gait analysis at your fingertips - aacpdm · 2018-10-12 · gait analysis at your fingertips:...
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www.shrinerschildrens.org/aacpdm2018
Gait Analysis at Your Fingertips:Enhancing Observational Gait Analysis Using Mobile Device Technology and the
Edinburgh Visual Gait Scale
Jon R. Davids, MD; Shriners Hospitals for Children – Northern California; Sacramento, CA
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Disclosure Information
The following relationships exist:
•OrthoPediatrics–Consultant
•OrthoPediatrics Foundation for Education and Research
–Board Member
Presenter Disclosure Information
JON R. DAVIDS, MDEnhancing Observational Gait Analysis Using Mobile Device Technology
and the Edinburgh Visual Gait Scale
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www.shrinerschildrens.org/aacpdm2018
• Full Handouts• Gait Scoring Sheets• Links to resources
….and more!
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Decision-making in Gait Surgery
History & Physical, Patient Goals
Pre- & Intra-operative Physical Exams
Gait Analysis:Kinematics
KineticsEMG
Dynamic Pedobarography
Individualized Surgical Prescription to Improve Gait Radiographs:
Hip, Ankle, Foot
www.shrinerschildrens.org/aacpdm2018
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Gait Analysis Without a Lab = Observational Gait Analysis (OGA)
• Role of Observational Gait Analysis:• No access to 3-dimensional gait lab
• Frequent documentation of gait pattern change
• Child that cannot cooperate with 3D Gait Study• Very young (less than 5)
• Behavioral or cognitive issues
www.shrinerschildrens.org/aacpdm2018
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Observational Gait Analysis
www.shrinerschildrens.org/aacpdm2018
• Prerequisites• Understand Normal Gait Cycle and Select Key Subphases• Recognition / Classification of Common Deviations
• Visual Assessment• Systematic• Forest / Trees
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OptimizingObservational Gait Analysis
www.shrinerschildrens.org/aacpdm2018
•Modern Technology•Mobile Videography•Cell Phones and Tablets
•Structured Analysis• Edinburgh Visual Gait
Scale
•Case Example
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High Quality Video: Your Key to Observational Gait Analysis
•Good observations take time!
•Videos help take decision-making out of busy clinic
•Permanent record
www.shrinerschildrens.org/aacpdm2018
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Principles of Mobile Videography
20 feet
15 feet
www.shrinerschildrens.org/aacpdm2018
• Lighting and Focus• Well-lit hallway or room with
minimal distractions in background
• Perspective• At least 20 feet distance for
coronal
• At least 10 foot distance for sagittal
• Quality sagittal video allows for objective observational gait• Anyone can get coronal in their
clinic!
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Principles of Mobile Videography: High Quality Sagittal Video
•High Quality Sagittal Video = High Quality Observations
•Panning camera•Parallax Problems•Cannot see more than
1 stride in-plane
www.shrinerschildrens.org/aacpdm2018
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Principles of Mobile Videography: High Quality Sagittal Video
•Camera moves with child with minimal motion artifact• Allows for in-plane visualization of
more than one stride• May require specialized
equipment
www.shrinerschildrens.org/aacpdm2018
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Principles of Mobile Videography: Low-Cost Image Stabilization
•Gimbal•platform that maintains orientation in space despite inclines or rotation
•Nature Documentaries
www.shrinerschildrens.org/aacpdm2018
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Principles of Mobile Videography: Low-Cost Image Stabilization
•Gimbal•platform that maintains orientation in space despite inclines or rotation
•Drones•Geopolitical/ Personal
www.shrinerschildrens.org/aacpdm2018
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Principles of Mobile Videography: Low-Cost Image Stabilization
www.shrinerschildrens.org/aacpdm2018
•Gimbal•platform that maintains orientation in space despite inclines or rotation
•Selfie Stick with 3 Axis Gimbal•$50-300 USD
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Principles of Mobile Videography: Low-Cost Image Stabilization
Without Image Stabilization Hand-held Image Stabilization
www.shrinerschildrens.org/aacpdm2018
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Principles of Mobile Videography: Skin Markings to Improve Observation
• Optimal clothing and marking for gait analysis• Tight-fitting swimsuit
or bike shorts
• Marking of ASIS, Patella, TibialTubercle, and Achilles
www.shrinerschildrens.org/aacpdm2018
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Technology to Improve Your Video Observations
• Sports Performance Video Analysis Apps• Allow for slow
motion analysis
• Zoom function
• Can annotate with angles, lines, or shapes
• Split Screen and Imaging Overlay Options
Hudl TechniqueFree
SlomoFree
Coach’s Eye$4.99
Dartfish Express
$6.99
www.shrinerschildrens.org/aacpdm2018
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Hudl Technique App: Features
www.shrinerschildrens.org/aacpdm2018
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OptimizingObservational Gait Analysis
www.shrinerschildrens.org/aacpdm2018
•Modern Technology•Mobile Videography•Cell Phones and Tablets
•Structured Analysis• Edinburgh Visual Gait
Scale
•Case Example
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Observational Gait Assessment Scoring Systems
Physician Rating Scale Salford Gait Tool Observational Gait Analysis
Observational Gait Scale
Edinburgh Visual Gait Score
www.shrinerschildrens.org/aacpdm2018
Rathinam et al. Gait & Posture40 (2014) 279–285.
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• 17 observations/limb
• 10 Joint Angle Measurements
• 7 Gait Phase Timing Assessments
• 6 anatomic levels scored:
• trunk, pelvis, hip, knee, ankle and foot
• 3 planes of motion
• 12 stance phase items and 5 swing phase items
The Edinburgh Visual Gait Score (EVGS)
www.shrinerschildrens.org/aacpdm2018
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1. Terminal Swing/Initial Contact
2. Mid-Stance Sagittal3. Terminal Stance4. Mid-Swing
EVGS Scoring Six Stops in Gait Video
1. Mid-Stance Front2. Mid-Stance Back
Sagittal Video Coronal Video
www.shrinerschildrens.org/aacpdm2018
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EVGS Scoring Six Stops in Gait Video
www.shrinerschildrens.org/aacpdm2018
• 3 point ordinal scale:• 0 – within normal range (mean ±1.5 SD)• 1 – moderate deviation (1.5 – 4.5 SD from mean)• 2 – marked deviation (> 4.5 SD from mean)
• Score total of 0-34 per limb; 0-68 per gait cycle• Lower is better!
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Phase Trunk Pelvis Hip Knee Ankle Foot
IC
M St
T St
M Sw
M St Front
M StBack
Segment Total
LIMB TOTALS
EVGS Summary Scoring Worksheet and Grid
www.shrinerschildrens.org/aacpdm2018
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OptimizingObservational Gait Analysis
www.shrinerschildrens.org/aacpdm2018
•Modern Technology•Mobile Videography•Cell Phones and Tablets
•Structured Analysis• Edinburgh Visual Gait
Scale
•Case Example
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Right Spastic Hemiplegic Cerebral Palsy
www.shrinerschildrens.org/aacpdm2018
Preop1 year post
Achilles + Plantar Fascia2 years post
Achilles + Plantar Fascia
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Preop EVGS Grading: Right Mid Stance Sagittal
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Preop EVGS Grading: Right Mid Stance Front Coronal
www.shrinerschildrens.org/aacpdm2018
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www.shrinerschildrens.org/aacpdm2018
Midstance Terminal Stance Mid-swingInitial Contact
2
1
1
2
1
1 2
1
2
EVGS: Right Limb
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Right Limb EVGS Grading
Phase Trunk Pelvis Hip Knee Ankle Foot
IC 1 0 2
M St 1 0 2
T St 0 0 2
M Sw 1 2 0
M St Front 0 1 0 0
M St Back 1
Segment Total
1 1 1 1 6 3
LIMB TOTALS PREOP TOTAL = 13
www.shrinerschildrens.org/aacpdm2018
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www.shrinerschildrens.org/aacpdm2018
Midstance Terminal Stance Mid-swingInitial Contact
2 2 2 2
EVGS: Left Limb
1
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Left Limb EVGS GradingPhase Trunk Pelvis Hip Knee Ankle Foot
IC 0 0 2
M St 1 0 2
T St 0 0 2
M Sw 0 2 0
M St Front 0 0 0 0
M St Back 0
Segment Total
1 0 0 0 6 2
LIMB TOTALS PREOP TOTAL = 8
www.shrinerschildrens.org/aacpdm2018
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Right Limb EVGS Grading
PhaseTrunk Pelvis Hip Knee Ankle Foot
P 1 2 P 1 2 P 1 2 P 1 2 P 1 2 P 1 2
IC 1 0 0 2 0 0
M St 1 0 0 2 0 0
T St 2 0 0
M Sw 1 2 1 2 0 0
M St Front 1 0 0
M St Back 1 0 0
Segment Total
1 0 0 1 0 0 1 0 0 1 2 1 6 0 0 3 0 0
1 year
www.shrinerschildrens.org/aacpdm2018
2 11
2
2 yearPre
Resolution of Mid-Swing Stiff Knee at 2 years
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Left Limb EVGS Grading
PhaseTrunk Pelvis Hip Knee Ankle Foot
P 1 2 P 1 2 P 1 2 P 1 2 P 1 2 P 1 2
IC 2
M St 1 1 0 2 1
T St 2
M Sw 2
M St Front
M St Back
Segment Total
1 1 0 6 2 1
www.shrinerschildrens.org/aacpdm2018
2
1
1
1
Trunk lean and vaulting resolve at 2 years
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Total Body EVGS Grading
www.shrinerschildrens.org/aacpdm2018
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• Proximal segments (hip, pelvis) are less accurate than distal segments (ankle, foot)
• Less experienced observers have lower inter-rater reliability• GMFCS III patients have lower scoring reliability than I or II• Agreement between observers between 64 – 92%• Agreement to 3D gait analysis is between 60 – 70%
Limitations of EVGS
Orozco et al. Gait & Posture 49 (2016) 14–18.
www.shrinerschildrens.org/aacpdm2018
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• EVGS vs Kinematics• Cell Phone / Gimbel Platform• MAC System• Simultaneous Capture
• Refine Technique• Other Software Platforms• Additional Kinematic
Variables• Establish Clincial Boundries
Current Research
www.shrinerschildrens.org/aacpdm2018
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SimultaneousInstrumented Gait Capture
Sagittal Camera on Gimbal
Coronal Camera
Additional Markings
EVGS Set-Up
www.shrinerschildrens.org/aacpdm2018
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Terminal Swing/Initial Contact R
Peak Hip Flexion (EVGS #13)Markedly increased flxn (>60° ) 2Increased flxn (46°-60°) 1Normal flxn (25°-45°) 0Reduced flxn (10 °-24 °) 1Severely reduced flxn (<10 ° ) 2
Knee Position (EVGS #10)Severe flxn (>30 °) 2Moderate flxn (16 ° -30 °) 1Normal flxn (5 ° -15 °) 0Moderate extn (4 ° flxn - 10 extn) 1Severe hyperextn (>+10 ° extn) 2
Foot Position (EVGS #1)Heel Contact 0Flatfoot Contact 1Toe Contact 2
For EVGS #1 Foot Position: Look at foot inclination graph at Initial Contact, which is 0.0% of Gait Cycle:
If the value is positive, this equates to heel contact.If the value is zero, this equates to flatfoot contact.If the value is negative, this equates to toe contact.
www.shrinerschildrens.org/aacpdm2018
Example EVGS Scoring Worksheet
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Heart Function
Gait Function
Pulse RateStethoscope Echocardiogram
Hallway Examination
Observational Gait Analysis
3D Gait Analysis
Increasing Patient Complexity
www.shrinerschildrens.org/aacpdm2018
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OptimizingObservational Gait Analysis
www.shrinerschildrens.org/aacpdm2018
•Modern Technology•Mobile Videography• Cell Phones and Tablets
• Image Stabilization
•Structured Analysis• Edinburgh Visual Gait
Scale
•New Possibilities!
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www.shrinerschildrens.org/aacpdm2018
• Full Handouts• Gait Scoring Sheets• Links to resources
….and more!• [email protected]