BTS G-WALK. clinical notebook. english. version 2.0.0

Transcription

1 clinical notebook english version 2.0.0

2 Edited by Luciano Bissolotti, MD Specialist in Physical Medicine and Rehabilitation Specialist in Sports Medicine Paolo Gaffurini, PhD Functional Rehabilitation and Recovery Service LARIN Rehabilitation Clinic Domus Salutis and Robert Meier, CO, BOCO Kassel Group Inc. Document Number : ERGSN Published: January 2013 Copyright BTS SpA. All Rights Reserved.

3 contents contents 1 icons, symbols and acronyms 3 copyright 4 introduction 5 spatial-temporal gait parameters 5 in clinical procedures: application fields and clinical cases 8 case 1 - rehabilitation outcomes of male CVA 8 case 2 - comparison of AFO intervention on Male CVA 11 case 3 - comparison of two patients with the Dx of Parkinson s disease 13 case 4 - Parkinson s patient comparing over-ground to treadmill walking 15 standard evaluation protocol with 17 global functional evaluation protocols associated with 19 core evaluation associated with 19 mobility evaluation scale associated with system 20 appendix A references 23 BTS Bioengineering 1

4

5 icons, symbols and acronyms Symbol in the notebook. The icon represents the information which requires special attention. Acronyms used in this manual ADL Activity of Daily Living AFO Ankle-Foot Orthosis CVA Cerebral Vascular Accidents Dx Diagnosis ROM Range Of Motion TUG Timed Up and Go BTS Bioengineering 3

6 copyright No part of this notebook may be copied or transmitted in any form or means, electronic or mechanical, including photocopying, without prior written permission from BTS S.p.A. Unless otherwise specified, any reference to companies, names, data and addresses used in the reproduction of the screens and the examples are purely incidental, and has the sole purpose of illustrating the use of the BTS product. All trademarks are registered by the respective owners. This publication contains reserved informations which are the property of BTS S.p.A. The recipient acknowledges that the illustrations and informations supplied in this manual shall not be made available to third parties without explicit written agreement by BTS S.p.A. 4 BTS Bioengineering

7 introduction Use of the gait analysis system allows the clinician to perform the following evaluations: 1. Overground functional gait analysis of patients with movement disorders secondary to neurological disorders, amputation or soft tissue dysfunctions. This computerized movement analysis of the gait cycle can be performed on different kinds of surfaces - smooth or rough, indoors or outdoors. 2. Functional gait analysis during treadmill training at different velocities, from 0.8 to 6.5km/h ( ft/s) with or without body weight suspension. All these tests can be performed quickly and easily with an attractive cost/benefit ratio because the fitting process of the device on patients is quick and the powerful software is easy and intuitive. Spatial-temporal gait parameters Velocity Cadence Step Length Stride Length Gait Cycle duration Stance phase duration Swing phase duration Double and single support duration BTS Bioengineering 5

8 introduction provides objective data to assess temporal-spatial parameters with comparison of left to right and to normal data. The system also provides pelvic kinematic data in all three planes, as well as acceleration data of each limb. Gait kinematic assessments using can be applied in many different pathological conditions: 1. Orthopedic involvement: Congenital or acquired gait disorders due to spinal deformities like scoliosis, kyphosis and lordosis, with or without neurologic involvement due to spinal stenosis. Lower extremity dysfunction due to trauma (fractures, sprains, ligament injuries) and surgery (joint replacement, anterior cruciate ligament reconstruction, etc.), or congenital and structural biomechanical dysfunctions (patella-femoral alignment issues, lower extremity asymmetries). Amputations, from partial foot to trans-femoral, to assess functional capacity using various interventions to objectively quantify gait capacity using one device as opposed to an alternative device. 2. Neurological involvement: Gait training for congenital or acquired brain injury patients such as Traumatic Brain Injury (TBI) or Cerebral Vascular Accidents (CVA), including the assessment of pharmacological interventions such as Botulin toxin in pediatric populations or different orthotic interventions to quantify which enables the best functional outcome. 6 BTS Bioengineering

9 introduction Outcome of Spinal Cord Injury (SCI) as a result of incomplete para- or quadriplegia in order to define baseline status and to document functional progress on follow up. Neurodegenerative diseases such as Parkinson s disease, Normal Pressure Hydrocephalus (NPH) and Multiple Sclerosis (MS) in order to define the efficacy of pharmacological and rehabilitation treatments. Orthotic and prosthetic evaluation with or without aids (cane, crutches or walkers) can be used during the assessment process. Balance and movement disorders strictly connected to the vestibular system such as Menière s disease, or cerebral disorders leading to ataxic gait. BTS Bioengineering 7

10 in clinical procedures: application fields and clinical cases Computerized movement analysis for evaluation of gait parameters through the provides unique benefits through advanced technologies that provide comprehensive data that is quick and easy to use. The ability to detect data simultaneously in multiple parameters produces a cost benefit ratio that benefits the field of clinical rehabilitation characterized by a growing disparity between available resources and emerging demands. The clinical cases reported below are a testimony to the sensitivity of the system to detect even minimal changes in a patient motor performance. Case 1 - Rehabilitation outcomes of male CVA HZ, male patient presented with expressive aphasia and right hemiparesis secondary to haemorrhagic stroke in the left basal ganglia region in the sub-acute phase (> 30 days) for neuro-motor rehabilitation designed to improve safety and gait symmetry. Initial clinical evaluation: - Scale Trunk Control Test 75/100; - Motricity index: lower limb 81/100; upper limb 0/100. Aim of the assessment: functional evaluation before and after rehabilitation. 8 BTS Bioengineering

11 in clinical procedures: application fields and clinical cases Upon intake he was G-WALK tested on a 10m (32.8ft) path. The following data was obtained (Fig.1a): Upon later clinical evaluation: - Scale Trunk Control Test 100/100; - Motricity index: lower limb 100/100; upper limb 0/100; - Patient independently executed postural changes; - Patient walked independently without the use of aids and without any hesitation; - RANKIN 3/5; - Rivermead 15/15; - Tinetti: 27/28. When the final goal of the rehabilitation had been achieved, another G-WALK gait analysis was performed obtaining these data (Fig.1b): BTS Bioengineering 9

12 in clinical procedures: application fields and clinical cases Even more significant is the comparative evaluation of the biomechanical adjustments of the trunk/hip sector (pelvic oscillation during the gait cycle): this highlighted gait pattern changes throughout rehabilitation (Fig.1c-d). Min: -1.2 Max: 5.7 Range: 6.9 Min: -0.9 Max: 1.0 Range: 2.8 Min: -3.7 Max: 5.0 Range: 8.7 Min: -2.5 Max: 3.4 Range: BTS Bioengineering

13 in clinical procedures: application fields and clinical cases Conclusions: this objective documentation shows an improvement in selfselected walking speed, more normal symmetry in step length (Fig.1a-b) and a reduction in proximal trunk compensations (Fig.1c-d) in both the sagittal plane (flexion-extension) and the transverse plane (rotation of the pelvis) as represented in a reduction of the oscillation range. Case 2 - Comparison of AFO intervention on Male CVA ZG, male patient presented with left hemiparesis secondary to a right ischemic stroke. Aim of the assessment: Assess functional outcome of AFO intervention to assist with ambulation. Without leg-foot orthoses (NO AFO) ), G-WALK gait analysis provided the following results (Fig.2a): BTS Bioengineering 11

14 in clinical procedures: application fields and clinical cases With AFO1 (Fig.2b): With AFO2 (Fig.2c): Conclusions: this documentation shows a marked improvement in self- 12 BTS Bioengineering

15 in clinical procedures: application fields and clinical cases selected walking speed with AFOs compared to baseline data (Fig.2a-b and Fig.2a-c). The time in swing and stance is also much closer to normal. There are no significant differences between AFO1 and AFO2 (Fig.2b-c), so that decision can be based on other clinical, biomechanical or potential patient compliance factors. Case 3 - Comparison of two patients with the Dx of Parkinson s disease This is the computerized movement analysis of two patients with the diagnosis of Parkinson s disease, one assessed at Hohen Yahr 4.5/5 and the other at Hohen Yahr 2/5. Aim of the assessment: objective quantification of the level of gait impairment, comparing two patients with a similar diagnosis but at different levels of neurological and functional impairment. These are the G-WALK data of the Hohen Yahr 4.5/5 (Fig.3a): BTS Bioengineering 13

16 in clinical procedures: application fields and clinical cases These are the G-WALK data of the Hohen Yahr 2/5 (Fig.3b): These are the acceleration graphs of the 4.5/5 patient compared to the 2/5 patient (Fig.3c-d): Conclusions: this case demonstrates that is extremely sensitive in detecting differences in temporal and spatial parameters between two patients with the same diagnosis but at different functional levels (Fig.3a-b). 14 BTS Bioengineering

17 in clinical procedures: application fields and clinical cases The system accurately detects qualitative and quantitative differences between two patients with the same diagnosis. Once baseline is established, it is quick and easy to capture subsequent data to objectively document the progression of the disease in terms of gait performance. Case 4 - Parkinson s patient comparing over-ground to treadmill walking Computerized motion analysis of a patient with the diagnosis of Parkinson s disease rated at Hohen Yahr 3/5, comparing over-ground vs. treadmill walking. Aim of the assessment: objectively quantify gait function of one patient comparing two different rehabilitation environments: Over-ground G-WALK data (Fig.4a): BTS Bioengineering 15

18 in clinical procedures: application fields and clinical cases Treadmill G-WALK data (Fig.4b): Conclusions: these data show improvement in self-selected walking speed, increase in stride length and reduction of gait cycle on treadmill vs. overground gait (Fig.4a-b). This provides evidence to confirm that treadmill walking is the preferred method of gait training for this patient at this stage of rehabilitation. 16 BTS Bioengineering

19 standard evaluation protocol with can be used on any number of patient presentations: 1. Neuromuscular involvement: Acquired brain injuries such as Cerebral Vascular Accidents (CVA) or Traumatic Brain Injury (TBI) Acquired diseases such as Parkinson s disease or Multiple Sclerosis Acquired lower-motor lesions such as incomplete spinal cord injury or disruption of the common peroneal nerve Congenital conditions such as Cerebral Palsy or Spina Bifid 2. Orthopedic injuries or dysfunctions: ACL or other ligamentous injuries Achilles tendonopathy or other overuse injuries Plantar fasciitis or other stress injuries Post-surgical joint replacement Amputations, from partial foot to trans-femoral Inclusion criteria for evaluation: Self selected gait speed at least 0.3m/s for 8 meters (1ft/s, for 26ft). Procedure for conducting the test: Subject in their neutral standing position, linear walking for a minimum of 8 meters (26ft). Ask the patient to walk the distance at their self-selected speed and then at their maximum speed. BTS Bioengineering 17

20 standard evaluation protocol with positioning: Place over L5. Parameters collected in association with gait analysis: Perceived safety during walking (score from 0 to 10, 0= no safety, 10= maximum safety); Perceived fatigue during walking (score from 0 to 10, 0= no fatigue, 10= maximum fatigue); Perceived pain during walking (score from 0 to 10, 0= no pain, 10= maximum pain); If the path is over 50m (164ft), capability to maintain a constant acceleration by measuring time intervals every 10m (32.8ft). Indications: Gait analysis of subjects with gait deficits secondary to neuromuscular involvement, orthopaedic injuries or surgery. Evaluations can be: Acquisition of baseline data. Comparison of different conditions including functional responses to different types of orthoses, prostheses, ambulatory aids or walking conditions. Functional improvements secondary to rehabilitation or orthotic/ prosthetic intervention over time. 18 BTS Bioengineering

21 global functional evaluation protocols associated with Core evaluation associated with A multidimensional evaluative model of back pain patients may include the following considerations: Quantify the pain using the VAS scale (soft <20, mild moderate 20-40, moderate 40-60, moderate severe e severe >60). Quantify the degree of impaired mobility through measurements of objective data such as fingers-ground distance in trunk forward flexion or lateral flexion. To quantify the shortening of hamstring indicate any limitation to knee ROM in extension with hip flexed to 90 (patient in supine position). Quantify the degree of impairment of trunk and pelvis muscle strength and endurance with a simple lower limb leak test suspended from the bed (keep trunk pelvis at 180 ) or more simply bridge the trunk supine, measuring time expenditure in seconds. Activity and participation in ADL impairment (see disability) using Roland Morris scale (range 0-24 with a cut-off at 16 to define a level of severe disability) or Oswestry Disability Index (range with cut off: 0-20 mild disability, moderate, severe, not able, 80/100 bedridden). Resume of evaluation indexes: BTS Bioengineering 19

22 global functional evaluation protocols associated with Evaluated dimension Measuring device Range Pain VAS Mobility Adams Test or trunk lateral flexion Distance fingers-ground (cm) Trunk force/endurance Bridge position Time interval (sec) Activities and participation Impairment Roland Morris or Oswestry Disability Index 0-24 for Roland for Oswestry Mobility evaluation scale associated with Body and cognitive functions field: 1. Hoehn & Yahr scale (range 0-5) is used in multidimensional evaluation protocols of patients affected by Parkinson s disease also for assessing the effectiveness of pharmacological treatments (Munro Neville 2011). 2. The Tinetti scale (range 0-28, cut off for high fall risk if <19 points) has already proven its reliability and repeatability in the qualitative assessment of mobility and risk of accidental falls in parkinsonian patient (Kegelmeyer 2007, Gray 2009, Brusse 2005). 3. The Rivermead Mobility Index is used for the motor quantitative evaluation both in neurodegenerative disease and in elder people (Busse 2004). 4. Rankin scale 5. Expanded Disability Status Scale 6. Walking Handicap Scale Following functional and clinical evaluation, rehabilitation programs 20 BTS Bioengineering

23 global functional evaluation protocols associated with can be created to help patient overcome symptoms and minimize compensatory mechanism. objective data can be used to validate interventions that optimize outcomes. BTS Bioengineering 21

24

25 appendix A references 1. Kegelmeyer DA, Kloos AD, Thomas KM, Kostyk SK. Reliability and validity of the Tinetti Mobility Test for individuals with Parkinson disease. Phys Ther Oct;87(10): Epub 2007 Aug Brusse KJ, Zimdars S, Zalewski KR, Steffen TM. Testing functional performance in people with Parkinson disease. Phys Ther. 2005;85: Busse ME, Pearson OR, Van Deursen R, Wiles CM. Quantified measurement of activity provides insight into motor function and recovery in neurological disease. J Neurol Neurosurg Psychiatry Jun;75(6): Quinn TJ, McArthur K, Dawson J, Walters MR, Lees KR. Reliability of structured modified rankin scale assessment. Stroke Dec;41(12):e602; author reply e603. Epub 2010 Oct Amato MP, Grimaud J, Achiti I, Bartolozzi ML, Adeleine P, Hartung HP, Kappos L, Thompson A, Trojano M, Vukusic S, Confavreux C. Evaluation of the EDMUS system (EVALUED) Study Group. European validation of a standardized clinical description of multiple sclerosis. J Neurol Dec;251(12): BTS Bioengineering 23

26 appendix 6. Roorda LD, Green JR, Houwink A, Bagley PJ, Smith J, Molenaar IW, Geurts AC. Item hierarchy-based analysis of the Rivermead Mobility Index resulted in improved interpretation and enabled faster scoring in patients undergoing rehabilitation after stroke. Arch Phys Med Rehabil Jun;93(6): Epub 2012 Mar BTS Bioengineering

27

28 BTS Bioengineering Corp. 147 Prince Street - Suite Brooklyn NY USA info: helpdesk: BTS S.p.A. viale Forlanini Garbagnate M.se MI Italy tel fax info@btsbioengineering.com