As I mentioned previously, this one is perhaps the most severe and complex so far. Velocity is very low, at 0.7 m/s. Stride Length only 0.75 m, with a normal cadence. So the problem (as usual) is inadequate stride length.
What is limiting stride length? There are two main possibilities:
What's causing the toeing in? Here the physical exam helps: femoral anteversion both left (60°) and right (75°). So why is the right side more toed-in? The hip must be internally rotated too. The kinematics shows an extra 20° on that side. Both frontal hip powers suggest weak hip abductors (Trendelenberg), made worse by the hip adduction, and the reason why she uses her arms so much.
This leaves us with the knees, which are both fixed. Why? It doesn't seem to be rectus/hamstrings spasticity, or at least there's not much EMG evidence (if I read it correctly). Although there are marked rectus signs bilaterally, the hamstrings are less tight. The missing tight knee flexors are, of course, the spastic adductors, which we don't have EMG data on. By the way, the huge knee moments (with consequently severe bone-on-bone forces) are surely going to damage her knees in time.
How is she advancing then? look at the sagittal hip powers - they're huge: on the right both H1 and H3, on the left the pull-off only (H3). There are also big K2s, especially right, but I don't know whether these are artefactual (Cardan angle problem) due to the knee being flexed.
Well, I'm now as exhausted as she must be! I'll leave the treatment to someone else...
Dr. Chris Kirtley (Kwok Kei Chi) MD PhD Assistant Professor Department of Rehabilitation Sciences The Hong Kong Polytechnic University <email@example.com>
REASON FOR REFERRAL:
*PASSIVE ROM: *JBJS, V 77-A, No. 5, pp784-798, 1995.
HIP S EXT-0-FLEX
T ABD (90 HIP FL)
T EXT ROT-0-INT ROT (Prone)
KNEE S EXT-0-FLEX
PRONE KNEE FLEXION (grab)
STRAIGHT LEG RAISE
KNEE EXT W/HIP @ 90 (grab)
ANKLE S DORSI-0-PLANTAR
FOOT POSITION (weight-bearing)
THIGH-FOOT ANGLE RANGE EXT-0-INT (resting)
Equil: sitting standing Calf Girth
Active Dorsi to
Clonus of Gastroc Post Tib
MUSCLE TONE: Note velocity-dependent increase in resistance to passive motion. Test patient supine,
head in mid-line.
Scale for grading spasticity (modified Ashworth and Bohannon)
5 = Extreme Affected part rigid in flexion or extension.
4 = Severe Considerable increase in tone, passive movement is difficult.
3 = Moderate More marked increase in tone through most of range of motion but affected part is easily
2 = Mild Slight increase in tone "catch" in limb movement or mild resistance to movement through
less than half of the range.
1 = Normal No increase in muscle tone.
0 = Hypotonic Less than normal muscle tone, floppy.
MANUAL MUSCLE TEST
Hip flexion (R/L)
(P) = Resistance is given in the patient's active range but active range
of motion is less than passive range.
*Plantarflexion grade indicates number of toe rises possible with (P) for partial rise.
Key - Kendall
100% 5 N Normal: Completes arc of motion against gravity with a maximum resistance.
80% 4 G Good: Completes arc of motion against gravity with a moderate amount of
resistance or is unable to complete arc of motion when done with a
maximum amount of resistance.
50% 3 F Fair: Completes arc of motion against gravity. (3+ takes a minimum
amount of resistance)
20% 2 P Poor: Moves through partial arc of motion with gravity eliminated.
5% 1 T Trace: A contraction is felt, but there is no apparent movement of part.
0 0 Zero: No contraction felt in muscle.
GAIT LABORATORY EVALUATION FORM
Shriners Hospital for children
Portland, Oregon USA 7/93
Michael Orendurff, MS
Portland Shriners Hospital
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