INSTRUMENTED MOTION ANALYSIS COMPARED WITH TRADITIONAL PHYSICAL EXAMINATION AND VISUAL OBSERVATION

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1 INSTRUMENTED MOTION ANALYSIS COMPARED WITH TRADITIONAL PHYSICAL EXAMINATION AND VISUAL OBSERVATION Susan Rethlefsen, P.T., D.P.T. Motion Analysis Lab Physical Therapist, Children s Orthopaedic Center Children s Hospital Los Angeles and Tishya Wren, Ph.D. Director of Research, Children s Orthopaedic Center Children s Hospital Los Angeles Associate Professor, Department of Orthopaedic Surgery Keck-University of Southern California School of Medicine Objectives: 1) Summarize research comparing clinical evaluation and visual gait assessment to instrumented 3D gait analysis 2) Describe specific situations in which instrumented gait analysis is especially useful CLINICAL EVALUATION & VISUAL GAIT ASSESSMENT Relationship Between Clinical Evaluation and Dynamic Function 1. Poor correlation between static and dynamic joint ROM (McMulkin et al., 2000) 2. Cannot extrapolate passive ROM to dynamic function a. Children with hip flexion contracture often do not have excessive hip flexion during gait i. Weak association (r=0.41) between hip flexion contracture by Thomas test and peak hip extension during gait (Lee et al., 1997) ii. Half of children with >10 passive hip flexion contracture by Thomas test do not have excessive hip flexion in terminal stance (Rethlefsen et al., 2010) b. Tight plantarflexors can stretch under dynamic loading c. Popliteal angle does not indicate dynamic hamstring length during gait (Thompson et al., 2001) 3. Dynamic function depends on more than isometric muscle strength (Dallmeijer et al., 2011) a. Ankle moment during walking far exceeds moment generated by isometric plantarflexion. i. Children with CP have 90% reduction in plantarflexor strength compared with typical, but ankle moment during gait is only reduced 20%, power is reduced 40% Instrumented motion analysis compared to traditional techniques, AACPDM 2013 Part 3-1

2 Visual Versus Instrumented Gait Analysis 1. Observational gait scales provide structure for visual gait assessment a. Multiple scales have been developed i. Physician Rating Scale (Corry et al., 1998; Koman et al., 1993) 1. Observational Gait Scale (Boyd & Graham) 2. Visual Gait Assessment Scale (Dickens and Smith, 2006) 3. Video Gait Analysis (Ubhi et al., 2000) ii. Edinburgh Visual Gait Score (Read et al., 2003) iii. Salford Gait Tool (Toro et al., 2007a) b. Usually utilize split-screen biplanar video (front/back and side views) which can be viewed in slow motion or frame-by-frame c. Typically semi-quantitative, often using scores based on ranges of joint angles 2. Intra- and Inter-Observer Reliability a. Studies have generally shown reasonable intra- and inter-rater reliability (Dickens and Smith, 2006; Kawamura et al., 2007; Mackey et al., 2003; Read et al., 2003; Toro et al., 2007b; Viehweger et al., 2010; Wren et al., 2005) although one study reported excellent reliability within, but poor reliability between observers (Maathuis et al., 2005) b. Experienced observers are more reliable than inexperienced observers (Brown et al., 2008; Maathuis et al., 2005; Viehweger et al., 2010) c. Use of slow motion video can improve reliability, particularly at the knee and ankle (Wren et al., 2005) d. Reliability decreases proximally such that reliability is good at the foot and ankle but poor at the hip, pelvis, and trunk (Brown et al., 2008; Dickens and Smith, 2006; Read et al., 2003; Viehweger et al., 2010; Wren et al., 2005). Reliability at the knee is variable. 3. Accuracy / Validity a. Evaluated through comparison with 3DGA b. Some studies indicate moderate to good (58-64%) accuracy of visual assessment of joint angles (Mackey et al., 2003; Read et al., 2003) while others indicate poor accuracy (Dickens and Smith, 2006; Kawamura et al., 2007; Wren et al., 2005) c. Experienced observers are more accurate (Brown et al., 2008). Inexperienced observers have poor accuracy; accuracy of experienced observers is variable (Mackey et al., 2003). d. Use of slow motion video improves accuracy for foot contact, ankle, and knee but not hip (Wren et al., 2005) e. Accuracy is greatest for knee flexion/extension and pelvic obliquity (Kawamura et al., 2007; Wren et al., 2005) f. Ankle dorsiflexion is underestimated in visual assessment (Wren et al., 2005) g. Hip flexion is overestimated in visual assessment (Wren et al., 2005) h. Visual assessment is most accurate for extreme cases or when joint angles are clearly normal. The greatest inaccuracy occurs for borderline measurements, Instrumented motion analysis compared to traditional techniques, AACPDM 2013 Part 3-2

3 when accurate assessment is most critical for clinical decision making. (Wren et al., 2005) SPECIFIC APPLICATIONS OF COMPUTERIZED GAIT ANALYSIS 1. Transverse plane problems: intoeing, out toeing a. Often multiple causes of intoeing (Rethlefsen et al., 2006) i. Most often internal hip rotation/femoral anteversion and/or internal tibial torsion ii. Pes varus is a frequent cause in unilaterally involved patients, rare in bilaterally involved subjects iii. Pelvic rotation, metatarsus adductus also contribute in many cases b. Poor correlation between static measures of femoral anteversion and hip rotation and foot progression measured with gait analysis (Aktas et al., 2000; Carriero et al., 2009; Radler et al., 2010) c. Multiple causes of out-toeing i. External tibial torsion ii. External hip rotation iii. Pes valgus d. Case example of above video vs. gait analysis data 2. Varus feet in patients with CP a. Only dynamic EMG can identify cause(s) (Michlitsch et al., 2006; Scott and Scarborough, 2006) i. Posterior tibialis (PT) ii. Anterior tibialis (AT) iii. Both AT and PT iv. Bony deformities v. Other muscle imbalances (tight gastroc-soleus, peroneal weakness) b. Case example of above video vs. EMG 3. Valgus thrust at the knee in myelomeningocele a. Only kinematics and kinetics can determine if actual valgus or visual valgus i. True knee valgus thrust is more common in patients with greater levels of disability ii. Associated with hip abductor weakness and compensatory excessive trunk lateral lean during gait (Gupta et al., 2005; Ounpuu et al., 2000) iii. Visual assessments are inaccurate, often underestimate true valgus thrust 1. Visual valgus likely reflects combined internal hip/pelvic rotation, hip/knee flexion, and external rotation of the lower leg b. Case example of above video vs. kinematics and kinetics REFERENCES Aktas, S., Aiona, M.D., Orendurff, M., Evaluation of rotational gait abnormality in the patients cerebral palsy. Journal of pediatric orthopedics 20, Instrumented motion analysis compared to traditional techniques, AACPDM 2013 Part 3-3

4 Brown, C.R., Hillman, S.J., Richardson, A.M., Herman, J.L., Robb, J.E., Reliability and validity of the Visual Gait Assessment Scale for children with hemiplegic cerebral palsy when used by experienced and inexperienced observers. Gait Posture 27, Carriero, A., Zavatsky, A., Stebbins, J., Theologis, T., Shefelbine, S.J., Correlation between lower limb bone morphology and gait characteristics in children with spastic diplegic cerebral palsy. Journal of pediatric orthopedics 29, Corry, I.S., Cosgrove, A.P., Duffy, C.M., McNeill, S., Taylor, T.C., Graham, H.K., Botulinum toxin A compared with stretching casts in the treatment of spastic equinus: a randomised prospective trial. J Pediatr Orthop 18, Dallmeijer, A.J., Baker, R., Dodd, K.J., Taylor, N.F., Association between isometric muscle strength and gait joint kinetics in adolescents and young adults with cerebral palsy. Gait Posture 33, Dickens, W.E., Smith, M.F., Validation of a visual gait assessment scale for children with hemiplegic cerebral palsy. Gait Posture 23, Gupta, R.T., Vankoski, S., Novak, R.A., Dias, L.S., Trunk kinematics and the influence on valgus knee stress in persons with high sacral level myelomeningocele. Journal of pediatric orthopedics 25, Kawamura, C.M., de Morais Filho, M.C., Barreto, M.M., de Paula Asa, S.K., Juliano, Y., Novo, N.F., Comparison between visual and three-dimensional gait analysis in patients with spastic diplegic cerebral palsy. Gait Posture 25, Koman, L.A., Mooney, J.F., 3rd, Smith, B., Goodman, A., Mulvaney, T., Management of cerebral palsy with botulinum-a toxin: preliminary investigation. J Pediatr Orthop 13, Lee, L.W., Kerrigan, D.C., Della Croce, U., Dynamic implications of hip flexion contractures. American journal of physical medicine & rehabilitation / Association of Academic Physiatrists 76, Maathuis, K.G., van der Schans, C.P., van Iperen, A., Rietman, H.S., Geertzen, J.H., Gait in children with cerebral palsy: observer reliability of Physician Rating Scale and Edinburgh Visual Gait Analysis Interval Testing scale. J Pediatr Orthop 25, Mackey, A.H., Lobb, G.L., Walt, S.E., Stott, N.S., Reliability and validity of the Observational Gait Scale in children with spastic diplegia. Dev Med Child Neurol 45, McMulkin, M.L., Gulliford, J.J., Williamson, R.V., Ferguson, R.L., Correlation of static to dynamic measures of lower extremity range of motion in cerebral palsy and control populations. J Pediatr Orthop 20, Michlitsch, M.G., Rethlefsen, S.A., Kay, R.M., The contributions of anterior and posterior tibialis dysfunction to varus foot deformity in patients with cerebral palsy. The Journal of bone and joint surgery. American volume 88, Ounpuu, S., Thomson, J.D., Davis, R.B., DeLuca, P.A., An examination of the knee function during gait in children with myelomeningocele. Journal of pediatric orthopedics 20, Radler, C., Kranzl, A., Manner, H.M., Hoglinger, M., Ganger, R., Grill, F., Torsional profile versus gait analysis: consistency between the anatomic torsion and the resulting gait pattern in patients with rotational malalignment of the lower extremity. Gait & posture 32, Instrumented motion analysis compared to traditional techniques, AACPDM 2013 Part 3-4

5 Read, H.S., Hazlewood, M.E., Hillman, S.J., Prescott, R.J., Robb, J.E., Edinburgh visual gait score for use in cerebral palsy. J Pediatr Orthop 23, Rethlefsen, S.A., Healy, B.S., Wren, T.A., Skaggs, D.L., Kay, R.M., Causes of intoeing gait in children with cerebral palsy. The Journal of bone and joint surgery. American volume 88, Rethlefsen, S.A., Lening, C., Wren, T.A., Kay, R.M., Excessive hip flexion during gait in patients with static encephalopathy: an examination of contributing factors. J Pediatr Orthop 30, Scott, A.C., Scarborough, N., The use of dynamic EMG in predicting the outcome of split posterior tibial tendon transfers in spastic hemiplegia. Journal of pediatric orthopedics 26, Thompson, N.S., Baker, R.J., Cosgrove, A.P., Saunders, J.L., Taylor, T.C., Relevance of the popliteal angle to hamstring length in cerebral palsy crouch gait. J Pediatr Orthop 21, Toro, B., Nester, C.J., Farren, P.C., 2007a. The development and validity of the Salford Gait Tool: an observation-based clinical gait assessment tool. Archives of physical medicine and rehabilitation 88, Toro, B., Nester, C.J., Farren, P.C., 2007b. Inter- and intraobserver repeatability of the Salford Gait Tool: an observation-based clinical gait assessment tool. Archives of physical medicine and rehabilitation 88, Ubhi, T., Bhakta, B.B., Ives, H.L., Allgar, V., Roussounis, S.H., Randomised double blind placebo controlled trial of the effect of botulinum toxin on walking in cerebral palsy. Archives of disease in childhood 83, Viehweger, E., Zurcher Pfund, L., Helix, M., Rohon, M.A., Jacquemier, M., Scavarda, D., Jouve, J.L., Bollini, G., Loundou, A., Simeoni, M.C., Influence of clinical and gait analysis experience on reliability of observational gait analysis (Edinburgh Gait Score Reliability). Ann Phys Rehabil Med 53, Wren, T.A., Rethlefsen, S.A., Healy, B.S., Do, K.P., Dennis, S.W., Kay, R.M., Reliability and validity of visual assessments of gait using a modified physician rating scale for crouch and foot contact. J Pediatr Orthop 25, Instrumented motion analysis compared to traditional techniques, AACPDM 2013 Part 3-5