journal of Perlialric Orthopaedics. 6.6’kW 1986
1996
OF KINEMATIC DATA: VISUAL vs. COMPUTER-BASED ANALYSIS TECHNIQUES mDobson. B.S., Jennifer Dabelstein, B.Phty., Anita BagleY,Ph.D., Jon Davids, M.D. Sbriners Hospital for Crippled Children. 950 West Fans Road.Greenville, SC 29605
INTERPI~I~TATION
Introduction Clinical interpretation of three-dimensionaljoint motion data (generatedvia computerized gait analvsis) is tycdcally performed visually. Treatment recommendations are based on both qua&&e &d qu.&tivc judgments of this date. The accuracy of this visually based technique versus a computer-based analysis of the same data has not been determined. The feasibility of applying tiifkial inldigettCe (Al) techniques to the intexpretation of kinematic data, both for clinicsl and research work. has just begun to be explored (Bagley et al., 19%). ‘Thequestion addressed by thu study is. what is the observer versus computer-based reliability of this data analysis? We hypothesize that observer and computer agreement will be high if the rules Wr the computer are appropriately defined.
GAIT ABNORMALITY
I Gait & Posture
7 (1998)
144490
IN THE PATIENTS
Seref Aktas, MD, Michael D Aiona. MD, Michael OrendurE, MS Shriners Hospital For Childrm Portland, Dregon 97201
Ambulatory patients with Cerebral Palsy (CP) may present with complex 3-D gait abnormalities.Many studies have described the segittal plane gait deviations in this patient population. However, transverse plane deviations can be present with the intental rotation of the femur commottly seen. These gait deviations can be identitied by observation and quantified by 3-D instrumented gait analysis. The purpose of this study is to detamine if static physical exam measures and /or computed axial tomography (CT) radiologic evaluation of torsional deformities CM quantitatively predict the amount of gait deviation present
Evaluation of 13 ambulatory CP patients consisted of static physical exam (FE) measures of the femoral arc of rotation in hip eaemion, thigh-foot aegJeand tmesmalleoler axis in prone position. Radiognpbic assessment included stattdard CT scan -rements of frmorai anteversion &l tibiel torsion. I of the 13 patients did not bwe a tibial CT scan Gait data was u&cted wins . Ccamen VICON 370 system with two AMTI force plates, and subsequently pro&d wing VICON Clitti&l Manager s&ware (&ford Metrics, oxford, Englettd). Gait analysis data of the shtdy gmttp was reviewed and average hip rotation and average tibial rotation were calatlated for each limb during gait The data gathered from PE and CT 8cans were analyzed stUistically with linear regression analysis to the average rotation of each segmentdwitt8 geit
On PE of 26 hips, the PE wera8zehip intental rotation wu 63. I’=*1 I .9Owith average hip extetnel rotetion of 23.3“+14.6“. The wemae thiab foot attule of 24 leas was 13.8°*Z0.20. with en everqe tmnsmdlleolx tis of 185°~18.80. Gai~attalysis d& documeeted an average internal hip rotation of lS.0°i13.P and an average extental tibial rotation of 24.0%24.6. CT evektetion revealed fwml anteversion angles benveee -9 P and 60’ with e man of 30.3*+16 3Oend external tibial torsion between -8 9 and 62’ with the mean of 35 I”*18 8” Lii rqlrrssion enslysis reveekd no reledonship behveett the varisbles for the hips. PE intent& external hio rotation as well as CT femoral anteversion failed to quantitatively predii j, medial hip rotation in gait (T&k I). The relationship between transmalleoler axis, thigh-foot angle, CT tibia1 torsion nteasuremettt and gait analysis tibial rotation were statistic& significant The best predictor of gait tibial rotation was CT tibial rotation meawement followed by thigh foot angle and transmalle&r axis respectively (Table 2)
Discussion Excessive femoral anteversion and increased static internal bip rotation are commonly present in the patient with cerebral palsy. Though many patients may have these identified abnortttalities, the e&t of femoral anteversion on gait is variable and unpredictable In CP. spastic muscles contribute to dynamic defomtify. For example, we b&l two patients with almost same CT femoral anteversion values (20’ and 20.97: Whik the one with 20’ femoral anteversion walked with 60.3” internal hip rotation, the’other with 20.9’ femoral etttwtion wdked with 12.6Ointernal hip rotation. Hip mtation during the gait is subject to both dynamic forces and anatomic variations In our study, the static measurements failed to predict the gait hip rotation but did predict the tibial rotation during gait. Tibial rotation can not be a&ted by abnotnul muscle forces As such CT scan correlated well with the tibial rotation seen in gait. Based cm this study, CT ecaes are no longer obtained on the CP patients to quantify femoral anteversion for evaluation of rotational ebncmdities es its contribution is variable patient to patient. The question remains whether the amowt of rotetionnl correction paformed in surgery should be based on quantified amaunt of deviation meawred on gait enaJy& or bucd on nomulization of the phyajcal exam or anwersion mew.& radiogmpbicdlly es the static and dynamic cmnponutts cmtrib4on veties in each patient Acknowledgment: We would like to thank Roseamy Pierce. PT and Linda Smith Portland Sbrie-em Hospital For Cbildme Gait Amdwis Laboratorv for their e%brt in suppat of this study.
Wellding Punctiost in Children with Cerebral P&y : Stride AdeptehiIity end Gross Motor Skills Nencv Lennon PT’, Freeman Miller, M.D.‘, Patrick Castagna, M S ’ * lames Richards. Ph.D l Memo Orlin. PT. M.S .** *The duPont Hospital For Children~ Wilmbtgb&, DE’19899 l *Alleghmty University of the Health Sciences, Philadelphia,PA 19102 Iatmduetion: The sophisticated and adaptablenature of human walking emerges in the early childhood years as multiple body systems organize propulsive forces and balance requirements for gait In the child with cerebral palsy (C P ). impaimtents in muscle tone.
upright locomotion. The abtmdaw of deb on tcmpoml-epetial gait patterm children with C.P supports this observuion. Sludii that exetnined stride diannsions st differeet walking spuds bwe shown that children with C.P. have e limited ability to vaty walking speed,and we different stntegies than able-bodied peers to increase walking speed The goals of this project were to examine the strategies uwd to adapt stride dimensions, and to describe the relationship of stride pattans to gross motor abilitieu in children with cerebral Palsy Methoddog: Thirty children, ranging in agefrom six to fourken, with a diagwsis of spastic cerebral palsy were tested for this pmject All children were able to walk a mimmum of thiny meters without an usistive device Physical examination included lower extremity goiniometry, ettthropmxeaiw, snd muscle tone usasmmt Motor ability wss evaluated by sdminismtiott of the Gross Motor Function Measure. Fxb child wre his or her usual footwear for the gmsa motor and wlking test collection. A tbrc+ dimensional high-resolution video system was used for collection of the gait data Retroreflective markers were tapedto the subjects’ sneakem at the first metatarsal head, posterior cakanmus, and superior aspect of the sacrum. Children were asked to walk a minimum of three time8 along a twelve meter walkway in each of four conditions Selfselected speed and fart walking conditions were collected first. The child’s natural cadence was calctdued fmm e self-selected speal trial Next. the child practiced walking in rhythm to a metmnonte set first at this n&al cadence, then set at a &dence IS-2O!hlower and I5-20% hiaha than natural. Followina the twactice session. three walkinn trials at lower and at three G higher cadexe were c&&d ‘This method ofmutipulsting~peed and step frequency pmdwed s wide range of temporal-spstial datafor each subject Gait cycle evarts were idmtified from toe and heel msrkers using s projkt specific pmgmm Each subjects’ ability to walk et the expected low and high cadence wea examined by comparing the achieved to the expected cadence Mean values for velocity, stride and step lengths, cadence, and support times were calculated for each walking wndltion The percent change (from natural) for each vanable in each condition was generated Preliminary analysis on this data w.w initiated using descriptive stetistics to Identify the strategies used to adapt stride dimensions and the relationship between adaptive patents and gross motor ability Results: Preliminary analysis includes data from twenty five subjeas Natural or selfselectedwalking speed, fast walking speed,and percmtt increase in speed were all found to be positively correlated with GMFM t&al wxe Strategiesused by those subjects who were able to increase walking speedranged from elewting cadettec only to increasing stride length and cadencein prop&ion. The letter p&tent was adopted by the highest functioning children. The youngest subjects relied on elevating cadence alone to achieve faster speeds. With r@rd to the conditions of high and low imposed c&we, 76% of subjects successfully walked at the low cedettce, and 88% walked et the expecied high cadence. Failure to achieve a de&d cadencewas ietluettced by age;the younga subjects had difficulty with dtc low cadence.and subjects who failed the high cadence condition were older Adaptations to the high cadence condition were similar to those made in the fast condition for the majority of subjects h4ost ntbjecta append to achieve their maximum cadence during the fast walking trials. Subjects with the mc+t limited motor function decreasedboth walking speedand step length to achieve the imposed high cadence Adaptations to the low cadencealso appearal to be related to motor function Subjects with the highest motor function tendedto maintain a velocity similar to their self selected condition, and so ittcredsed their stride length to achieve the imposed low cadence A secmtd strategy observed in the high motor timctioning subjects wss to maintain their natural stride length, and slightly reduce walking speed Finally, the lowest motor functioning subjects achieved the low cadence by dmmatically reducing velocity, using a proportional decrease in both stride ler& and cadence Discussion: Preliminary findings from this study sre cm&tent with thme of Abel and Drouin (1996) with regard to the stride patterns of children with cerebal palsy. Walking speed in self-selected and fast conditions is relatedto the extent of motor impairment in this population As Abel and colleagues found, there is a strong preference in children with C P to elevatecadence over stride length to walk at fasta speeds This is most evident in young children, evm those with minimal nunor impaimtenb. The expected normal trend in fast walhng is to achieve higher maximum cadencevalue8 with increasmg The reverse wes observed in our sample. At older ages.differences in the strategies used to increase speedwere ntost apparent, and were related to motor function Perhaps the higher functioning children leareednew and more dficient walking strategieswith age Additionally, the observation in certain subjects of lengthening strides at reduced cadence values suppottt the idea that children with C P can learn to adopt a more eff~cwnt stride panem Some of the strategies identified in this study may be effective in teaching younger patients with C P to overcome velocity-induced spasticity during gait
age
Referettces Abel MF et al Jowml ofPtx6aIric Ord~~pae&s, 16 753-758, 1996 Drouin LM et al Dew/opmenra/~&inr ondChi/dNeuro/o~. 38 1007-1019, Holt KG et al Medicine and Science in Sports andFxercire, 23 491-498, 1991 Norlin R et al Journal of Perlialric Orthopaedics. 6.6’kW 1986
1996
OF KINEMATIC DATA: VISUAL vs. COMPUTER-BASED ANALYSIS TECHNIQUES mDobson. B.S., Jennifer Dabelstein, B.Phty., Anita BagleY,Ph.D., Jon Davids, M.D. Sbriners Hospital for Crippled Children. 950 West Fans Road.Greenville, SC 29605
INTERPI~I~TATION
Introduction Clinical interpretation of three-dimensionaljoint motion data (generatedvia computerized gait analvsis) is tycdcally performed visually. Treatment recommendations are based on both qua&&e &d qu.&tivc judgments of this date. The accuracy of this visually based technique versus a computer-based analysis of the same data has not been determined. The feasibility of applying tiifkial inldigettCe (Al) techniques to the intexpretation of kinematic data, both for clinicsl and research work. has just begun to be explored (Bagley et al., 19%). ‘Thequestion addressed by thu study is. what is the observer versus computer-based reliability of this data analysis? We hypothesize that observer and computer agreement will be high if the rules Wr the computer are appropriately defined.