- Email: [email protected]
The quality assessment of gait in cerebral palsy
280
Gait and Posture 1995; 3: No 4
the movement of the hip, whereas symmetry of gait and the ROM of the knee improved in most patients. Interestingly, all but one of the hemiplegics showed slower mean velocity with their orthoses on, which reflected a prolongation of the support phase in hemiplegic limb.The parents reported a favourable effect in 17118 patients; the negative one was correctly identified also in the locomotion analysis. It was concluded that the registration yielded valuable, detailed information of the influence of the orthoses, and that the simplified scoring system made the information digestible, but that the lack of standardized norms for this equipment compromised the reliability of the interpretations. References
1 Butler P, Nene A. The biomechanics of fixed ankle foot orthoses and their potential in the management of cerebral palsied children. Physiotherapy1991; 77: 81-88. 2 Hylton N. Postural and functional impact of dynamic AFOs and FOs in a pediatric population. J ProsthetOrthot 1989; 2: 40-53. Hip function in cerebral palsy the kinematic and kinetic effects of psoassurgery C Y Chung, T F Novacheck, J R Gage
Motion Analysis Lab, Gillette Paul, MN, USA
Children’s
Hospital,
St
To evaluate the effects of surgery on the hip in patients with cerebral palsy, this study was undertaken at the Motion Analysis Laboratory at Gillette Children’s Hospital. In particular the changes due to psoas lengthening over the brim of the pelvis were assessed. The study group consisted of 34 subjects (48 sides) that had adequate preoperative and postoperative kinematic and kinetic data available for comparison. In addition, the study group was compared to a control group of 13 patients (14 sides) who underwent a comparable set of surgeries with the exception that no psoas surgery was performed. Each of the patients in both groups underwent multiple other procedures under the same anesthetic. The Vicon Clinical Manager was used to process the data. The preoperative kinematic status of the study and control groups was slightly different consistent with the preoperative decision-making regarding psoas lengthening. The peak (22”) and minimum (13”) anterior pelvic tilt was increased in the study group compared to normal but not in the controls (normal values are 13” and 1 lo, respectively). Hip motion was skewed toward flexion in both groups but to a greater extent in the study group. There was increased peak hip flexion in both groups (43” vs. 42”) at initial contact (normal 35”) and decreased peak hip extension (10” vs. 1” flexion) in preswing (normal 7” extension). Postoperatively, in the study group, all of these values significantly improved toward normal representing an
improvement in their crouch gait pattern. There was no change in the control group. Sagittal plane hip kinetics showed corresponding preoperative deviations in the study group including an increased peak hip extensor moment (0.82 Nm/kg) which occurred later in the gait cycle (13%) than normal (0.48 N&kg @ 4%). The hip moment crossover point from extension to flexion was also delayed to 41% of the gait cycle (normal = 24%). The peak hip flexor moment was similarly decreased (0.59 Nm/kg) and delayed (56%) compared to normals (1.08 Nm/kg @ 52%). Postoperatively, all of these values were significantly improved in both groups but more so in the study group. In addition, the total extensor moment and total flexor moment were improved with psoas surgery. The sagittal plane powers were also abnormal preoperatively in both the control and study groups. The power generation and absorption were diminished in both groups compared to normals. Postoperatively, the Hl generation peak was significantly decreased in the study group (0.12 to 0.05 J/kg) implying less hip flexor dominance. The H2 absorption peak increased (0.03 to 0.05 J/kg), but perhaps most importantly, the H3 hip flexor power generation was not diminished with psoas lengthening. These patients were found to have statistically increased walking velocity with diminished oxygen consumption and oxygen cost revealing overall improvement in their walking function with surgical intervention. This study shows that surgical intervention including psoas lengthening over the brim of the pelvis significantly improves hip kinematics and kinetics in nearly all aspects without sacrificing hip flexor power generation. The quality assessm ent of gait in cerebral palsy I Kelly, A Jenkinson, T O’Brien
Gait Laboratory, The Central Remedial tarf, Dublin 3, Ireland
Clinic, Clon-
Study Objective
To combine the kinematic, functional and cosmetic features of walking, to develop a Quality Score of gait in cerebral palsy. Design
Sixty children with spastic diplegia were randomly selected. All were independently ambulant. Each child was assessed in three ways. A. Sagittal plane kinematic analysis: We used the CODA-3 motion analyzer. B. Functional Walking Assessment: Each child performed eleven tasks of balance and an endurance test and was awarded a functional walking score. C. Cosmetic appearance scoring: A barometer of severity of the cosmetic appearance of walking was developed. Each patient was assessedby eight observers,
Abstracts
by video analysis, on two separate occasions, a minimum of four weeks apart. The kinematic and functional parameters of the first forty children were correlated with their cosmetic scores, to determine which parameters influenced the appearance of walking. These parameters were then combined and weighted, to be highly predictive of the cosmetic score. The same weighting of the objective data was applied to the final twenty patients, to test the accuracy of the weighting system. The combination of the weighted parameters allows prediction of visual appearance. We then developed a Quality Score which encompasses kinematic, functional and cosmetic features of walking. Results
Statical analysis of variance showed a high interobserver (0.907) reliability of the cosmetic scoring system. The features of walking that alter cosmetic appearance are velocity, balance and total range of motion of the six lower limb joints. No one joint has an effect on visual appearance. Conclusion
We have developed a means of quantifying the quality of walking in cerebral palsy. We have highlighted the features of walking that alter visual appearance. This is the first Quality Score of gait described. An investigation into the relationship measures and gait analysis variables J Linskell, S Fairgrieve
between clinical
The Dundee Gait Lab, DLFC, Scotland A retrospective study was carried out on data from 26 patients seen in the Dundee Gait Lab with a general diagnosis of spastic diplegia. Each patient underwent a full clinical examination and a gait analysis which included the use of Vicon Clinical Manager software for calculation of joint kinematics and kinetics. Dynamic surface EMG tests were carried out where appropriate. Clinical measurements taken into consideration were; i. Hip flexion contracture (Thomas test), ii. Popliteal angle, and iii. Duncan-Ely test (angle of positive test). These measures were considered in relation to the following sagittal plane gait analysis variables; i. Pelvic tilt, ii. Hip flexion-extension, and iii. Knee flexion-extension. Individual values, at key points of the gait cycle, were extracted from each gait variable. The difference between each patient’s legs were calculated for each variable. The differences were then statistically analyzed using paired f-tests. The analysis was performed on the whole study population and on population sub-groups defined by characteristics of pelvic tilt.
28 1
The population sub-groups were defined using the following pelvic tilt parameters; i. Mean pelvic tilt, ii. Range of pelvic tilt, and iii. Difference in pelvic tilt at contralateral mid-swing. Correlations were not obtained between clinical measures and gait parameters when considering population as a whole. However correlations were obtained between the clinical parameters and relevant gait analysis parameters for specific sub-groups of patients. These results indicate that dynamic pelvic tilt may be influenced by measurable clinical factors. The clinical interpretation of gait analysis data in diplegic cerebral palsy-an estimation problem? E B Zwick, L Doederlein. A Siebel, R Berghof
Department of Orthopedic Heidelberg, Germany
Surgery,
University
of
Introduction
An increasing number of medical institutions use sophisticated motion analysis equipment to quantify pathological gait. Cerebral palsy is one of the best studied pathologies in gait analysis and there are customly available applications that focus on the documentation of cerebral palsy locomotion. By applying well established protocols 3D gait analysis can be of benefit for diagnostic and documentation purposes in spastic movement disorders. Although some changes in joint angles, net joint moments and joint powers as well as in muscle activation patterns are well described and have been attributed to certain underlying pathomechanisms, there is still room for discussions on data interpretation and on clinical relevance. It was the purpose of this investigation to discuss a selection of interpretation and estimation problems which are sources for discussion in our clinical gait analysis laboratory. Methods
In the gait analysis laboratory at the Dept. of Orthopedic Surgery in Heidelberg we routinely use 3D gait analysis to quantify cerebral palsy gait. For the pre- and postoperative evaluations kinematic, kinetic, and electromyographic parameters are measured by applying a standard gait analysis protocol. The data acquisition and presentation of joint angles, net joint moments and joint powers follows the example given by the Newington Childrens Hospital, Newington, CT, USA. The staff of the gait laboratory and the involved orthopedic surgeons picked gait analysis parameters that they found to be difficult to interpret for clinical purposes. Out of a collective of 120 patients with diplegic cerebral palsy we used a relational database to identify feasible examples that could adequately illustrate the apparent problems. Selected Problems
The term ‘double bump’ pattern is frequently used to describe pelvic motion in the sagittal plane. In diplegic
Gait and Posture 1995; 3: No 4
the movement of the hip, whereas symmetry of gait and the ROM of the knee improved in most patients. Interestingly, all but one of the hemiplegics showed slower mean velocity with their orthoses on, which reflected a prolongation of the support phase in hemiplegic limb.The parents reported a favourable effect in 17118 patients; the negative one was correctly identified also in the locomotion analysis. It was concluded that the registration yielded valuable, detailed information of the influence of the orthoses, and that the simplified scoring system made the information digestible, but that the lack of standardized norms for this equipment compromised the reliability of the interpretations. References
1 Butler P, Nene A. The biomechanics of fixed ankle foot orthoses and their potential in the management of cerebral palsied children. Physiotherapy1991; 77: 81-88. 2 Hylton N. Postural and functional impact of dynamic AFOs and FOs in a pediatric population. J ProsthetOrthot 1989; 2: 40-53. Hip function in cerebral palsy the kinematic and kinetic effects of psoassurgery C Y Chung, T F Novacheck, J R Gage
Motion Analysis Lab, Gillette Paul, MN, USA
Children’s
Hospital,
St
To evaluate the effects of surgery on the hip in patients with cerebral palsy, this study was undertaken at the Motion Analysis Laboratory at Gillette Children’s Hospital. In particular the changes due to psoas lengthening over the brim of the pelvis were assessed. The study group consisted of 34 subjects (48 sides) that had adequate preoperative and postoperative kinematic and kinetic data available for comparison. In addition, the study group was compared to a control group of 13 patients (14 sides) who underwent a comparable set of surgeries with the exception that no psoas surgery was performed. Each of the patients in both groups underwent multiple other procedures under the same anesthetic. The Vicon Clinical Manager was used to process the data. The preoperative kinematic status of the study and control groups was slightly different consistent with the preoperative decision-making regarding psoas lengthening. The peak (22”) and minimum (13”) anterior pelvic tilt was increased in the study group compared to normal but not in the controls (normal values are 13” and 1 lo, respectively). Hip motion was skewed toward flexion in both groups but to a greater extent in the study group. There was increased peak hip flexion in both groups (43” vs. 42”) at initial contact (normal 35”) and decreased peak hip extension (10” vs. 1” flexion) in preswing (normal 7” extension). Postoperatively, in the study group, all of these values significantly improved toward normal representing an
improvement in their crouch gait pattern. There was no change in the control group. Sagittal plane hip kinetics showed corresponding preoperative deviations in the study group including an increased peak hip extensor moment (0.82 Nm/kg) which occurred later in the gait cycle (13%) than normal (0.48 N&kg @ 4%). The hip moment crossover point from extension to flexion was also delayed to 41% of the gait cycle (normal = 24%). The peak hip flexor moment was similarly decreased (0.59 Nm/kg) and delayed (56%) compared to normals (1.08 Nm/kg @ 52%). Postoperatively, all of these values were significantly improved in both groups but more so in the study group. In addition, the total extensor moment and total flexor moment were improved with psoas surgery. The sagittal plane powers were also abnormal preoperatively in both the control and study groups. The power generation and absorption were diminished in both groups compared to normals. Postoperatively, the Hl generation peak was significantly decreased in the study group (0.12 to 0.05 J/kg) implying less hip flexor dominance. The H2 absorption peak increased (0.03 to 0.05 J/kg), but perhaps most importantly, the H3 hip flexor power generation was not diminished with psoas lengthening. These patients were found to have statistically increased walking velocity with diminished oxygen consumption and oxygen cost revealing overall improvement in their walking function with surgical intervention. This study shows that surgical intervention including psoas lengthening over the brim of the pelvis significantly improves hip kinematics and kinetics in nearly all aspects without sacrificing hip flexor power generation. The quality assessm ent of gait in cerebral palsy I Kelly, A Jenkinson, T O’Brien
Gait Laboratory, The Central Remedial tarf, Dublin 3, Ireland
Clinic, Clon-
Study Objective
To combine the kinematic, functional and cosmetic features of walking, to develop a Quality Score of gait in cerebral palsy. Design
Sixty children with spastic diplegia were randomly selected. All were independently ambulant. Each child was assessed in three ways. A. Sagittal plane kinematic analysis: We used the CODA-3 motion analyzer. B. Functional Walking Assessment: Each child performed eleven tasks of balance and an endurance test and was awarded a functional walking score. C. Cosmetic appearance scoring: A barometer of severity of the cosmetic appearance of walking was developed. Each patient was assessedby eight observers,
Abstracts
by video analysis, on two separate occasions, a minimum of four weeks apart. The kinematic and functional parameters of the first forty children were correlated with their cosmetic scores, to determine which parameters influenced the appearance of walking. These parameters were then combined and weighted, to be highly predictive of the cosmetic score. The same weighting of the objective data was applied to the final twenty patients, to test the accuracy of the weighting system. The combination of the weighted parameters allows prediction of visual appearance. We then developed a Quality Score which encompasses kinematic, functional and cosmetic features of walking. Results
Statical analysis of variance showed a high interobserver (0.907) reliability of the cosmetic scoring system. The features of walking that alter cosmetic appearance are velocity, balance and total range of motion of the six lower limb joints. No one joint has an effect on visual appearance. Conclusion
We have developed a means of quantifying the quality of walking in cerebral palsy. We have highlighted the features of walking that alter visual appearance. This is the first Quality Score of gait described. An investigation into the relationship measures and gait analysis variables J Linskell, S Fairgrieve
between clinical
The Dundee Gait Lab, DLFC, Scotland A retrospective study was carried out on data from 26 patients seen in the Dundee Gait Lab with a general diagnosis of spastic diplegia. Each patient underwent a full clinical examination and a gait analysis which included the use of Vicon Clinical Manager software for calculation of joint kinematics and kinetics. Dynamic surface EMG tests were carried out where appropriate. Clinical measurements taken into consideration were; i. Hip flexion contracture (Thomas test), ii. Popliteal angle, and iii. Duncan-Ely test (angle of positive test). These measures were considered in relation to the following sagittal plane gait analysis variables; i. Pelvic tilt, ii. Hip flexion-extension, and iii. Knee flexion-extension. Individual values, at key points of the gait cycle, were extracted from each gait variable. The difference between each patient’s legs were calculated for each variable. The differences were then statistically analyzed using paired f-tests. The analysis was performed on the whole study population and on population sub-groups defined by characteristics of pelvic tilt.
28 1
The population sub-groups were defined using the following pelvic tilt parameters; i. Mean pelvic tilt, ii. Range of pelvic tilt, and iii. Difference in pelvic tilt at contralateral mid-swing. Correlations were not obtained between clinical measures and gait parameters when considering population as a whole. However correlations were obtained between the clinical parameters and relevant gait analysis parameters for specific sub-groups of patients. These results indicate that dynamic pelvic tilt may be influenced by measurable clinical factors. The clinical interpretation of gait analysis data in diplegic cerebral palsy-an estimation problem? E B Zwick, L Doederlein. A Siebel, R Berghof
Department of Orthopedic Heidelberg, Germany
Surgery,
University
of
Introduction
An increasing number of medical institutions use sophisticated motion analysis equipment to quantify pathological gait. Cerebral palsy is one of the best studied pathologies in gait analysis and there are customly available applications that focus on the documentation of cerebral palsy locomotion. By applying well established protocols 3D gait analysis can be of benefit for diagnostic and documentation purposes in spastic movement disorders. Although some changes in joint angles, net joint moments and joint powers as well as in muscle activation patterns are well described and have been attributed to certain underlying pathomechanisms, there is still room for discussions on data interpretation and on clinical relevance. It was the purpose of this investigation to discuss a selection of interpretation and estimation problems which are sources for discussion in our clinical gait analysis laboratory. Methods
In the gait analysis laboratory at the Dept. of Orthopedic Surgery in Heidelberg we routinely use 3D gait analysis to quantify cerebral palsy gait. For the pre- and postoperative evaluations kinematic, kinetic, and electromyographic parameters are measured by applying a standard gait analysis protocol. The data acquisition and presentation of joint angles, net joint moments and joint powers follows the example given by the Newington Childrens Hospital, Newington, CT, USA. The staff of the gait laboratory and the involved orthopedic surgeons picked gait analysis parameters that they found to be difficult to interpret for clinical purposes. Out of a collective of 120 patients with diplegic cerebral palsy we used a relational database to identify feasible examples that could adequately illustrate the apparent problems. Selected Problems
The term ‘double bump’ pattern is frequently used to describe pelvic motion in the sagittal plane. In diplegic