Feedback from the expert speakers at the ESMAC meeeting is here.
What people said...
Q. What is the primary cause of this gait pattern?
A. He walks with stiff knees, complicated by rotational deformities
(femoral anteversion and/or tibial torsion). I find it surprising,
though, that both knees hyperextend on clinical examination to -10
degrees.
Q. What is the cause of the high energy consumption?
A. He is vaulting with the stance ankle in order to compensate
for lack
of toe-clearance. This causes increased rise and fall of the
trunk,
requiring more energy (mainly from the planarflexors).
Q. What treatment would you recommend in relation to energy consumption?
A. He needs to improve toe-clearance. This could be done by freeing
the
knees by a combination of hamstrings lengthening and rectus transfer
to
gracilis. I also wonder whether he has tried walking with a stick (cane)?
Chris
--
Dr. Chris Kirtley MD PhD
Dept. of Rehabilitation Sciences
The Hong Kong Polytechnic University
Hong Kong
Special Administrative Region of The People's Republic of China
I am a relatively novice clinician, and am fortunate enough to work
with one
who is very experienced. I evaluated a child who toe walks the
other day
(although he was referred for hamstring tightness). He definitely
needed his
hamstrings stretched, but his trunk was very weak. My counterpart
was telling
me how when the trunk is weak the hamstrings will substitute as
trunk
extensors to add stability, and therefore get very tight.
Ankle
plantarflexion is part of that strategy as well, to keep him from falling
backwards. If only his hamstrings were stretched, his overall
stability would
be compromised, so trunk stability activities were added.
In regards to the case, perhaps the gastroc lengthenings, while
well-intended,
decreased his stability overall. (Does more dorsiflexion without
stability
result in an increased crouch gait?) Range of motion also needs to
be
addressed,because he cannot be expected to walk any better without
the
necessary range. However, he obviously needs to be able to control
the range.
Maybe the answer is not in the legs....
Melanie Weller MPT
I'll give an account of the case discussions for all three cases over
the
next few weeks. Hopefully these will spark yet more discussion. As
discussion flags on one I'll put the next set of comments on.
We'll start with the case published on 17-09-98 as the patient asked
to be
removed from the web after the conference. We'll leave him on for say
three
weeks more to facilitate any further discussion. Inevitably discussion
centred more on clinical options than on the questions which had been
posed
when the cases where published.
In presenting the case a little more information was given regarding
EMG
than had been given on the web. The Rectus Femoris was continuously
active
throughout gait and the Vastus Lateralis throughout stance (bilaterally).
It
was also commented that there was a large population of these older
patients
now attending rehab hospitals.
Speaker A thought the subject would definitely benefit from surgery.
He
identified internal rotation, short hamstrings, short TAs, short
hip flexors
and thought all required surgical correction. It was important
to appreciate
that the subject was experiencing increasing difficulties with walking
and
intervention was needed soon to prevent this continuing.
Speaker B first drew attention to this as an example of a failed
isolated
early TAL and drew parallels with a paper presented earlier
in the
conference (Morton et al) highlighting the dangers of such procedures.
He
also saw the need for bilateral psoas, hamstrings lengthenings and
derotation osteotomies and also added that the feet should
be made
braceable. He concluded by suggesting that the patient would
probably end up
taller and straighter but would also be weaker and slower.
He thought it
unlikely the subject would become independent of crutches and
thought that
the objectives of surgery should be clearly explained in counselling
the
patient.
Speaker C added his support to this opinion, particularly with regard
to
crutches, but added that post-operatively the gait might be more
energy
efficient.
Speaker D asked about the length of time needed to rehabilitate adults
after
such major surgery.
Speaker A agreed that this was a concern and reiterated that keeping
the
subject walking in the long term was the aim of surgery. He
drew attention
to the fact that these subjects have been used to walking in this fashion
for many years and that this needs to be taken into account when planning
surgery. He suggested not completely derotating the femurs for
example as
the subject is used to an internally rotating gait.
Speaker C suggested the use of intrathecal baclofen. With such
a patient the
procedure he would adopt is to have a trial dose of baclofen before
implanting the pump. A low dose is required because if the tone is
taken
away completely the subject will lose the ability to walk at all.
Speaker C also emphasised the need to keep the subject on his feet and
suggested the possibility of operating on right and left separately
to avoid
confining the subject to a wheelchair completely during rehab.
Speakers included Reinhold Brunner, Jim Gage, Kerr Graham and Sybil
Farmer.
The above account is based on notes I took during the discussion which
may
well contain misunderstandings and errors which are mine and not those
of
the original speakers.
Richard Baker
Gait Analysis Service Manager
Musgrave Park Hospital
Stockman'sLane
BELFAST
BT9 7JB
Tel: +44 (0)1232 669501 ext 2155
Fax: +44 (0)1232 611064