Gait analysis and medical treatment strategy

Transcription

1 Gait analysis and medical treatment strategy Sylvain Brochard Olivier Rémy-néris, Mathieu Lempereur CHU and Pediatric Rehabilitation Centre Brest Course for European PRM trainees Mulhouse, October 22, 2008

2 Aims To know how to evaluate and observe gait of children with cerebral palsy To know which informations 3D gait analysis provides To improve your visual assessment of gait using video and 3D gait analysis To define the optimal medical treatment according to the gait pattern To give you complete references to improving your knowledge For pedagogic reason we will limit the slide show to CP children with hemiplegia

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4 The 5 prerequisites of normal gait Gage,1991 Stability in stance Sufficient foot clearance Appropriate swing phase prepositionning of the foot Adequate step length Energy conservation

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7 Gait analysis Physiatrist eyes Gillette s functional assessment questionnaire Novacheck, T.,J Pediatr Orthop, Observational Gait Scale (modified Physician Rating Scale) Mackey AH, 2003, Dev Med Child Neurol 2003 Video Chaleat-Valayer E, J Pediatr Orthop B EMG-Video Blanc Y 1996 EMG timing errors of pathological gait. SENIAM european activities 3D gait analysis Mackey Ah, gait and posture 2005

8 Clinical assessment

9 Motion lab

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12 Spatio-temporal parameters -Gait speed -Cadence -step and stride length -% of stance phase and swing phase -% simple support and double support

13 Motion lab: kinetic parameters

14 Dynamic superficial EMG

15 CLASSIFICATIONS For hemiplegic CP: Winters Classification (1987): 4 gait patterns based on sagittal plane kinematic analysis Winters TF, 1987 J Bone Joint Surg Sutherland classification is often used to describe knee sagittal pattern Sutherland, D. and J. Davids, For diplegic CP: Rodda et Graham (2004): 4 gait patterns based on sagittal plane kinematic analysis Rodda, J. J bone Joint Surg, 2004 Although gait classification in CP can be useful in clinical and research settings, the methodological limitations of many classifications restrict their clinical and research applicability Dobson F. Gait Posture 2007

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17 Type I: Drop foot Winters paper: 43,5%, age of 9,5 Drop foot during swing Adequate range of dorsiflexion during stance Increased Knee F, Hip F Due to a bad selectivity or strength of Tibialis anterior

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20 Medical treatment Physical therapy Electrical stimulation of the Tibialis Anterior Ankle foot orthosis (AFO)

21 Type II: True equinus 28,2%, age of 10,5 Plantar flexion throughout the gait cycle Stance phase: True equinus Full knee extension= IIA Recurvatum knee= IIB Sometimes increased HIP flexion Swing phase: Insuffisant dorsiflexion

22 Type IIA

23 Type IIA

24 Type IIB

25 Type IIB

26 Type II: True equinus Cause: Hyperactivity of plantarflexor Static contracture of plantarflexor Insufficient dorsiflexor or balance between agonists and antagonists Medical treatment: Physical therapy, Serial casting Botulinum toxin in the triceps surae AFO

27 Type III: true equinus, jump knee, +- stiff knee 10%, age 14,5 ans True equinus throughout the gait cycle Total range of knee motion < 45 In stance phase: Excessive knee flexion at IC In swing phase: Limited knee flexion

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30 Type III: true equinus and jump knee Cause: Spasticity or static contracture of triceps surae Spasticity or static contracture of hamstrings Spasticity or static contracture of rectus femoris Cocontraction hamstrings/rectus femoris Medical treatment: Physical therapy Botulinum toxin for spasticity AFO

31 Type IV: Type III and proximal involvement 17,4%, 12,2 years True equinus throughout the gait cycle Knee limited F/E Hip limited F/E 35 Hip flexion, adduction and internal rotation Pelvic anteversion

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34 + video frontal

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37 Type IV Cause: Spasticity or contracture of psoas, adductor, internal rotator Constitutional rotational bone deformity (excessive hip anteversion) Medical treatment: Physical therapy Botulinum toxin in involved muscles AFO

38 Be careful!!! The Winters classification can not be applied to every type of hemiplegia with CP Group 0: 49% of hemiplegia are not classified with the Winters classification Mac Dowell BC, gait and posture, 2008 Although gait classification in CP can be useful in clinical and research settings, the methodological limitations of many classifications restrict their clinical and research applicability Dobson F, Morris ME, Baker R, Graham HK. Gait classification in children with cerebral palsy: a systematic review. Gait Posture 2007

39 Type 1 Type 2A Type 2B Type 3 Type 4

40 Case report

41 Enya, 3 years No perinatal problem At 6 months, movements were asymetrics RMI: right sylvius stroke

42 Clinical assessment Weakness on Tibialis anterior No contracture at low speed of stretch At fast speed of stretch, Ashworth 2/4 at 0 of dor siflexion knee fexed and extended Other muscles are not spastic

43 Question 1 Which joints are involved in the gait pattern and at which time of the cycle?

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45 Question 2 Which prescrition would you do? 1. Physical therapy 1 day/week, 2. Physical therapy 5 day/week 3. No physical therapy 4. Walking AFO 5. AFO during the night 6. Serial casting 7. Botulinum toxin 8. Electrostimulation of the Tibialis Anterior

46 EBM answers: none 1: No evidence for physical therapy and no study about the frequency «Moderate evidence of ineffectiveness was found of strength training on walking speed and stride length. Conflicting evidence was found for strength training on gross motor function». Antilla H, Effectiveness of physical therapy interventions for children with cerebral palsy: a systematic review.bmc pediatrics et 5:«The following evidence was found: Orthoses that restrict ankle plantar flexion have a favorable effect on an equinus walk, but the long-term clinical significance is unclear. Our conclusion is that there is a paucity of evidence from primary studies on the use of orthoses in children with cerebral palsy» Autti-Ramo I, Effectiveness of upper and lower limb casting and orthoses in children with cerebral palsy: an overview of review articles. Am J Phys Med Rehabil. 2006

47 Answer 2 6 Casting has a short term effect Autti-Ramo I, 2006 (overview EBM) «There is little evidence that casting is superior to no casting» Blackmore AM DMCN 2007 For a static contracture about 10 of dorsi-flexion Quesnot KS «Botulinum neurotoxin should be offered as a treatment option for the treatment of spasticity children (Level A): spastic equinus and adductor (based on 6 good methodological studies)» Simpson DM Assessment: Botulinum neurotoxin for the treatment of spasticity (an evidencebased review): report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology Many positive studies but lack of methodology Claire Kerr, Electrical stimulation in cerebral palsy: a review of effects on strength and motor function.dev Med Child Neurol. 2004

48 Question 3 You decide to inject botulinum toxin in triceps surae. Would you like to inject: 1. Gastrocnemius 2. Soleus 3. Twice 4. With guidance (Electrostimulation, EMG, echography,..) 5. Without guidance (Electrostimulation, EMG, echography,..)

49 Answer 3: 3 et 4 Injection of gastrocnemius and soleus: effect on dorsiflexion measures in 3D motion analysis Boyd, 2000 Simpson DM 2008 Most of studies inject the twice Nolan et al 2006 There is argument in favour of the role of soleus in equinus Decq Lancet 1998

50 Answer 3 Triceps surae without guidance Graham 2000 No evidence for guidance Childers MK Phys Med Rehabil Clin N Am 2003 But european consensus recommends to use guidance Heinen F, European consensus table 2006 on botulinum toxin for children with cerebral palsy. Eur J Paediatr Neurol. 2006

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53 Questions 4 Which muscles would you inject after analysis? Which type of hemiplegia is it?

54 Answer 4 Rectus femoris and Hamstrings Triceps surae? Be careful to apparent equinus!!! Group 0 of Winters classification

55 Conclusion Learning the visual gait assessment is essential to treat walking children with cerebral palsy Learning classifications is useful but each classification presents defects and must be used with hindsight Video, EMG video and 3D gait analysis help us to train the eyes to look at gait and have to be used when gait is complex These tools also allow the quantification of gait for Interdisciplinary discussion Comparison between before and after treatment Follow up of cohorte

56 ARTICLES: Novacheck, T., J. Stout, and R. Tervo, Reliability and Validity of the Gillette Functional Assessment Questionnaire as an Outcome Measure in Children with Walking Disabilities. J Pediatr Orthop, Mackey AH, 2003, Reliability and validity of the Observational Gait Scale in children with spastic diplegia Dev Med Child Neurol 2003; Chaleat-Valayer E, Use of videographic examination for analysis of efficacy of botulinum toxin in the lower limbs in children with cerebral palsy.j Pediatr Orthop B Mackey Ah, gait and posture 2005 Reliability of upper and lower limb three-dimensional kinematics in children with hemiplegia Winters TF, 1987 Gait patterns in spastic hemiplegia in children and young adults. J Bone Joint Surg Sutherland, D. and J. Davids, Common Gait Abnormalities of the Knee in Cerebral Palsy. Clin Orthop, : p Rodda, J., et al., Sagittal gait patterns in spastic diplegia. J bone Joint Surg, 2004 Dobson F. Gait classification in children with cerebral palsy: a systematic review. Gait Posture 2007;25: Antilla H, Effectiveness of physical therapy interventions for children with cerebral palsy: a systematic review.bmc pediatrics 2008 Autti-Ramo I, Effectiveness of upper and lower limb casting and orthoses in children with cerebral palsy: an overview of review articles. Am J Phys Med Rehabil Simpson DM Assessment: Botulinum neurotoxin for the treatment of spasticity (an evidence-based review): report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology 2008 Claire Kerr, Electrical stimulation in cerebral palsy: a review of effects on strength and motor function.dev Med Child Neurol Heinen F, European consensus table 2006 on botulinum toxin for children with cerebral palsy. Eur J Paediatr Neurol BOOK: The treatment of gait problems in cerebral palsy edited by JR Gage, 2004, Mac Keith Press.

57 Thank you for your attention

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