Gait Analysis CP


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Gait Analysis CP
  EOR   |   󰁶󰁯󰁬󰁵󰁭󰁥 󰀱   |   󰁄󰁥󰁃󰁥󰁭󰁂󰁥󰁒 󰀲󰀰󰀱󰀶 DOI: 10.1302/ Stéphane Armand 1 Geraldo Decoulon 2 Alice Bonnefoy-Mazure 1    Cerebral palsy (CP) children present complex and hetero-geneous motor disorders that cause gait deviations.   Clinical gait analysis (CGA) is needed to identify, under-stand and support the management of gait deviations in CP. CGA assesses a large amount of quantitative data con-cerning patients’ gait characteristics, such as video, kine-matics, kinetics, electromyography and plantar pressure data.   Common gait deviations in CP can be grouped into the gait patterns of spastic hemiplegia (drop foot, equinus with different knee positions) and spastic diplegia (true equinus, jump, apparent equinus and crouch) to facilitate communication. However, gait deviations in CP tend to be a continuum of deviations rather than well delineated groups. To interpret CGA, it is necessary to link gait devia-tions to clinical impairments and to distinguish primary gait deviations from compensatory strategies.   CGA does not tell us how to treat a CP patient, but can provide objective identification of gait deviations and fur-ther the understanding of gait deviations. Numerous treat-ment options are available to manage gait deviations in CP. Generally, treatments strive to limit secondary defor-mations, re-establish the lever arm function and preserve muscle strength.   Additional roles of CGA are to better understand the effects of treatments on gait deviations. Keywords:  cerebral palsy; clinical gait analysis; gait deviationsCite this article: Armand S, Decoulon G, Bonnefoy-Mazure A. Gait analysis in children with cerebral palsy. EFORT Open Rev   2016;1:448-460. DOI: 10.1302/2058-5241.1.000052. Introduction Cerebral palsy (CP) is the most frequent cause of motor disability among children in Europe representing 700 000 citizens. 1  The prevalence of CP in Europe has been stable over the last 30 years, and ranges between 1.5 and 3.0 cases per 1000 live births. 1  The motor disorders of indi-viduals with CP are complex. They are related to primary deficits such as muscle spasticity, muscle weakness and loss of selective motor control, and secondary deficits such as muscle contractures and bony deformities. The main dysfunctions are related to motor disorders during posture and movement causing limitation in activities (e.g. walking). Around 75% of CP children are ambulatory. 2  The severity and type of impairments are variable in the CP population. Clinical classifications distinguish the topog-raphy of impairments (hemiplegia, diplegia, quadriple-gia), motor disorders (spastic, athetotic, dystonic, hypotonic, ataxic and a mixed group) and functional capacities with the Gross Motor Function Classification System (GMFCS). 3  Walking is essential for activities of daily living and social participation; therefore, it is often considered one of the most important activities in daily life. 4  Nowadays, due to the complexity of gait and especially pathological gait, clinical gait analysis (CGA) is generally used to iden-tify, quantify and understand the deficits of a specific patient and is fully integrated into the clinical decision- making of patients with complex gait disorders. 5  Moiss-enet and Armand have proposed a simple algorithm for the management of a patient with complex gait disor-ders. 6  This algorithm has three steps: identify gait devia-tions; understand gait deviations by linking them with clinical impairments; and choose the best therapeutic option.Based on these three steps, the aim of this paper is to present 1) methods to analyse gait and identify gait devia-tions in CP; 2) gait patterns and gait deviations in CP and their interpretation; and 3) an overview of gait deviations management in CP. Clinical gait analysis Clinical gait analysis (CGA) aims to determine what is causing a patient to walk in the way he/she does. To reach this aim, CGA collects and analyses a large amount of quantitative data concerning the gait characteristics of a patient. In fact, CGA provides detailed information on four main types of data recorded simultaneously: spatiotem-poral, kinematics, kinetics and electromyography data. Gait analysis in children with cerebral palsy 1.0000 EOR   0   0   10.1302/2058-5241.1.000052research-article   2016  Paediatrics  449 GAIT ANALYSIS IN CHILDREN WITH CEREBRAL PALSY  During the same session, standardised clinical videos are recorded with numerical video cameras generally syn-chronised with the opto-electronic system (Fig. 1).In addition, a standardised physical examination of the lower limbs is performed to measure anthropometry, pas-sive range of motion, muscle force and muscle spasticity. 7 Gait can be separated into cycles. A gait cycle starts at the instant where one foot touches the floor and stops as the same foot comes into contact for the next step. It can be divided in different phases: stance phase and swing phase. Stance phase can be also sub-divided into sub-phases: first double support (both feet in contact with the floor), single support (one foot in contact with the floor) and second double support. Based on the gait cycle, temporal and spatial characteristics of gait can be calculated: walking speed, cadence, stride length, step length, step width, duration of the stance and swing phases (Fig. 2).Kinematic data correspond to the movement of the body described in CGA by the angular variations of the different joints/segments: ankle, knee, hip, pelvis and trunk. The raw data are measured by opto-electronic sys-tems from the position of passive (or active) reflective markers attached directly on the skin of the patient during CGA. These markers are fixed on the patient in an accurate standardised position relative to anatomical or technical landmarks. 8  These positions are dependent on the model used to compute the kinematics. The most used models in the clinical field are the conventional gait models such as ‘Plug-InGait’. 9  More advanced models and methods have been developed by different research teams in order to be more accurate. For example, calibration techniques 10  or foot models 11  have been developed; standardisation of joint definitions have been proposed. 12 The model then permits the computation of joint angles (the angle between two adjacent segments in a specific plane). For this, the rotation around mobile axis (named Euler angles) are generally used to decompose the three-dimensional rotations in three successive ele-mentary rotations. The three common planes used in description of the gait patterns are: the sagittal plane for flexion-extension movements; the frontal plane for adduc-tion-abduction movements; and the transverse plane for internal-external rotations (Fig. 3).Dynamic or kinetic data describe the forces applied by the patient during his/her gait. 13  This information corre-sponds to the ground-reaction forces, joint moments and powers of each joint. For this computation, data meas-ured by force-plate(s) embedded in the ground of the gait laboratory are used. Using this information, it is possible to quantify ground-reaction force, which is the force exerted by the ground on the foot. With the addition of inertial parameters and kinematic data, it is possible to cal-culate by inverse dynamics the joint moments and joint powers applied at each joint during gait (Fig. 4). Fig. 1 Example of data in clinical gait analysis report for bilateral spastic cerebral palsy (video stills). ParametersLeft sideRight sideNormalGait speed (m/s)0.88 ± 0.05 0.88 ± 0.051.1-1.3Cadence (step/min)107.36 ± 3.45107.42 ± 3.49110-130Step length (m)0.51 ± 0.020.47 ± 0.030.65-0.75Step width (m)0.14 ± 0.030.15 ± 0.030.05-0.15Stance phase (%)60.59 ± 2.0462.42 ± 1.6455-65Step time (s)0.56 ± 0.030.56 ± 0.020.45-0.55Cycle time (s)1.12 ± 0.041.12 ± 0.040.9-1.1Cycle length (m)0.99 ± 0.030.98 ± 0.031.4-1.6Single support (%)37.54 ± 1.3639.33 ± 1.3640-50Double support (%)23.05 ± 2.8823.1 ± 2.8910-20 Fig. 2 Example of data in clinical gait analysis report for bilateral spastic cerebral palsy: spatiotemporal parameters.  450 Fig. 3 Example of data in clinical gait analysis report for bilateral spastic cerebral palsy: kinematics. Fig. 4 Example of data in clinical gait analysis report for bilateral spastic cerebral palsy: kinetics.  451 GAIT ANALYSIS IN CHILDREN WITH CEREBRAL PALSY  Based on kinematic data, gait scores such as Gait Profile Scores and Movement Analysis Profile 14  or Gait Deviation Index 15  can be computed to summarise gait deviations (Fig. 5)Electromyography (EMG) data show the timing and intensity of the muscle activity (Fig. 6). Thus, it is possible to describe the timing of the activity (such as lacking, delayed or permanent activity), co-contraction periods and also muscle spasticity during gait. 16  In CGA, surface electrodes are generally used with specific procedures rec-ommended by the SENIAM. 17 Moreover, during a CGA, it is also possible to record pedobarography measures. These data give information about contact of the feet (without shoes) with the ground during stance phase and how plantar surface pressures are distributed (Fig. 7).Major limitations of CGA data are linked to external measurements used to estimate the movement of internal structures. These limitations include: marker placement on anatomical landmarks; skin movement (soft tissue arte-facts); 18  definition of joint centres; 19  definition of anatomi-cal axis respecting anatomical and clinical reality; and deformation of the segments (as for the foot  20 ). However, CGA allows identification of gait deviations and allows fur-ther understanding of gait deviations.To go deeper in the understanding of gait deviations, it is now technically possible to use personalised (neuro)-musculoskeletal modelling by merging data from medical imaging, CGA and clinical evaluation. Such modelling per-mits the simulation and testing of different hypotheses of the causes of gait deviations of a specific patient and to vis-ualise the effect of treatments of impairments (e.g. increase length of a muscle, correction of bony deformity). 21  Cur-rently, the major clinical limitations of this approach are the validation of the models used and the time needed to build an accurate model of a specific patient. Gait deviations in cerebral palsy A large variety of gait deviations can be observed in CP patients. Classification systems to group common gait devia-tions in gait patterns are often used to facilitate communica-tion 22  but are a simplification of the reality. In CP patients, we can observe a continuum between the different classes (no strict boundaries). Some gait deviations or combinations of gait deviations are not described in the classification systems. Therefore, a more accurate definition of gait deviations and related impairments is often needed to have a precise under-standing of gait deviations and to better guide treatments using CGA results. The first part of this section describes the main gait patterns observed in CP. The second part describes the main gait deviations with related impairments. Gait patterns Classifications in gait patterns are generally different for unilateral spastic CP and for bilateral spastic CP. Most of the classifications are based the observation of the kine-matics of the sagittal plane. Impairments and typical treat-ments are often associated with the gait patterns. Gait patterns in unilateral spastic CP  The first pattern classification for unilateral spastic CP was proposed by Winters et al. 23  Four groups of gait patterns were identified based on observation of kinematic data in the sagittal plane (Fig. 8). Fig. 5 Example of data in clinical gait analysis report for bilateral spastic cerebral palsy: gait scores.
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