Introduction. Research Using Motion Analysis: Movement Pathology. Objectives. Outline. Textbook gait description: Charcot-Marie-Tooth CMT

Transcription

1 roduction Research Using Motion Analysis: Impact in Understanding Movement Pathology Sylvia Õunpuu, MSc Kristan Pierz, MD Center for Motion Analysis Connecticut Children s Medical Center Motion analysis techniques have been used to understand typical and pathological movement since the 10 s Computerized motion analysis moved this tool from the research realm into routine clinical services in the 19 s The resulting documentation of movement has expanded to a wide variety of gait pathologies Outline Review how motion analysis has improved our understanding of movement pathology that impacts children s gait Charcot-Marie-Tooth Myelomeningocele Cerebral palsy Natural progression Prevalence of gait deviations Classification/patterns Skeletal modeling Objectives At the end of this section, participants will be able to: Describe how motion analysis has improved our understanding of the pathomechanics in a number of gait pathologies Charcot-Marie-Tooth CMT most commonly inherited neurological disorder = de-myelination of large peripheral nerves CMT is characterized by: distal muscle weakness and imbalance foot and ankle deformities associated gait implications impairment progression at varying rates Textbook gait description: foot drop (excessive equinus) in swing phase steppage (hyper- flexion of knee and hip in swing) circumduction and pelvic hiking in swing (Fenton, JOPA 1984) (Morrisy, Pediatric Orthopedics) (Vinci, Archives of Physical Medicine & Rehab 02) Motion analysis in understanding gait pathology, AACPDM 13 Part 2-1

2 iations in presentation... CMT and Motion Analysis Adults or across all ages Vinci et al, Archives of Phys Med and Rehab, 02 CMT patients grouped together Newman et al, Gait and ture, 07 Don et al, Clinical Biomechanics, 07 Description of different gait patterns Burns et al. Muscle and Nerve, 09 Ferrarin et al, Gait and ture, 11 Õunpuu et al, Gait and ture, 13 (Õunpuu S et al, Gait and ture, 13) Clinical Examination Findings The most common impairments at the ankle reduced passive dorsiflexion ROM plantar flexor weakness dorsiflexor, forefoot invertors and evertors ertors weakness cavus Ankle Sagittal Plane Kinematic Sub Groups less than typical (dashdot) typical (large dash) greater than typical (solid) Long axis of the shank vs. plantar aspect of the foot Group 1 Toe Walkers Group 2 Cavus Foot (toe walkers = dashed/dot black line) (cavus foot = large dashed red line) Motion analysis in understanding gait pathology, AACPDM 13 Part 2-2

3 Group 3 Flail Foot (flail foot = solid blue line) Conclusions Patients with CMT present differently from typically developing and within the diagnosis Therefore, TREATMENT needs to be SPECIFIC to the INDIVIDUAL patient Weak plantar flexors were consistent with the functional findings reported by many patients difficulty in running Delayed peak dorsiflexion may be the first gait sign of CMT Treatment Implications Relationship between cavus and ankle dorsiflexion capability (plantar flexor length)? Consider benefit of some plantar flexor tightness with simultaneous plantar flexor weakness? Implications of progressive weakness? Õunpuu et al., Gait and ture, 13. Future What is left to do! Motion analysis can help establish: How pathomechanics related to phenotype Understanding of functional changes with disease progression Define prognosis of future function using documentation of pathomechanics and phenotype Treatment outcomes studies More detailed foot skeletal model needed Congenital malformation that results from failure of embryonic neural tube closure. 4-5 of every 10,000 births Damage to the spinal cord and other congenital deformities persist Myelomenigocele Implications for Ambulation Characterized by level of lesion: sacral, low lumbar (L5 and L4), etc. Loss of muscle function weakness to paralysis Sensory dfiit deficits Asymmetry in lower extremity function Contractures and bony torsions Balance issues related to CNS injury and weakness Functional loss over time: tethered cord Spasticity Motion analysis in understanding gait pathology, AACPDM 13 Part 2-3

4 Pathomechanics of Myelomeningocele Vankoski SJ et al,. Characteristic pelvic, hip, and knee kinematic patterns in children with lumbosacral myelomeningocele, Gait and ture, 3(1):51-57, Duffy, C. M., Three-Dimensional Gait Analysis in Spina Bifida, JPO, 16(6): , Byung Kyu Park et al., Gait electromyography in children with myelomeningocele at the sacral level, Rehabilitation, 78(5):Pages , Õunpuu S, et al., An Examination of the Knee Function During Gait in Children with Myelomeningocele, JPO, (5), , 00. Pathomechanics of Myelomeningocele Bartonek A et al, per body movement during walking in children with lumbo sacral myelomeningocele, Gait and ture, 15(2), 1-129, 02. Gutierrez EM et al, Characteristic gait kinematics in persons with lumbosacral myelomeningocele, Gait and ture, 18(3): , 03. Gutierrez EM, et al., Centre of mass motion during gait in persons with myelomeningocele, Gait and ture, 18(2): 37-46, 03. Gutierrez EM et al, Kinetics of compensatory gait in persons with myelomeningocele, Gait and ture, 21(1), 12-23, 05. Energy Cost Thomas, Susan Sienko, Longitudinal Assessment of Oxygen Cost and Velocity in Children With Myelomeningocele: Comparison of the Hip-Knee- Ankle-Foot Orthosis and the Reciprocating Gait Orthosis, JPO, 21(6): 798-3, 01 Galli M et al.,, Energy consumption and gait analysis in children with myelomeningocele, Functional Neurology, 15(3): , 00. Treatment Assessment Lim, R et al., gus Knee Stress in Lumbosacral Myelomeningocele: A Gait-Analysis Evaluation, JPO, 18(4): ,1988. Hullin, MG et al., Ankle-Foot Orthosis Function in Low-Level Myelomeningocele, JPO, 12(4): , Õunpuu S et al., Joint kinetics: methods, interpretation and treatment decision-making in children with cerebral palsy and myelomeningocele, Gait and ture, 4(1): 62-78, Thomson, JD et al., The Effects of Ankle-Foot Orthoses on the Ankle and Knee in Persons with Myelomeningocele: An Evaluation Using Three-Dimensional Gait Analysis, JPO, 19(1): 27-33, Sacral Level 1 Barefoot Walking Sagittal Plane Kinetics - Right Partial loss of: intrinsics of the foot, gastrocnemius, soleus, lateral hamstrings and gluteus maximus. Hip and knee Typical Ankle Increased dorsiflexion terminal stance Passive ankle ROM typical Plantar flexor strength 4/5 Motion analysis in understanding gait pathology, AACPDM 13 Part 2-4

5 60 Dor Pla - Pfl Dfl Add Abd Add Abd Abd Add Gait Cycle Gait Cycle 60 Dor Pla - Gait Cycle Gait Cycle Gait Cycle Gait Cycle Lumbar Level 5 Barefoot Walking Lumbar Level 5 Trunk Obliquity Trunk Tilt Trunk Rotation - Loss of: gastrocnemius and soleus, lateral hamstrings, gluteus maximus, flexor hallicus and digitorum longus. Partial loss of: gluteus medius and minimus, medial hamstrings, posterior tibialis, long toe extensors, peroneals 3D Kinematics Increased ankle dorsiflexion in terminal stance Increased crouch and hip flexion Minimally increased trunk range of motion in coronal and transverse planes Add Abd Pelvic Obliquity Hip Ab-Adduction Knee us-gus Pelvic Tilt - Hip Flexion-ension 60 Dor Pla - Knee Flexion-ension Plantar-Dorsiflexion Left (4/9/04) Right (4/9/04) Pelvic Rotation Hip Rotation Knee Rotation Foot Progression Lumbar Level 5 Trunk Tilt Lumbar Level 5 Trunk Obliquity Sagittal plane kinematics and kinetics Reduced ankle plantar flexor moment and power Increased hip and knee extensor moments Pelvic Tilt Hip Flexion-ension Hip Moment Hip Power Knee Flexion-ension Knee Moment Knee Power Right (4/9/04) Right (4/9/04) Right (4/9/04) Plantar-Dorsiflexion Ankle Moment Ankle Power Coronal plane kinematics and kinetics Increased lateral trunk lean Reduced hip abductor moment Knee adductor moment Pelvic Obliquity Hip Ab-Adduction Hip Moment Hip Power Knee us-gus Knee Moment Knee Power Right (4/9/04) Right (4/9/04) Right (4/9/04) Ankle / Ankle Moment Ankle Power Lumbar Level 4 Barefoot Gait Lumbar Level 4 Trunk Obliquity Trunk Tilt Trunk Rotation Loss of Sacral and L5 level muscles Additional loss of: Gluteus medius and minimus, tensor fascia latae, medial hamstrings, extensor digitorum longus, posterior tibialis, peroneals (longus and brevis) 3D - Kinematics Increased lateral trunk lean and transverse plane trunk ROM Increased hip and pelvis coronal and transverse plane ROM Increased ankle dorsiflexion in TST Pelvic Obliquity Hip Ab-Adduction Knee us-gus Pelvic Tilt Hip Flexion-ension Knee Flexion-ension Plantar-Dorsiflexion Left (2/21/08) Right (2/21/08) Pelvic Rotation Hip Rotation Knee Rotation Foot Progression Motion analysis in understanding gait pathology, AACPDM 13 Part 2-5

6 60 Dor Pla - Pfl Dfl Add Abd Abd Add Lumbar Level 4 Trunk Tilt Lumbar Level 4 Trunk Obliquity Sagittal plane kinematics and kinetics Decreased peak ankle plantar flexor moment and power Minimal knee and hip moment and power Pelvic Tilt Hip Flexion-ension Hip Moment Hip Power Knee Flexion-ension Knee Moment Knee Power Plantar-Dorsiflexion Ankle Moment Ankle Power Coronal plane kinematics and kinetics Hip moment minimal Knee adductor moment (valgus thrust) Pelvic Obliquity Hip Ab-Adduction Hip Moment Hip Power Knee us-gus Knee Moment Knee Power Ankle / Ankle Moment Ankle Power Right (10/5/05) Right (10/5/05) Right (10/5/05) Right (10/5/05) Right (10/5/05) Right (10/5/05) What have we learned? Complex Gait Issues in the L4 Patient Complex relationships between trunk motion and strength and knee function Excessive trunk motion is a compensation for hip abductor weakness motor to assist in forward progression Increased knee adductor moment (valgus thrust) (Õunpuu JPO, : ; 00 Gutierrez Gait and ture, 03) Mean per Body and Pelvic Motion L4 Level Coronal Plane Knee Moments Sacral L5 L4 Motion analysis in understanding gait pathology, AACPDM 13 Part 2-6

7 What have we learned? Ankle-foot-orthosis (AFO) improved ankle/knee and hip sagittal plane function increased knee transverse plane motion Hullin, M. G. et al., JPO, 12: , Thomson et al., JPO, 19:27-33, Sagittal plane ankle and knee kinematics/kinetics (dashed line = barefoot, solid line = AFO for the left side) Knee Transverse Plane Motion Barefoot vs. AFO. Level Walking Condition Transverse Knee ROM normal Barefoot 11±5 L4 Barefoot 22±9 AFO 28±12 L5 Barefoot 15±6 AFO 23±9 S1-3 Barefoot 11±6 AFO 22±13 Thomson et al., JPO, 19:27-33, Conclusions Ambulation for persons with myelomeningocele is complex Appreciating pathomechanics is the best way to make treatment decisions Visual assessment is limited Cerebral Palsy Gait Analysis and Cerebral Palsy Natural progression Prevalence Studies Classification or gait patterns in cerebral pals Classification or gait patterns in cerebral palsy Electromyography Skeletal Modelling Motion analysis in understanding gait pathology, AACPDM 13 Part 2-7

8 Natural Progression and Motion Analysis Understanding the implications of not undergoing surgical intervention in children with cerebral palsy Required to interpret treatment results such as orthopaedic intervention Provide a justification for the importance of treatment Johnson et al. Results 18 subjects with spastic diplegia, ranging in age from 4 to 14 years assessed at 32 months apart deterioration of gait stability evidenced by increases in double support and decreases in single support with time and growth (p < 0.05). kinematic analysis revealed a loss of excursion about the knee, ankle, and pelvis (p < 0.05). passive range-of-motion analysis revealed a decrease in the popliteal angle over time (p < 0.05). Published Studies Johnson, David C.; Damiano, Diane L; Abel, Mark F. The Evolution of Gait in Childhood and Adolescent Cerebral Palsy, J Pediatr Orthop, 17: , 1997 Bell KJ, Õunpuu S, DeLuca PA, Romness MJ. Natural Progression of Gait in Children with Cerebral Palsy. J Pediatr Orthop, 22:677-82, 02 Martin Gough, Linda C, Richard O Robinson, Adam P Shortland, Short-term outcome of multilevel surgical intervention in spastic diplegic cerebral palsy compared with the natural history, DMCN, 46(2): 91-97, 04. Gough et al, Results twelve patients (mean age 10 years) with no treatment (control group) showed a significant increase in minimum hip and knee flexion in stance 17 months after first gait analysis Bell et al. 25 children with cerebral palsy Two gait analyses an average of 4 years apart No intervening surgery Clinical Measures Statistically significant reductions in popliteal angle passive maximum ankle dorsiflexion No change in passive maximum hip internal/external ROM Gait Changes: Functional Walkers (>81 cm/sec walking velocity) Less Functional Walkers (< cm/sec) Motion analysis in understanding gait pathology, AACPDM 13 Part 2-8

9 Conclusions Functional Walkers Getting stiffer Decreased knee flexion in swing Decreased ankle, knee and hip range of motion Less Functional Walkers Increased crouch Increased knee flexion and ankle dorsiflexion in stance Conclusions ambulatory ability tends to worsen over time in children with spastic cerebral palsy outcome studies comparing postoperative gait with preoperative gait require this understanding to interpret results Future What is left to do! Increase study numbers Understand natural progression by GMFCS level Prevalence Studies Studies that help to define the characteristics/pathomechanics of a particular diagnostic group such as cerebral palsy Provides important information for counseling parents and patients with cerebral palsy Information about prognosis in terms of possible treatment needs future gait function Prevalence of Gait Abnormalities in CP 492 patients with cerebral palsy computerized motion analysis prevalence of 14 specific gait abnormalities was evaluated and compared based on involvement (hemiplegia, diplegia, or quadriplegia) age history of previous lower extremity surgery Wren et al. JPO, 05 Prevalence of Gait Abnormalities in CP In hemiplegic, diplegic, and quadriplegic groups, more than 50% of patients had stiff knee in swing equinus in-toeing In diplegic and quadriplegic groups, more than 50% of patients also had increased hip flexion crouch Wren et al. JPO, 05 Motion analysis in understanding gait pathology, AACPDM 13 Part 2-9

10 Prevalence of Gait Abnormalities in CP In quadriplegic group, more than 50% of patients also had Increased hip adduction Prevalence of Gait Abnormalities in CP The likelihood of having stiff knee in swing, out-toeing, calcaneus deformity, and crouch increased with prior surgery. The likelihood of having rotational malalignment of the leg (internal hip rotation with out-toeing), calcaneus, out-toeing, varus and valgus foot deformities, and hip internal rotation increased with age. Wren et al. JPO, 05 Wren et al. JPO, 05 Understanding Gait Pathology Increased understanding of pathomechanics causes of gait issues Increased understanding of appropriate treatment options Causes of In-toeing Gait in Children with Cerebral Palsy 412 children with cerebral palsy (587 involved sides) Combination of motion analysis and clinical assessment information Rethlefsen, S et al., Causes of In-toeing Gait in Children with Cerebral Palsy, JBJS (Am), 88(10): , 06. Most common causes of in-toeing internal hip rotation (322 of 587 sides) internal tibial torsion (296 of 587 sides). pes varus contributed ted to in-toeing of 35 of the eighty-two involved limbs of the patients with hemiplegia pes varus contributed to in-toeing in 42 of the 505 limbs of the patients with diplegia or quadriplegia 1/3 rd of children with CP have multiple causes of internal rotation Multiple causes of in-toeing were noted in 215 of the 587 involved limbs bilateral involvement: 176 of the 505 limbs of the patients with bilateral involvement hemiplegic involvement : 39 of the 82 involved limbs Motion analysis in understanding gait pathology, AACPDM 13 Part 2-10

11 Causes of in-toeing Bilateral involvement: internal hip rotation (288 of 505) internal tibial torsion (261 of 505) internal pelvic rotation (ninety-two t of 505) Hemiplegic involvement: internal tibial torsion (35 of 82) pes varus (35-82) internal hip rotation (34-82) metatarsus adductus (-82) Conclusion 1/3 of children with CP have multiple causes of internal rotation Pes varus is common in hemiplegia and rare in children with bilateral involvement Knowledge of possible causes helps direct clinical assessment and understanding Is critical to treatment decision making Gait Classifications/Patterns in Cerebral Palsy Effort to develop a typology that differs from the present diagnostic system which classifies a cerebral palsy patient as either quadriplegic, diaplegic or hemiplegic or more recently GMFCS level. Typology based upon function at the joint level Single joint knee Multiple joints knee and ankle Motion analysis data based Benefits of Classification/Patterns standardization of gait management/treatment communication within and across professions if organized based upon visually identifiable gait characteristics: crouch, equinus etc. must be: Clinically meaningful categories Related to specific impairments illustrative representation of characteristics for each pattern = clinically friendly Initial Efforts Wong MA, et al, Statistical analysis of gait patterns of persons with cerebral palsy, Statistics in Medicine, 2(3), pages , July/September Kadaba M, et al., Gait pattern recognition in spastic diplegia. Dev Med Child Neurol. S33:28, Sutherland et al., Common gait abnormalities of the knee in cerebral palsy. Clin Orthop Relat Res, , Gait Patterns in Hemiplegia Winters T et al., Gait patterns in hemiplegia in children and adults. JBJS (Am): 69 (A): , Hullin MG et al., Gait patterns in children with hemiplegic spastic cerebral palsy, JPO, 5:247-51, Õunpuu S, DeLuca PA, Davis RB, Chapter 7: Gait Analysis, In Congenital Hemiplegia, Ed Brian Neville, Robert Goodman, Cambridge University Press, Suffolk, 81-97, 00. Motion analysis in understanding gait pathology, AACPDM 13 Part 2-11

12 Con t Rodda J et al., Classification of gait patterns in spastic hemiplegia and spastic diplegia: a basis for a management algorithm, European Journal of Neurology, 8: , 01. Stebbins J et al., Gait classification in hemiplegic cerebral palsy based on EMG, Gait and ture, :S2-3, 04. Classifications - Methodology Quality is limited: Reliability idity Arbitrary decisions Adequate numbers Sagittal plane focus Dobson, F et al., Gait classification in children with cerebral palsy: A systematic review, Gait and ture, 25(1): 1-152, 07. Gait Patterns: Hemiplegia Type 1 Provided frame work for thinking about hemiplegia as a continuum of increasing involvement with associated increasing requirements for treatment 4 types sagittal plane (Winter, 1987) Kinetics and EMG (Hullin, 1996) Addition of transverse plane (Õunpuu, 00 and Rodda, 01) EMG alone (Stebbins, 04) Excessive equinus in swing Associated drop foot in swing Heel cord tightness and/or anterior tibial weakness TREATMENT = excessive equinus in swing Dor Pla - Plantar-Dorsiflexion E Type 2 Type 3 Excessive equinus in stance and swing Associated toe walking and drop foot in swing Heel cord contracture/spasticity and/or anterior tibial weakness TREATMENT = excessive equinus in stance and swing - Plantar-Dorsiflexion Gait Cycle Increased knee flexion at initial contact Hamstring spasticity and or tightness TREATMENT = excessive equinus in swing and knee issues Knee Flexion-ension Knee Flexion-ension E E Motion analysis in understanding gait pathology, AACPDM 13 Part 2-12

13 Type 4 Transverse Plane Decreased hip extension in terminal stance on involved side (solid line) Increasing anterior pelvic tilt on involved side during stance (solid line) TREATMENT = excessive equinus in swing and knee and hip issues 60 Pelvic Tilt Hip Flexion-ension Increased internal hip rotation, involved side (solid line) Compensatory external pelvic rotation, involved side (solid line) Increased femoral anteversion involved side Visual vs. actual inconsistencies - - Pelvic Rotation Hip Rotation Knee Patterns Sutherland D et al., Common Gait Abnormalities of the Knee in Cerebral Palsy, Clinical Orthopaedics & Related Research, 288, children with CP Each abnormality is described by its motion analysis laboratory profile (clinical exam, motion parameters, electromyography data, and force plate data). CROUCH HYPER EXTENSION Knee Patterns Knee Flexion-ension Knee Flexion-ension E Knee Flexion-ension Knee Flexion-ension E E E JUMP STIFF Joint Kinetic Patterns Background Framework for the discussion of gait pathology Link to surgical intervention decision-making Establishing the link between kinematics i (joint angles) and kinetics (joint loads) Chii-Jeng Lin, et al., Common abnormal kinetic patterns of the knee in gait in spastic diplegia of cerebral palsy, Gait and ture, 11(3): , 00. Gage JR, The Clinical Use of Kinetics for Evaluation of Pathological Gait in Cerebral Palsy, J Bone Joint Surg Am,76(4): , Motion analysis in understanding gait pathology, AACPDM 13 Part 2-13

14 EMG and Cerebral Palsy Double Bump Ankle Pattern: Kinematic and kinetic (moment and power) Toe initial contact Spasticity in ankle plantar flexors Continuously active Prolonged Premature Out of phase Reverse phase EMG and Cerebral Palsy Berger W et al., Pathophysiology of gait in children with cerebral palsy. Electroencephalography and Clinical Neurophysiology, 53(5): , children with CP during gait co-activation of antagonistic leg muscles during the stance phase of a gait cycle and a general reduction in amplitude of EMG activity EMG and toe walking Romkes J, Brunner R, An electromyographic analysis of obligatory (hemiplegic cerebral palsy) and voluntary (normal) unilateral toe- walking. Gait ture. 26(4):577-86, 07. Evaluated EMG data from typically developing persons during normal walking and walking in crouch and toe walking patterns and compared to children with CP walking in crouch and toe walking EMG and Bracing Gastrocnemius and tibialis anterior activity was similar in both groups Rectus femoris activity in mid-swing phase in persons with CP and not typically developing Help to consider differences between primary and secondary deformity Romkes J, Hell AK, Brunner R, Changes in muscle activity in children with hemiplegic cerebral palsy while walking with and without ankle-foot orthoses, Gait ture. 24(4):467-74, 06. peak activity of the tibialis anterior muscle was reduced by 36.1% at initial contact and loading response and by 57.3% in initial swing when using a HAFO Motion analysis in understanding gait pathology, AACPDM 13 Part 2-14

15 EMG and Treatment Planning Perry J et al., Preoperative and postoperative dynamic electromyography as an aid in planning tendon transfers in children with cerebral palsy. JBJS (Am), 59(4): , Motion Analysis - Skeletal Modeling Peak Knee Flexion Deficit Role of rectus femoris vs. vastii Other factors: Stance phase knee kinetics (increased knee extensor moment) Rotational deformity Simulation Õunpuu S. et al., Gait and ture, 5(3): , Goldberg S R, et al., Journal of Biomechanics, 36, , 03. Goldberg S R, Journal of Biomechanics, 39: , 06. Biomechanical Factors that can Contribute to Stiff-knee Gait Summary Decreased knee flexion velocity at toeoff Excessive force in: rectus femoris vasti Decreased peak knee flexion Excessive force in: rectus femoris vasti Diminished force in: iliopsoas Decreased knee flexion velocity at toe-off Computerized motion analysis techniques have increased our understanding of the pathomechanics of gait in a wide variety of pathologies Leads to more informed treatment decisionmaking and improved outcomes opposite heel strike double support toe-off early swing phase (Reinbolt J, et al., Journal of Biomechanics 08) peak knee flexion Motion analysis in understanding gait pathology, AACPDM 13 Part 2-15