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== Gait Analysis ==
== Gait Deviations in Children with Cerebral Palsy ==
Children with cerebral palsy (CP) often exhibit several gait deviations, largely due to motor control abnormalities, muscle weakness, contractures, and spasticity. Common deviations can be seen across various stages of the gait cycle:


Atypical gait is a common problem in ambulant children with Cerebral Palsy, making optimising or improving the efficacy of gait a key orthotic treatment goal.<ref name="p1">Harvey AGJW. Video gait analysis for ambulatory children with cerebral palsy: Whay, when, where and how! Gait Posture. 2011;33(3):501-3</ref> Gait analysis plays an important part in clinical decision-making when managing children with Cerebral Palsy. It is used to identify gait abnormalities, assist with the setting of treatment goals and also in the appraisal of ambulation following orthotic intervention. Hence the assessment and chronicling of a child’s gait is a critical element of the orthotic assessment process for ambulant children with Cerebral Palsy.<br>  
# Initial Contact and Loading Response: Children with cerebral palsy often demonstrate a flat foot or an equinus foot (heel does not touch the ground) during initial contact, with ensuing knee hyperextension or flexion during the loading response.<ref>Wren TA, Rethlefsen S, Kay RM. Prevalence of specific gait abnormalities in children with cerebral palsy: influence of cerebral palsy subtype, age, and previous surgery. Journal of Pediatric Orthopaedics. 2005 Jan 1;25(1):79-83.</ref> This could lead to instability and increased energy expenditure during walking.
# Mid-Stance and Terminal Stance: In these stages, the child may exhibit excessive hip internal rotation due to muscle imbalances, contractures, or overactivity of certain muscle groups (e.g., hip adductors or internal rotators).
# Pre-Swing and Swing Phase: There may be problems with foot clearance, mainly due to decreased hip and knee flexion and ankle dorsiflexion. This might lead to an altered swing phase, often manifesting as a circumduction gait, where the child swings their leg in a semi-circle due to the inability to flex their knee or hip adequately.<ref>Schwartz MH, Rozumalski A, Trost JP. The effect of walking speed on the gait of typically developing children. Journal of biomechanics. 2008 Jan 1;41(8):1639-50.</ref>


Visual Observational Gait Analysis (VOGA) provides the clinician with useful information concerning the presence of any musculoskeletal abnormalities and the alignment, coordination and proprioception of the lower limbs. VOGA relies on the clinician being able to assess body segment motion in two planes and at many levels at particular points of the gait cycle. For optimal orthotic management to occur, the treating clinician requires an awareness of what constitutes normal and pathological gait for a child at their particular stage of development. The clinician should therefore be able to identify the motor function deficits and differentiate primary impairment from substitutive actions. <ref name="p1" />&nbsp;<ref name="p2">Brehm M, Bus SA, Harlaar J, Nollet F. A candidate core set of outcome measures based on the international classification of functioning, disability and health for clinical studies on lower limb orthoses. Prosthet Orthot Int. [Research Support, Non-U.S. Gov't]. 2011 Sep;35(3):269-77</ref><br>VOGA is relatively subjective and relies on the individual orthotist to identify and record gait abnormalities in real time. This can lead to low validity, reliability, sensitivity and specificity when compared to kinematic analysis in a gait laboratory. <ref name="p3">Bella GP, Rodrigues NB, Valenciano PJ, Silva LM, Souza RC. Correlation among the Visual Gait Assessment Scale, Edinburgh Visual Gait Scale and Observational Gait Scale in children with spastic diplegic cerebral palsy. Rev Bras Fisioter. [Comparative Study]. 2012 Apr;16(2):134-40.</ref>&nbsp;<ref name="p4">Toro B. NC, Farren P. A review of observational gait assessment in clinical practice. Physiotherapy Theory and Practice. 2003;19:137-49</ref>&nbsp;To improve reliability, validity and sensitivity to change during VOGA the following gait scales have all been used in the evaluation of Paediatric Cerebral Palsy Gait:  
== Importance of Gait Analysis ==
Gait analysis plays an essential role in the assessment, planning, and evaluation of treatment strategies for children with cerebral palsy. Research indicates that gait analysis can provide essential insights into motor disorders in cerebral palsy, leading to improved treatment planning and prognosis.<ref>Schwartz MH, Trost JP, Wervey RA. Measurement and management of errors in quantitative gait data. Gait & posture. 2004 Oct 1;20(2):196-203.</ref> Quantitative gait analysis, which involves the use of advanced technology such as motion capture systems and force plates, offers detailed insights into spatiotemporal parameters, kinematics, kinetics, and muscle activity during gait.<ref>Wren TA, Gorton III GE, Ounpuu S, Tucker CA. Efficacy of clinical gait analysis: A systematic review. Gait & posture. 2011 Jun 1;34(2):149-53.</ref>Gait analysis aids clinicians in:


*Physicians Rating Scale (PRS)
# Identifying Specific Deviations: Gait analysis can help identify specific gait deviations and the phase of the gait cycle where they occur. This information can guide targeted therapeutic interventions.
*Observational Gait Scale (OGS)
# Quantifying Abnormalities: Gait analysis tools offer quantitative data about the child's walking pattern, providing an objective measure of the severity of gait abnormalities.
*Visual Gait Assessment Scale (VGAS)
# Monitoring Progress: Gait analysis can track changes over time, allowing the healthcare provider to monitor the effectiveness of interventions and adjust the treatment plan as necessary.
*Edinburgh Visual Gait Scale (EVGS)
# Informing Surgical Planning: In some cases, gait analysis can provide valuable information that informs the planning of orthopaedic surgery, such as selective dorsal rhizotomy or muscle-tendon lengthening.


These scales provide the assessor with tick box forms to identify gait abnormalities, rate severity and provide an overall score for a child’s gait.<br>
== Gait Analysis Tools and Assessment Aids ==
For effective management and treatment planning, it's essential to accurately identify and quantify these gait deviations, a process significantly facilitated by gait analysis tools and assessment aids.  Tools allow precision and objectivity, eliminating the subjectivity associated with simple observational methods. They provide quantifiable and standardised measurements of various aspects of gait, thus permitting the accurate identification of specific deviations, be it in foot contact, knee motion, or trunk sway.


=== Physicians Rating Scale (PRS)  ===
Aside from identifying specific abnormalities, these tools serve as invaluable resources in monitoring the evolution of a child's gait over time, capturing changes attributable to natural progression or in response to therapeutic interventions. This longitudinal tracking of gait patterns facilitates evidence-based evaluation of treatment efficacy and allows for necessary adjustments in the treatment plan.


The PRS classifies six gait variables that are viewed in the sagittal plane on a 2 - 4 point scale. It has been shown to have good intra-observer reliability but poor inter-observer reliability when used in children with spastic hemiplegia and bilateral lower limb spasticity.<ref name="p5">Maathuis KG, van der Schans CP, van Iperen A, Rietman HS, Geertzen JH. Gait in children with cerebral palsy: observer reliability of Physician Rating Scale and Edinburgh Visual Gait Analysis Interval Testing scale. J Pediatr Orthop. 2005 May-Jun;25(3):268-72</ref> Development of the PRS led to the introduction of the OGS and VGAS. However, the major limitation of all of these scales is that they only assess gait in the sagittal plane. It has also been found that visual assessment using the PRS and subsequent versions does not appear to accurately measure what it is most commonly used to assess; the ankle position in stance phase.<ref name="p6">Wren TA, Rethlefsen SA, Healy BS, Do KP, Dennis SW, Kay RM. Reliability and validity of visual assessments of gait using a modified physician rating scale for crouch and foot contact. J Pediatr Orthop. 2005 Sep-Oct;25(5):646-50</ref><br>
Certain tools, notably the GDI and GPS, offer a comprehensive understanding of a child's gait 'abnormality' by consolidating multiple variables into a single score. On the other hand, tools that measure temporal-spatial parameters provide rich insights into various functional aspects of a child's walking ability.


=== Edinburgh Visual Gait Scale (EVGS) ===
Tools such as the FMS explore life scenarios, assessing how gait deviations impact daily life and independence. This perspective aids clinicians in goal setting and prioritising interventions that significantly enhance the child's participation and overall quality of life. Some tools commonly used when assessing gait in children with cp include:


The EVGS was developed specifically for children with Cerebral Palsy and has stronger psychometric properties to enhance reliability. <ref name="p7">Read HS, Hazlewood ME, Hillman SJ, Prescott RJ, Robb JE. Edinburgh visual gait score for use in cerebral palsy. J Pediatr Orthop. [Research Support, Non-U.S. Gov't]. 2003 May-Jun;23(3):296-301</ref>&nbsp;The assessment is carried out in both the sagittal and coronal planes and evaluates the lower limb joint angles in both the stance and swing phases of gait. By incorporating the sagittal and coronal planes it allows for inferences to be made about the transverse plane and provides a more comprehensive representation of the child’s gait pattern than gait classification systems based solely on sagittal plane data. Similar to the other observational gait analysis scales, the EVGS has good intra-observer reliability, but poor inter-observer reliability. <ref name="p5" />&nbsp;<ref name="p7" />&nbsp;The EVGS has also shown good sensitivity to change in children with Cerebral Palsy following orthopaedic surgery and therapeutic interventions. <ref name="p8">Gupta S, Raja K. Responsiveness of Edinburgh Visual Gait Score to orthopedic surgical intervention of the lower limbs in children with cerebral palsy. Am J Phys Med Rehabil. [Evaluation Studies Research Support, Non-U.S. Gov't]. 2012 Sep;91(9):761-7</ref>&nbsp;To ensure consistently good levels of reliability and sensitivity are achieved, the assessor must be well trained and experienced in the evaluation and application of the EVGS. <ref name="p9">Viehweger E, Zurcher Pfund L, Helix M, Rohon MA, Jacquemier M, Scavarda D, et al. Influence of clinical and gait analysis experience on reliability of observational gait analysis (Edinburgh Gait Score Reliability). Ann Phys Rehabil Med. [Validation Studies]. 2010 Nov;53(9):535-46</ref>&nbsp;<ref name="p0">Ong AM, Hillman SJ, Robb JE. Reliability and validity of the Edinburgh Visual Gait Score for cerebral palsy when used by inexperienced observers. Gait Posture. [Comparative Study]. 2008 Aug;28(2):323-6</ref>&nbsp;It may be possible to use the EVGS to evaluate orthotic intervention, however further work is required to evaluate the sensitivity of the EVGS to gait changes following orthotic intervention.
# '''Physicians Rating Scale (PRS)''': This widely-used clinical tool provides a qualitative assessment of gait abnormalities in children with cerebral palsy. By evaluating various parameters like foot contact, knee motion, symmetry, and trunk sway, PRS helps clinicians identify specific areas for therapeutic intervention.
# '''Edinburgh Visual Gait Scale (EVGS'''): The EVGS is an observational tool designed for subjective assessment of gait in children with cerebral palsy. With a total of 17 items, it provides a comprehensive view of a child's gait, focusing on aspects such as foot strike, knee flexion, and trunk movement.
# '''Visual Gait Assessment Scale (VGAS)''': The VGAS offers an objective way to rate gait pathologies in children with cerebral palsy. Comprising 18 items related to common gait abnormalities, it helps healthcare professionals to pinpoint specific issues and monitor changes over time.
# '''Three-Dimensional Gait Analysis (3DGA)''': Considered the gold standard for gait analysis, 3DGA uses advanced technology to provide in-depth insights into the kinematics, kinetics, and electromyographic activity during walking. Although resource-intensive, its precision and accuracy make it invaluable for personalized treatment planning.
# '''Gait Deviation Index (GDI)''': This is a summary measure of overall gait 'abnormality'. It takes multiple variables from 3DGA and reduces them to a single score, with lower scores indicating greater deviation from typical gait.<ref>Schwartz MH, Rozumalski A. The Gait Deviation Index: a new comprehensive index of gait pathology. Gait & posture. 2008 Oct 1;28(3):351-7.</ref>
# '''Gait Profile Score (GPS)''': Similar to the GDI, the GPS provides a single score that summarises the overall deviation of an individual's gait from a reference normal. It specifically focuses on nine key kinematic variables.<ref>Baker R, McGinley JL, Schwartz MH, Beynon S, Rozumalski A, Graham HK, Tirosh O. The gait profile score and movement analysis profile. Gait & posture. 2009 Oct 1;30(3):265-9.</ref>
# '''Temporal-Spatial Parameters''': These include variables such as walking speed, step length, stride length, cadence, and the proportion of the gait cycle spent in different phases (stance, swing, double support). These parameters can be measured relatively simply and can provide important information about gait function.
# '''Functional Mobility Scale (FMS)''': The FMS assesses a child's usual performance in walking different distances (5, 50, and 500 metres), focusing on real-world functional mobility. This can help clinicians understand how gait deviations impact the child's everyday life.<ref>Graham HK, Harvey A, Rodda J, Nattrass GR, Pirpiris M. The functional mobility scale (FMS). Journal of Pediatric Orthopaedics. 2004 Sep 1;24(5):514-20.</ref> <br>


=== Visual Gait Assessment Scale (VGAS)  ===
== Conclusion ==
 
Gait analysis, is an important aspect of the assessment process.  By accurately identifying and quantifying gait deviations, these tools provide clinicians with invaluable insights into the unique gait patterns observed in these children. This understanding enables targeted interventions, precise monitoring of progress over time, and assessment of treatment effectiveness. By leveraging these comprehensive and objective measures, clinicians can optimise therapeutic strategies, improve gait function, and enhance the overall quality of life for children with cerebral palsy.
In an attempt to overcome some of the problems associated with naked eye evaluation of gait, such as the speed of movements and only seeing the gait cycle once, Video Gait Analysis (VGA) has become a popular tool in the clinical setting. The video recording of a child’s gait should be conducted along a five-metre walkway at a self-selected walking speed in both the coronal and sagittal planes. The conditions to examine should comprise of barefoot, shoes only and if orthoses are being used, with shoes and orthoses. Reasons for considering the use of VGA in children with Cerebral Palsy are:<br>
 
1. To establish a baseline of walking ability at the initial assessment;<br>2. Allow the documenting of any changes in gait pattern during growth;<br>3. Permit the evaluation of interventions such as surgery, botulinum toxin injections, serial caring, intensive therapy or orthotic intervention.&nbsp;<ref name="p1" /><br>
 
The use of video analysis software that enables the user to take measurements of joint angles, distances and timing directly on digital video recordings, offers the potential to decrease the bias associated with subjective real time image assessments. <ref name="p1" />&nbsp;VGA incorporating the EVGS and specific video analysis computer software is an efficient approach to improve the reliability and repeatability of VGA with the added benefit of being easily incorporated into the orthotic clinical setting. <ref name="p1" />&nbsp;<ref name="p1" />&nbsp;It provides an alternative to a full-instrumented gait analysis for those children that would otherwise not be considered suitable or when time or other resources are limited.<br>
 
=== Three Dimensional Gait Analysis (3DGA) ===
 
The Three Dimensional Gait Analysis (3DGA) has proven to be a particularly powerful instrument to explicitly quantify joint kinematics and kinetics of the gait in children with Cerebral Palsy.<ref name="p2" />&nbsp;3DGA involves the use of video and infra-red cameras to record a person walking along a five metre walkway (FIGURE 1). Reflective dots are applied to the joints at predetermined intervals to capture information on body segment movement during gait and a force platform is positioned in the middle of the walkway to collect information on the Ground Reaction Force (GRF) during stance phase.  
 
[[Image:Gait Analysis CP.jpg|600px]]
 
'''FIGURE 1: '''Gait laboratory set up for Three Dimensional Video Gait Analysis.&nbsp;Six infra red motions sensitive cameras are positioned around the five-metre&nbsp;walkway, with a force platform located in the middle of the walkway. <ref name="p2" />
 
3DGA is the gold standard for the comprehensive assessment of gait function in ambulant children with Cerebral Palsy. <ref name="p3" />&nbsp;It allows for the in-depth analysis of three dimensional kinematics, kinetics, temporo-spatial measurements, dynamic electromyography and physiological testing. 3DGA also provides clinicians with the ultimate in outcome measures for evaluating the effect an orthosis may have on a child’s gait. Employing 3DGA for orthosis evaluation at the level of gait kinematics and kinetics can be regarded as a technical quality check of the orthotic intervention in itself. <ref name="p2" />&nbsp;However, the everyday application in a clinical setting is limited due to the costs involved of setting up and running a gait laboratory and the time required for each gait assessment.<br>


== References  ==
== References  ==
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[[Category:Paediatrics - Assessment and Examination]]
[[Category:Paediatrics - Assessment and Examination]]
[[Category:ICRC Cerebral Palsy Content Development Project]]
[[Category:ICRC Cerebral Palsy Content Development Project]]
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[[Category:Plus Content]]

Latest revision as of 10:33, 2 November 2023

Original Editor - Kim Jackson as part of ICRC Cerebral Palsy Content Development Project

Top Contributors - Kim Jackson, Naomi O'Reilly, WikiSysop, Simisola Ajeyalemi, 127.0.0.1 and Jess Bell  

Gait Deviations in Children with Cerebral Palsy[edit | edit source]

Children with cerebral palsy (CP) often exhibit several gait deviations, largely due to motor control abnormalities, muscle weakness, contractures, and spasticity. Common deviations can be seen across various stages of the gait cycle:

  1. Initial Contact and Loading Response: Children with cerebral palsy often demonstrate a flat foot or an equinus foot (heel does not touch the ground) during initial contact, with ensuing knee hyperextension or flexion during the loading response.[1] This could lead to instability and increased energy expenditure during walking.
  2. Mid-Stance and Terminal Stance: In these stages, the child may exhibit excessive hip internal rotation due to muscle imbalances, contractures, or overactivity of certain muscle groups (e.g., hip adductors or internal rotators).
  3. Pre-Swing and Swing Phase: There may be problems with foot clearance, mainly due to decreased hip and knee flexion and ankle dorsiflexion. This might lead to an altered swing phase, often manifesting as a circumduction gait, where the child swings their leg in a semi-circle due to the inability to flex their knee or hip adequately.[2]

Importance of Gait Analysis[edit | edit source]

Gait analysis plays an essential role in the assessment, planning, and evaluation of treatment strategies for children with cerebral palsy. Research indicates that gait analysis can provide essential insights into motor disorders in cerebral palsy, leading to improved treatment planning and prognosis.[3] Quantitative gait analysis, which involves the use of advanced technology such as motion capture systems and force plates, offers detailed insights into spatiotemporal parameters, kinematics, kinetics, and muscle activity during gait.[4]Gait analysis aids clinicians in:

  1. Identifying Specific Deviations: Gait analysis can help identify specific gait deviations and the phase of the gait cycle where they occur. This information can guide targeted therapeutic interventions.
  2. Quantifying Abnormalities: Gait analysis tools offer quantitative data about the child's walking pattern, providing an objective measure of the severity of gait abnormalities.
  3. Monitoring Progress: Gait analysis can track changes over time, allowing the healthcare provider to monitor the effectiveness of interventions and adjust the treatment plan as necessary.
  4. Informing Surgical Planning: In some cases, gait analysis can provide valuable information that informs the planning of orthopaedic surgery, such as selective dorsal rhizotomy or muscle-tendon lengthening.

Gait Analysis Tools and Assessment Aids[edit | edit source]

For effective management and treatment planning, it's essential to accurately identify and quantify these gait deviations, a process significantly facilitated by gait analysis tools and assessment aids. Tools allow precision and objectivity, eliminating the subjectivity associated with simple observational methods. They provide quantifiable and standardised measurements of various aspects of gait, thus permitting the accurate identification of specific deviations, be it in foot contact, knee motion, or trunk sway.

Aside from identifying specific abnormalities, these tools serve as invaluable resources in monitoring the evolution of a child's gait over time, capturing changes attributable to natural progression or in response to therapeutic interventions. This longitudinal tracking of gait patterns facilitates evidence-based evaluation of treatment efficacy and allows for necessary adjustments in the treatment plan.

Certain tools, notably the GDI and GPS, offer a comprehensive understanding of a child's gait 'abnormality' by consolidating multiple variables into a single score. On the other hand, tools that measure temporal-spatial parameters provide rich insights into various functional aspects of a child's walking ability.

Tools such as the FMS explore life scenarios, assessing how gait deviations impact daily life and independence. This perspective aids clinicians in goal setting and prioritising interventions that significantly enhance the child's participation and overall quality of life. Some tools commonly used when assessing gait in children with cp include:

  1. Physicians Rating Scale (PRS): This widely-used clinical tool provides a qualitative assessment of gait abnormalities in children with cerebral palsy. By evaluating various parameters like foot contact, knee motion, symmetry, and trunk sway, PRS helps clinicians identify specific areas for therapeutic intervention.
  2. Edinburgh Visual Gait Scale (EVGS): The EVGS is an observational tool designed for subjective assessment of gait in children with cerebral palsy. With a total of 17 items, it provides a comprehensive view of a child's gait, focusing on aspects such as foot strike, knee flexion, and trunk movement.
  3. Visual Gait Assessment Scale (VGAS): The VGAS offers an objective way to rate gait pathologies in children with cerebral palsy. Comprising 18 items related to common gait abnormalities, it helps healthcare professionals to pinpoint specific issues and monitor changes over time.
  4. Three-Dimensional Gait Analysis (3DGA): Considered the gold standard for gait analysis, 3DGA uses advanced technology to provide in-depth insights into the kinematics, kinetics, and electromyographic activity during walking. Although resource-intensive, its precision and accuracy make it invaluable for personalized treatment planning.
  5. Gait Deviation Index (GDI): This is a summary measure of overall gait 'abnormality'. It takes multiple variables from 3DGA and reduces them to a single score, with lower scores indicating greater deviation from typical gait.[5]
  6. Gait Profile Score (GPS): Similar to the GDI, the GPS provides a single score that summarises the overall deviation of an individual's gait from a reference normal. It specifically focuses on nine key kinematic variables.[6]
  7. Temporal-Spatial Parameters: These include variables such as walking speed, step length, stride length, cadence, and the proportion of the gait cycle spent in different phases (stance, swing, double support). These parameters can be measured relatively simply and can provide important information about gait function.
  8. Functional Mobility Scale (FMS): The FMS assesses a child's usual performance in walking different distances (5, 50, and 500 metres), focusing on real-world functional mobility. This can help clinicians understand how gait deviations impact the child's everyday life.[7]

Conclusion[edit | edit source]

Gait analysis, is an important aspect of the assessment process. By accurately identifying and quantifying gait deviations, these tools provide clinicians with invaluable insights into the unique gait patterns observed in these children. This understanding enables targeted interventions, precise monitoring of progress over time, and assessment of treatment effectiveness. By leveraging these comprehensive and objective measures, clinicians can optimise therapeutic strategies, improve gait function, and enhance the overall quality of life for children with cerebral palsy.

References[edit | edit source]

  1. ↑ Wren TA, Rethlefsen S, Kay RM. Prevalence of specific gait abnormalities in children with cerebral palsy: influence of cerebral palsy subtype, age, and previous surgery. Journal of Pediatric Orthopaedics. 2005 Jan 1;25(1):79-83.
  2. ↑ Schwartz MH, Rozumalski A, Trost JP. The effect of walking speed on the gait of typically developing children. Journal of biomechanics. 2008 Jan 1;41(8):1639-50.
  3. ↑ Schwartz MH, Trost JP, Wervey RA. Measurement and management of errors in quantitative gait data. Gait & posture. 2004 Oct 1;20(2):196-203.
  4. ↑ Wren TA, Gorton III GE, Ounpuu S, Tucker CA. Efficacy of clinical gait analysis: A systematic review. Gait & posture. 2011 Jun 1;34(2):149-53.
  5. ↑ Schwartz MH, Rozumalski A. The Gait Deviation Index: a new comprehensive index of gait pathology. Gait & posture. 2008 Oct 1;28(3):351-7.
  6. ↑ Baker R, McGinley JL, Schwartz MH, Beynon S, Rozumalski A, Graham HK, Tirosh O. The gait profile score and movement analysis profile. Gait & posture. 2009 Oct 1;30(3):265-9.
  7. ↑ Graham HK, Harvey A, Rodda J, Nattrass GR, Pirpiris M. The functional mobility scale (FMS). Journal of Pediatric Orthopaedics. 2004 Sep 1;24(5):514-20.
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