JOE THILMAN, SPT

METHODS OF CLINICAL OBSERVATIONOF GAIT FOR CHILDREN WITH CP

TABLE OF CONTENTS

1. Classification of Gait Deviations

2. Common Gait Disruption Patterns

3. Observational Gait Assessment Tools

4. Video gait assessment software

• Smartphone-based apps

• Computer-based software

CLASSIFICATION OF GAIT DEVIATIONS

1. Primary gait deviations

2. Secondary gait deviations

3. Tertiary gait deviations

1. PRIMARY GAIT DEVIATIONS

• Direct Consequence of CNS injury

• Deviations are the result of impairments such as spasticity, weakness, diminished selective motor control, and proprioceptive deficits

• Best managed by pharmacological and neurosurgical interventions that directly address impairments caused by CNS injury

2. SECONDARY GAIT DEVIATIONS

• The result of disrupted growth of musculoskeletal system due to asymmetrical stimulation and abnormal loading from the CNS injury

• Impairments include joint contractures and skeletal segmental malalignments

• Commonly addressed with orthopedic surgery

3. TERTIARY GAIT DEVIATIONS

• Compensations for consequences of primary or secondary deviations

• Can be sustainable or unsustainable

• Sustainable deviations should be embraced

• Tertiary deviations will resolve spontaneously once primary and secondary deviations are addressed

COMMON GAIT DISRUPTION PATTERNS

• Sagittal Plane Disruptions

• Transverse Plane Disruptions

• Coronal Plane Disruptions

SAGITTAL PLANE DISRUPTIONS

Davids et al., 2014

TRANSVERSE PLANE DISRUPTIONS

• Most difficult plane to identify common gait disruptions with observational gait analysis because you are unable to directly visualize this plane.

• Must make inferences based on observations of motion in other planes.

• Limited understanding of transverse plane gait disruptions in CP restricts our assessment to the stance phase alone.

TRANSVERSE PLANE DISRUPTIONS

Davids et. Al, 2014

CORONAL PLANE DISRUPTIONS

• True coronal plane disruptions are uncommon in children with CP and are generally of little functional significance.

• Visualized coronal plane deviations are the result of sagittal and transverse plane deviations being seen out of plane

OBSERVATIONAL GAIT ASSESSMENT TOOLS

• Rathinam et al. (2014) performed a systematic review comparing the reliability and validity of the available observational gait assessment tools for use in children with CP against IGA

Physician’s Rating ScaleObservational Gait Scale

Salford Gait ToolObservational Gait AnalysisEdinburgh Visual Gait Score

GENERAL STRUCTURE OF GAIT SCALES IN DIFFERENT PHASES AND PLANES

Rathinam C, Bateman A, Peirson J, Skinner J. Observational gait assessment tools in paediatrics – A systematic review. Gait & Posture. 2014;40(2):279-285. doi:10.1016/j.gaitpost.2014.04.187.

PHYSICIAN’S RATING SCORE

• Created to analyze motion in the sagittalplane for patient’s with cerebral palsy and an equinus gait pattern after botoxtreatment

• Lacked the necessary reliability and sensitivity to detect specific changes after botox treatment

• Has been modified by many clinicians in attempt to improve its reliability and sensitivity

OBSERVATIONAL GAIT SCALE

•Ordinal Scale with 24 items that look at the ankle/foot, knee, hip, and pelvis

•Developed for use on patients with spastic CP

•Reported to have very good inter-rater reliability, however only the sagittal plane (ankle/foot, and knee joints) items scored maximum agreement

•Rater’s level of experience contributes to the scales reliability

SALFORD GAIT TOOL

• Examines the gait of children with CP in the sagittal plane only

• Assesses the hip, knee, and ankle joint positions during 6 gait events (initial contact, end double support, midstance, start double support, toe off, and mid swing phases) in stance and swing.

• Knee items were highly reliable, hip items had low reliability

• Determined to have high intra-observer repeatability and intra-observer agreement

Toro et. al.

OBSERVATIONAL GAIT ANALYSIS

• 10-item ordinal scale examining hip, knee, pelvis, and ankle in the sagittal, coronal, and transverse plane both in stance and swing

• High inter-observer agreement and better criterion validity for knee flexion and pelvic obliquity but the other 8 items were unreliable for visual observation

EDINBURGH VISUAL GAIT SCORE

• Three-point Ordinal Scale

• 17 gait parameters

• Assess motion in the sagittal, coronal, and transverse planes

• Locations assessed: foot, knee, pelvis, and trunk

• Score range = 0-34

• Good intra- and inter-observer reliability among both experienced and inexperienced clinicians

• Correlates well with IGA

• Scoring of the ankle and knee joint angles is more reliable than the foot, pelvis and trunk items

LIMITATIONS OF AVAILABLE TOOLS

• Insufficient for pre-surgical planning or for diagnostic purposes due to limited reliability and validity

• Very few studies available for most gait assessment tools which limits their clinical usefulness

BEST AVAILABLE TOOL

• Edinburgh Visual Gait Score • Currently has the best concurrent validity and reliability for use in children with CP

• Would benefit from more research using low-cost technology

VIDEO GAIT ASSESSMENT SOFTWARE

Can be used to assist in clinical observation of gait

• Allow for slow motion or frame-by-frame playback

• Graphic tools allow for improved estimation of joint angles and visualization of deviations such as scissoring

• Allow for side-by-side comparison

• Can annotate or comment on videos

• Can share videos with patients for them to refer back to at a later time

AVAILABLE SOFTWARE

• Smartphone and Tablet Applications• Dartfish Express

• Ubersense

• Coach’s Eye

• Desktop and Web-Based program

• Kinovea

• Dartfish

DARTFISH EXPRESS

• Available for iPhone/iPad only.

• Application Cost: $6.99

• Features: playback, slow motion, frame-by-frame, split screen for comparison, graphic tools, and video sharing via creation of a Dartfish TV channel

ACCESS TO VIDEOS ON DARTFISH TV

• 0.25 GB of free cloud storage, enough room for approximately 20 clips

• Not publicly available but, anyone with a link to your free channel can see all the videos you have online.

• Cannot have multiple patients’ videos on the free channel without their permission

• Can pay for a premium channel where you can keep separate collections and would have more storage space

UBERSENSE

• Available on iPhone/iPad and Android devices

• Free to download

• Features: playback, slow motion, frame-by-frame, split screen for comparison, graphic tools, and video sharing

COACH’S EYE

• Available on iPhone/iPad and android devices

• Free to download; $19.99 for the “Unlock Everything Pack”

• Free Features: standard and slow motion playback

• Paid Features: frame-by-frame, split screen for comparison, graphic tools, and sharing via e-mail, messaging, Facebook, Twitter, & YouTube.

TEXT/AUDIO COMMENTARY

• Ubersense and Coach’s Eye allow you to provide audio commentary as the video is playing.

• Dartfish Express allows you to provide text or audio commentary to a still image only

• Can create printouts with still images and text commentary

KINOVEA

• Desktop Program compatible with Windows only

• Free

• Features: playback, slow motion, frame-by-frame, split screen for comparison, synchronize, graphic tools, magnify, measure distances and times either manually or through the use of semi-automated tracking, export analysis to spreadsheet

• Difficult to master

VIDEO

• https://www.youtube.com/watch?v=Z-sWCOBW344

DARTFISH (COMPUTER-BASED)

• Packages of varying costs

• Features: playback, slow motion, frame-by-frame, split screen for comparison, graphic tools, measurement of angles and distances, a stopwatch, creation of data tables and automatic tracking of angles, distance, and objects.

REFERENCES

1. Araújo PA, Kirkwood RN, Figueiredo FM. Validity and intra- and inter-rater reliability of the Observational Gait Scale for children with spastic cerebral palsy. Rev Bras Fisioter, 13 (13) (2009), pp. 267–273

2. Davids JR, Bagley AM. Identification of Common Gait Disruption Patterns in Children With Cerebral Palsy. J Am Acad Orthop Surg. 2014;22(12):782-790. doi:10.5435/JAAOS-22-12-782.

3. Kawamura CM, de Morais Filho MC, Barreto MM, et al. Comparison between visual and three-dimensional gait analysis in patients with spastic diplegiccerebral palsy. Gait & Posture 2007;25:18-24.

4. Rathinam C, Bateman A, Peirson J, Skinner J. Observational gait assessment tools in paediatrics – A systematic review. Gait & Posture. 2014;40(2):279-285. doi:10.1016/j.gaitpost.2014.04.187.

5. Read HS, Hazlewood ME, Hillman SJ, Prescott RJ, Robb JE. Edinburgh Visual Gait Score for use in cerebral palsy. J Pediatric Orthop 2003;23(3):296-301.

6. Toro B., Nester C.J. , Farren P.C. The development and validity of the Salford Gait Tool: an observation-based clinical gait assessment tool. Arch Phys Med Rehabil, 2007; 88(3): 321–327.

7. Wren TA, Rethlefsen S.A., Healy B.S., Do K.P, Dennis S.W., Kay R.M. . Reliability and validity of visual assessments of gait using a modified physician rating scale for crouch and foot contact. J Pediatr Orthop, 2005; 25(5):646–650.

REFERENCES

1. Coachseye.com

2. Ubersense.com

3. Dartfish.com/express

4. Kinovea.org