IC 9: Gait Analysis at your Fingertips : Enhancing Observational Gait Analysis using Mobile Device Technology and the Edinburgh Visual Gait Scale

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Visual Gait Scale Jon R. Davids, MD Vedant A.

Children Northern California / University of California, Davis

1 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:

2 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 September 15, 2017 NORMAL GAIT AND IDENTIFICATION OF COMMON GAIT DEVIATIONS IN CHILDREN WITH CEREBRAL PALSY I. Normal Gait A. The Gait Cycle B.

3 AACPDM IC 9: Gait Analysis at Your Fingertips September 15, 2017 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 1

4 AACPDM IC 9: Gait Analysis at Your Fingertips September 15, 2017 (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 2

5 AACPDM IC 9: Gait Analysis at Your Fingertips September 15, 2017 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) 3

6 AACPDM IC 9: Gait Analysis at Your Fingertips September 15, 2017 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 Limited Flexion Excess Flexion Internal Rotation External Rotation Gait Cycle Cause Significance Initial Contact / Loading Response Compensation for weak hip extensor muscle group Pre-swing Weak hip flexor muscle group Mid-swing Weak hip flexor muscle group Impaired motor control Hip pain Initial Contact / Loading Response Spasticity / Contracture of hip flexor muscle group Compensation for excess knee flexion / ankle dorsiflexion Mid-swing Compensation for diminished knee flexion / ankle dorsiflexion Mid-stance Increased femoral anteversion Compensation for external pelvic rotation Mid-stance Diminished femoral anteversion Increased thigh girth Compensation for knee / ankle / foot pain Decreased shock absorption Diminished knee flexion in Swing Poor foot clearance Poor foot position for initial contact Increased demand on knee and hip extensor muscle groups Decreased limb stability Helps clearance Intoeing gait pattern Impaired forward progression Disrupts patellofemoral tracking Outtoeing gait pattern Increased base of support Decreased foot lever arm Excess loading of medial knee and ankle ligaments 4

7 AACPDM IC 9: Gait Analysis at Your Fingertips September 15, 2017 Mid-swing Compensation for weak hip flexor muscle group 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) Abduction Mid-stance Compensation for long reference limb Mid-swing Compensation for long reference limb Compensation for weak hip flexor muscle group Helps clearance Decreased base of support Decreased limb stability Functional lengthening of reference limb Increased base of support Functional shortening of reference limb Functional shortening of reference limb Helps reference limb advancement in Swing 5

8 AACPDM IC 9: Gait Analysis at Your Fingertips September 15, 2017 B. Common Deviations at the Knee Deviation Gait Cycle Cause Significance Limited flexion Initial Contact / Loading Response Excessive Flexion Weak knee extensor muscle group Knee pain Impaired proprioception Mid-swing Secondary to poor hip flexor function Rectus femoris spasticity Knee pain Initial Contact / Loading Response Knee flexion spasticity/contracture Impaired proprioception Mid-stance Knee flexion spasticity/contracture Impaired proprioception Terminal Swing Knee flexion spasticity/contracture Impaired proprioception Hyperextension Mid-stance Secondary to excessive ankle plantar flexion Impaired proprioception Intentional to increase limb stability Decreased shock absorption Poor foot clearance Poor foot position for initial contact Decreased shock absorption Increased demand on knee extensor muscle group Decreased stability Poor foot position for initial contact Decreased forward progression Damage to knee ligaments 6

9 AACPDM IC 9: Gait Analysis at Your Fingertips September 15, 2017 C. Common Deviations at the Ankle / Foot Deviation Gait Cycle Possible Causes Significance Toe Strike Initial Contact Foot Slap Excessive Plantar Flexion (Toe-walking) Excessive Plantar Flexion (Foot Drag) Early Heel Rise (Vaulting) Delayed/Absent Heel Rise Loading Response Inadequate knee extension in TSw Inadequate ankle dorsiflexion in TSw Compensation for knee extensor weakness Hindfoot pain Weak ankle dorsiflexor muscles Mid-stance Plantar flexor muscle group spasticity / contracture Compensation for knee extensor weakness Ankle pain Mid-swing / Terminal Swing Weak dorsi-flexor muscles Plantar flexor muscle group spasticity / contracture Limited voluntary motor control of dorsiflexor muscle group Mid-stance Compensation for long (anatomic or functional) contralateral limb in swing phase Terminal Stance Weak ankle plantar flexor muscles Mid- /Forefoot pain In-toeing Mid-stance Internal pelvic rotation Increased femoral anteversion Internal tibial torsion Varus foot malalignment Loss of first rocker Disruption of forward momentum Diminished shock absorption Disruption of forward momentum Diminished shock absorption Disrupted second rocker Poor foot clearance Poor foot position for subsequent initial contact Overload of ankle plantar flexor muscle group Disrupted third rocker Decreased step/stride length Disruption of forward progression Mid-swing Internal pelvic rotation Poor foot 7

10 AACPDM IC 9: Gait Analysis at Your Fingertips September 15, 2017 Increased femoral anteversion Internal tibial torsion Varus foot malalignment Out-toeing Mid-stance External pelvic rotation Diminished femoral anteversion External tibial torsion Terminal Stance Valgus foot malalignment External pelvic rotation Diminished femoral anteversion External tibial torsion Valgus foot malalignment clearance (hitting against opposite limb) Diminished stability Disrupted third rocker 8

11 AACPDM IC 9: Gait Analysis at Your Fingertips September 15, 2017 References Gage JR. An overview of normal walking. Instr Course Lect. 1990;39: Epub 1990/01/ Gage JR, DeLuca PA, Renshaw TS. Gait analysis: principle and applications with emphasis on its use in cerebral palsy. Instr Course Lect. 1996;45: Epub 1996/01/ 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; p Harvey A, Gorter JW. Video gait analysis for ambulatory children with cerebral palsy: Why, when, where and how! Gait Posture. 2011;33(3): Epub 2010/12/ Kaufman KR, Sutherland DH. Kinematics Of Normal Human Walking. In: Rose J, Gamble JG, editors. Human Walking. 3rd ed. Philadelphia: Lippincott Williams & Wilkins; p Ounpuu S. Patterns of Gait Pathology. In: Gage JR, editor. The Treatment of Gait Problems in Cerebral Palsy. London: Mac Keith Press; p Perry J, Burnfield J. Gait Analysis: Normal and Pathologic Function. 2nd ed. Thorofare, N.J.: Slack incorporated; Rathinam C, Bateman A, Peirson J, Skinner J. Observational gait assessment tools in paediatrics-- a systematic review. Gait Posture. 2014;40(2): Epub 2014/05/ 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): Epub 2006/10/ Rethlefsen SA, Kay RM. Transverse plane gait problems in children with cerebral palsy. J Pediatr Orthop. 2013;33(4): Epub 2013/05/ Rodda JM, Graham HK, Carson L, Galea MP, Wolfe R. Sagittal gait patterns in spastic diplegia. J Bone Joint Surg Br. 2004;86(2): Epub 2004/03/ Saunders JB, Inman VT, Eberhart HD. The major determinants in normal and pathological gait. J Bone Joint Surg Am. 1953;35-A(3): Epub 1953/07/ Sutherland DH, Davids JR. Common gait abnormalities of the knee in cerebral palsy. Clin Orthop Relat Res. 1993(288): Epub 1993/03/01. 9

12 AACPDM IC 9: Gait Analysis at Your Fingertips September 15, 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): Epub 1989/02/ 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): Epub 2004/12/23. 10

13 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)

14 Video-Based Gait Analysis using Huddl Technique Download App from Apple App Store or Google Play

Terminal Swing/Initial Contact R EVGS Scoring Worksheet 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

(EVGS #1) Heel Contact 0 Flatfoot Contact 1 Toe Contact 2 Terminal Swing/Initial Contact L Peak Hip Flexion (EVGS #13) Markedly increased flxn (>60 ) 2 Increased flxn (46-60 ) 1 Normal flxn (25-45 )

15 Terminal Swing/Initial Contact R EVGS Scoring Worksheet 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 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

EVGS Scoring Worksheet Mid-Stance Right 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

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 Mid-Stance Left Peak Sagittal

16 EVGS Scoring Worksheet Mid-Stance Right 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 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

17 EVGS Scoring Worksheet Terminal Stance R 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 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

EVGS Scoring Worksheet Mid-Swing R 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

18 EVGS Scoring Worksheet Mid-Swing R 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-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

Mid-Stance Front View R Mid-Stance Front View L EVGS Scoring Worksheet Maximum Lateral Trunk Shift (EVGS #17) Reduced lat shift of trunk 1 Normal (approx 25 mm shift over stance leg) 0 Moderate inc

19 Mid-Stance Front View R Mid-Stance Front View L EVGS Scoring Worksheet 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 ) 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 ) 1 Normal/ Sl more ext than KPA (0-20 ) 0 Mod int > KPA (by 1-25 ) 1 Marked int > KPA (by > 25 ) 2

20 Mid-Stance Rear View R EVGS Scoring Worksheet 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 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

21 Client Name: DOB/Age: MRN: Diagnosis/GMFCS: Background/Date of Surgery/Procedures: Date of Video: Initial/Pre-op/Post-op/Follow-up (circle) Person scoring: Edinburgh Visual Gait Score: Summary Score Grid Phases of Gait Cycle Initial Contact (13, 10, 1) Mid Stance (16, 15, 2) Terminal Stance (12, 9, 3) Mid Swing (11, 7, 6) Mid Stance front (17,14,8,5) Mid Stance Back (4) Segment Totals Joint/Segment Trunk Pelvis Hip Knee Ankle Foot Right Left Right Left Right Left Right Left Right Left Right Left Sagittal EVGS # 13 EVGS # 10 EVGS # 1 EVGS # 16 EVGS # 15 EVGS # 2 EVGS # 12 EVGS # 9 EVGS # 3 EVGS # 11 EVGS # 7 EVGS # 6 Coronal EVGS # 17 EVGS # 14 EVGS # 8 EVGS # 5 EVGS # Right LE Total 34 Left LE Total 34

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