Dear All, I've got to give a talk to the European Federation of Ortopaedic and Trauma Surgery on the 5th June with the title "Gait Analysis: the State of the Art". I'm splitting the lecture into three: Technology, Understanding and Clinical Uses. How about an honest debate on real clinical uses. I'm obviously aware of the use of gait analysis in relation to CP (and to a lesser extent in relation to Spina bifida). In what other fields though does gait analysis have a well defined and proven clinical role? In this I'd like to distinguish between research and routine service provision. I'm interested primarily in routine clinical services. Richard Richard Baker Gait Analysis Service Manager Musgrave Park Hospital Stockman's Lane Belfast BT9 7JB Tel: 028 9066 9501 ext 2849 Fax: 028 9068 3816
We use it routinely for pre-operative assessment in adults with traumatic brain injury and stroke. We recently presented data at the American Academy of Orthopaedics meeting on its value to level the field for surgical planing in experience and less experienced surgeons. Also we use it for orthotic and prosthetic management. The trick here is to have a clinician that can make use of the kinetic, kinematic and EMG data (when appropriate) to answer specific clinical questions. Good luck in your presentation.
Alberto Esquenazi, MD Director Gait & Motion Analysis Laboratory and Regional Amputee Center MossRehab a Member of the Jefferson Health Network 1200 West Tabor Rd. Philadelphia, PA 19141 USA Voice: 215 456 9470 Fax: 215 456 9631 http://www.einstein.edu/phl/1214p2.html
Richard's provocative question prompts some reflection. It is interesting that the birth of modern gait analysis (at Berkely under Verne Inman and Howard Eberhart) was stimulated by a desire to improve lower-limb prosthetics for the returning veterans of World War II - for those interested, I have started to put together a history page on CGA - it's by no means complete and in a state of construction, but you're welcome to take a look and send me anything you think would be useful: /history Anyway, what is startling, I think, is how small a proportion of gait labs today look at amputees. I might be wrong, but on my travels around the globe nearly all labs I've noticed that nearly all labs are predominantly interested in cerebral palsy. Is there a reason for this change in emphasis, I wonder? I have some suggestions: ¤ 1. There are more people with CP than there are amputees - I don't think so, but I don't know for sure (perhaps someone could comment?) ¤ 2. The insights provided by computerized gait analysis are unhelpful in designing and aligning a better prosthesis; ¤ 3. Modern equipment is more suited to 3D and rather superfluous for most amputee studies (when 2D suffices); ¤ 4. Prosthetics research has simply "gone out of fashion". Much as it pains me to say so, I suspect #4 is the reason. Which begs the question: what will come into fashion when CP is no longer a la mode? Chris -- Dr. Chris Kirtley MD PhD Associate Professor HomeCare Technologies for the 21st Century (Whitaker Foundation) NIDRR Rehabilitation Engineering Research Center on TeleRehabilitation Dept. of Biomedical Engineering, Pangborn 105B Catholic University of America
Gait Analysis has been very helpful in the selection and design of lower-limb orthotics. As a team member of a local gait lab, I've found the information useful in designing FO's and AFO's for neuromotor and orthopedic dysfunctions. Often a physician or therapist will make a generic request for a brace or a splint. Usually, for an AFO, the focus of the request is the ROM of the talocrural joint in the sagittal plane. Often the pathomechanics are much more complex, and the design and function of the device can have a profound effect on the foot and ankle complex, as well as function up the kinetic chain. As someone involved in gait interpretation for several years, I am mystified at the blatant disregard for the inclusion of orthotist and prosthetist in gait analysis. The benefit to the clinical team and the patient is obvious. The selection of an orthosis is not like the selection of a drug or DME device. The prescription that reads "AFO" can yield vastly different designs and results depending on the way it is made by the orthotist. No matter how detailed the prescription, the orthotist must make decisions that will have a significant impact on the fit and function of the device. To pretend otherwise results in less than optimum results. If there is a group that should be intimately involved in gait analysis it is orthotist and prosthetist. There is no question of the functional and developmental benefits gait analysis gives the patient population served by this group. Locke Davis, CPO
I think you make some interesting points in the progression of the use of gait labs. From a total outsider and my interest laying in sport, I do not have a clear idea of the path but has money played a role in this. My understanding is that the proliferation of gait labs came as a result of insurance companies requesting objective results of surgical interventions for CP kids. Large surgical procedures generate significant income for especially surgeons as well as hospitals. The supply of prosthetics does little for this income. Do you think this has played a part or am I being cynical. Regards Peter Blanch
I just got a call from xxx, they are putting together a proposal to study gait with different prosthetic knee designs. Rancho Los Amigos Medical Center has recently (within the last 5 years or so) published studies on gait with different foot designs. Chris Powers work, at Rancho at the time, demonstrated the need for EMG in amputee gait analysis instead of just calculated moments and powers. I think CP is big because that is where the money is. Shriner's has money.
In our lab at the West Midlands Rehabilitation Centre, Birmingham, we have been using gait analysis over the past few years in two main areas: Orthotics and Prosthetics. One of our first clinical services was to use the GRF vector superimposed over a sagittal and coronal video view to assist correct prosthetic alignment for LL amputees (particularly above-knee). I agree with Chris's opinion that there seems to be a decline in requests for assessment of amputees. Over the last five years we have increasingly used the lab facilities to assess regional orthotic patients with complex problems, referred following failure of previous medical/ orthotic/ physiotherapy etc. treatment. Most of those patients are adults with an original diagnosis such as MS, polio, muscular dystrophy and CVA, complicated by secondary problems of a biomechanical nature. More recently we have also seen two other categories of patients: children with juv. chronic arthritis who had not been treated successfully previously, and dysvascular patients for limb salvage (many with previous amputations). We feel that the facilities of our gait laboratory, and very significantly our multi-disciplinary team approach (including physician, clinical scientist, physiotherapist and orthotist/ prosthetist/ podiatrist depending on the patient, in agreement with Locke Davis' comments), allow us to investigate both the primary problems and secondary complications in much more detail, in order to recommend the most appropriate treatment/s. In case of orthotics, it also allows us to calibrate the device to provide an optimum effect for the patient, and subsequently to evaluate the orthosis' effect . Regards to all, Alexandros Falkonakis MSc PgC MCSP Clinical Specialist Physiotherapist Clinical Measurements Laboratory West Midlands Rehabilitation Centre 91 Oak Tree Lane, Selly Oak Birmingham B29 6JA, U.K. Tel: +44 (0)121 627 8123 Fax: +44 (0)121 627 8210
Working, as I do, in a lab that was founded to support the rehab of amputees, but is also now predominantly CP-based, I have the following comments to make. There was undoubtably a phase when the study of basic biomechanics of walking was essential in order to progress the development of functionally effective prosthesis. Once that core knowledge on the role of a prosthesis in amputee gait was established, it appears to me that further developments in the field have had more to do with the incorporation of modern materials and methods for improved realisation of this role, than with more sophisticated understanding of gait. For example, today we see much of the gait-based research directed at trying to test the claims of manufacturers about the energy storing capabilities of their feet and the subsequent effect that this has on function. Following this period, there was a phase when gait analysis was an important tool in the training of prosthetists and the development of teaching materials, helping to illustrate to them the biomechnical basis of the effects of the alignment changes that they were making. Again this has led to an increase in the core knowledge which prosthetists now apply in their daily practice. The prosthetists makes adjustments to a limb, intuitively interpreting the gait changes in terms of the position of the 'load- line', relative to the limb. He/she does this fairly efficiently and efficiently and would need a good excuse to use a gait lab to interfere with this process, even with the modern super-fast, intelligent systems. Hence the routine use of gait analysis in prosthetic management hasn't been extensive. Having said all that, with the bewildering array of sophisticated and expensive prosthetic systems on the market, I believe that the tide is turning. Some of the systems have so many configuration choices and are so 'non-anatomical' in their construction, that objective support for the clincial decision-making process would be welcome (we have had an example of this recently); the routine audit of prescriptions may become an important tool in rationalising service provision; also the trend to 'intelligent' prostheses, with time- criticial functions, again lends itself to objective measurement as part of the CDM process. Also, even the best prosthetist will find himself pitched against a 'problem' amputee, whom it is impossible to satisfyand again, objective measurement may come to the rescue. Also, your comment about the 3-D systems being superfluous is possibly valid for BKs(sorry TTAs!), but I do not believe that they are valid for AKs(sorry TFAs!). This is because the various socket types and their claims with regards to ischial containment can only really be tested looking at M-L hip moments and it is in ab/adduction of the prosthesis that these effects are controlled, in the main. The situation in CP is very different. Yes gait analysis has taken our understanding of the subtleties of gait to a new level, applying this knowledge to education and directly to new treatments. Yes those who have been practising for a long time can recognise gait patterns and relate them to functional types and likely treatment options. But fundamentally you cannot see in 3-D, you cannot confirm moments or muscle activation patterns by observation. And most importantly unlike alignment changes, when you simple undo a particular component alteration, you cannot undo an injection and you certainly cannot undo surgery. I would hope that CGA is not only here to stay in CP management, but that it will become mopre widey accepted, and in the long term the case is the same for the mangement of most complex ambulatory conditions, once the clinical structures to incorporate CGA into their managment exists. For example, our Neuroscience department are evaluating the use of CGA as an outcome measure in the use of deep brain stimulation, for the mangement of tremor in Parkinson's Disease. I mention this to illustrate the importance of the clinical support, as it was the interest of the Neurosurgeon and his desire to proceed, that drives this forward. There are plenty of less exotic examples to choose from and I look forward to hearing from other CGAers what they are doing. Regards Jeremy Linskell
I have read with some interest of the variety of candidate groups that might benefit from CGA. Working in a lab with a client base comprising 95% CP, I am keen to add a little variety to my life. However, to be an effective decision making or even diagnostic tool, cga can only be used in conjunction with a decent model of interpretation. This model, in principle, may be constructed from experience or deterministically (if we were biomechanically and aetiologically clever enough). In CP, we prefer the experiential approach (sometimes our own experiences and sometimes the experiences of others reported in books or journals). I guess that any deterministic approaches are confounded because, with the data we have available, the biomechanical problems problems presented cannot be fully determined. The empirical model may be revised relatively quickly when we are able to do repeat analyses to assess the effect of our interventions. The problem with performing a cga on subjects with some of the conditions mentioned in previous correspondence is the number of individuals you would need to get referred to to build up a useful experiential model. For example, we have seen a few peeps with poliomyelitis, yet I find it difficult to draft a report with added value (yes, muscular weakness; yes hyperextension; yes, the world is roughly spherical). What is there in these instances that a keen eye and a few clinical test could not detect? Certainly, the only role for cga here is to report the effects of interventions. Jeremy reported the use of gait analysis as an outcome measure after deep brain stimulation in Parkinsonism, but I have my doubts about the appropriateness of anything but the most basic of gait tests (perhaps, when used as a outcome measure, it shouldn't be called analysis at all). Surely, an outcome measure must have simplicity on its side. The problem with traditional cga is that it gives one so much data that one is able to be quite selective. The use of of cga in prosthetics is appealing, naturally. Dealing with predictable mechanical items must be a joy, and of course cga lends itself to detrministically-based analysis with the number of DOF markedly reduced. The clinical rationale is also very clear in this area. The clinical reasoning for the use of orthoses seems to me, in most circumstances, to be less clear with the potential for doing harm quite high. Gait analysis may show you "improvement" by normalisation of a gait pattern, but how important is normalisation in improving function or preventing long term deformity. Any thoughts? I have been working in gait for only 3 years but I'm already a little depressed. CGA promises so much but seems to deliver a lot less. Contrary to what a lot of bioengineers think, the real problems with CGA are not technical, they are clinical. We get good(ish) data but unfortunately we don't use it very well. Where CGA does have a role is in teasing out a comprehensive understanding of the conditions of our subjects, but how long are the Financial gods going to wait for cga to become a really useful engine in decision-making? So Richard, strike while the iron is hot. Make your address to the Federation using examples from CP, spina bifida, and amputation for tomorrow your substantial analytical skills may be better employed elsewhere. Adam Adam Shortland PhD, One Small Step Gait Laboratory, Guy's Hospital LONDON UKWant to know more? Email the CGA list! [n/a]
Back to Clinical Gait Analysis home page