Cerebral Palsy - gait exam Flashcards
Gait Tests & Measures Participation and Activity ICF Level
Patient Specific Functional Scale
Pediatric Evaluation of Disability Inventory or PEDI-CAT
Gross Motor Function Measure Dim E: Walking, Running, and Jumping Domain
Timed Up and Go
Dynamic Gait Index (typically used in adult population)
Patient Specific Functional Scale (PSFS)
self-reported tool where patients identify and rate their difficulty with specific activities that are important to them
focuses on the individual’s perceived limitations in performing activities that are meaningful to them
Helps to measure activity limitations and set personalized functional goals
Pediatric Evaluation of Disability Inventory (PEDI-CAT)
assesses functional abilities and participation in various domains, including self-care, mobility, and social function
evaluates a child’s ability to perform daily activities and participate in family and community life
Gross Motor Function Measure (GMFM) - Dimension E: Walking, Running, and Jumping
standardized measure assessing gross motor function in children with CP. Dimension E specifically evaluates walking, running, and jumping
Assesses the child’s ability to perform gross motor tasks related to mobility and dynamic movement
Timed Up and Go (TUG)
measures the time it takes for an individual to stand up from a seated position, walk a short distance (usually 3 meters), turn around, walk back, and sit down
Evaluates basic mobility, balance, and gait speed
Dynamic Gait Index (DGI)
assesses gait, balance, and the ability to perform various walking tasks, including walking over obstacles and changing speeds
Evaluates how well an individual can maintain balance and adjust gait in different scenarios
Gait Tests & Measures Body Function and Structure
3D Gait Analysis
Edinburgh Visual Gait Scale
Endurance/Speed (eg, 6 min or 2 min walk test, 10-meter walk or shuttle test) – there are wheelchair user versions!
Motor Control (eg, Selective Control Assessment of Lower Extremity SCALE)
ROM and Strength
3D Gait Analysis
uses motion capture technology and force plates to provide a detailed, three-dimensional assessment of gait patterns
Measures joint angles, segmental movements, and forces during walking, running, or other dynamic activities
Provides comprehensive data on kinematic (movement) and kinetic (forces) aspects of gait, which can be used to plan surgical, therapeutic, or orthotic interventions
Edinburgh Visual Gait Scale
clinical tool used to visually assess and rate gait abnormalities
systematic approach to observing and documenting gait deviations, including foot progression, stride, and overall gait pattern
quick assessment of gait quality and deviations during clinical evaluations
Endurance/Speed Tests
6-Minute Walk Test (6MWT): Measures the distance an individual can walk in 6 minutes, assessing endurance and functional capacity.
10-Meter Walk Test (10MWT): Measures walking speed over a 10-meter distance, providing insights into gait speed and functional mobility.
Motor Control Tests
Selective Control Assessment of Lower Extremity (SCALE)
assesses the ability to control movements of the lower extremities in a selective manner
Evaluates motor control by examining how well an individual can isolate and control specific lower limb movements
Highly correlated with an individuals gait speed and TUG score
Range of Motion (ROM) and Strength
Measures the range of motion in joints and the strength of muscle groups
assesses the flexibility and movement capacity of joints, while strength tests evaluate the force that muscles can generate
*** gold standard for gait analysis =
3D gait analysis
requires high tech equipment in order to capture:
Kinematics
Muscle activity
Ground reaction forces
Gait analysis is required if a family is considering any surgical intervention
Edinburgh Visual Gait Score
Reliability: moderate to excellent
(60-92% agreement)
Validity: good correlation
with GMFM and 3D gait analysis
MCID: 2.4
17 observations of each leg through the gait scale
*higher scores = greater deviations
EVGS stance:
initial contact
peak hip flexion (S)
peak knee extension (S)
foot contact (S)
EVGS stance:
midstance
max trunk postion (S)
max trunk shift (C)
max pelvis obliquity (C)
pelvis rotation (T)
knee progression angle (T)
heel lift (S)
hindfoot varus/valgus (C)
foot progression angle (T)
EVGS stance:
terminal stance
peak hip extension (S)
peak knee extension (S)
max ankle DF (S)
EVGS swing:
midswing
peak knee flexion (S)
max ankle DF (S)
foot clearance (S)
Children with CP have increased co-activation of muscles disrupting the synergetic neuromuscular control needed for gait
One cause = increased muscle co-activation and asynchronies during ambulation
Activation of the TA muscle is much more noisier during the full gait cycle for children with CP than those who are typically developing
Not having NM control of their legs makes it hard for them to walk with a typical gait pattern
Increased co-activation leads to a lack of smoothness and coordination in movement, as opposing muscles work against each other rather than in a controlled, synergistic manner
Ankle Lever Arm Dysfunction
Toe walking decreases ankle power generation by ~50% (requires ½ the strength than heel-toe walking)
This may be a beneficial compensation for children with CP
a bit counter-intuitive
This gait deviation = compensation strategy for weak plantar flexors
Children without CP can also display this behavior when learning to walk
lever arm =
distance between the axis of rotation (the joint) and the point where force is applied (where muscles exert their force)
For the ankle, this involves the tibia and the foot.
The longer the child walks on their toes =
the more at risk they are for developing a contracture
Altered Propulsion:
Dysfunction in the ankle lever arm can reduce the efficiency of the push-off phase during walking, impacting forward propulsion and gait dynamics
Inefficiencies in the lever arm function lead to increased energy expenditure and potentially more fatigue during walking
Spasticity can restrict ankle dorsiflexion, affecting the lever arm function and leading to an altered gait pattern
Joint and Bony Abnormalities
As the child grows and develops, muscle imbalances can lead to bony or positional deformities
A set of conditions in which lever arms become distorted because of bony or positional deformities
Results in different force capabilities
Difficult to determine where rotation is occurring without full gait and physical examination
Examples include femoral anteversion, external rotation of the tibia, equinovalgus, genu recurvatum
altered Force Capabilities
Changes in joint alignment and bone structure can alter the mechanical leverage available to muscles, affecting propulsion, stability, and overall gait performance
Lever arms found up the LE chain and into the pelvis (NOT only at ankle)
Complexity of Rotation:
Identifying the exact location and nature of rotational abnormalities can be complex, as they may occur at multiple sites (e.g., hip, knee, ankle) and can interact in ways that are difficult to isolate without comprehensive evaluation
Femoral Anteversion
condition where the femoral head is rotated forward relative to the femoral shaft, leading to an internal rotation of the thigh
Results in an internally rotated gait pattern, often seen as “in-toeing” during walking
Requires examination of hip range of motion and gait patterns to determine the degree of anteversion and its impact on function
External Rotation of the Tibia
Occurs when the tibia is rotated outward relative to the femur
Causes an outward rotation of the foot during gait, which can contribute to a “toe-out” walking pattern
Involves evaluating tibial alignment and its effect on the foot and knee during walking
Equinovalgus
characterized by the foot being in a plantar-flexed (equinus) and everted (valgus) position
Results in a loss of normal foot alignment, which can affect weight distribution and gait efficiency
Often leads to difficulties with heel strike and push-off phases
Requires examination of foot positioning, range of motion, and gait dynamics to understand the impact on overall function
Genu Recurvatum
condition where the knee hyperextends, causing the tibia to move posteriorly relative to the femur
Leads to an abnormal knee alignment, which can affect stability and gait dynamic
can impact shock absorption and contribute to balance issues
Involves evaluating knee alignment, range of motion, and its impact on gait and functional mobility
Gene recurvatum = Compensating for lack of DF to get foot flat on floor OR tightness/contracture of quads
Gait Patterns in Cerebral Palsy
jump knee gait
TRUE VS APPARENT EQUINUS GAIT
crouch gait
stiff-knee gait
jump knee gait
Ankle in equinus, particularly in late stance. Knee and hip in hyperflexion in early stance, followed by extension to a variable degree in late stance, pelvis within normal ROM or anterior tilt
TRUE VS APPARENT EQUINUS GAIT
True: Ankle in equinus during stance, full knee extension, full hip extension, pelvis within normal ROM or anterior tilt
Apparent: Ankle normal ROM, knee and hip in hyperflexion throughout stance, pelvis within normal ROM or anterior tilt
CROUCH GAIT
Ankle in excessive dorsiflexion throughout stance, knee and hip in hyperflexion, pelvis in normal ROM, anterior or posterior tilt
STIFF-KNEE GAIT
Reduction in knee flexion during swing is coupled by excessive hip circumduction
Jump Knee Gait
CHARACTERISTICS
Increased hip and knee flexion at initial contact and in early stance
Rapid hip extension, knee extension and plantarflexion in midstance
Plantarflexion/knee extension couple
Looks like jumping from one foot to another
Often in younger children GMFCS Level II and III
More often in younger children who weigh less and haven’t spent much time in standing or walking
Equinus Gait
CHARACTERISTICS
True Equinus = Toe walking with plantarflexion in stance
*Heel never comes down
Apparent Equinus = Toe walking with neutral DF in stance
* Heel comes
down
during stance
* More with speed that you see
toe walking
* Can progress
to crouch
gait
Confirm by assessing ROM
Crouch Gait
CHARACTERISTICS
Increased hip and knee flexion; usually increased dorsiflexion in sagittal plane
Associated with high energy cost
Associated with decreased force production relative to body weight
Can make functional ambulation difficult or impossible
Often develops and/or worsens in adolescence - When body size/weight increases too
Stiff Knee Gait
CHARACTERISTICS
Reduced knee flexion in swing may be due to tight and/or spastic rectus femoris
Limits ability to flex the knee
Results in hip circumduction in order to progress leg forward
Reduced step length, single leg stance time, cadence, and velocity
Prob with foot clearance during swing phase
Risk of hip subluxation over time
Consider the —- before deciding which test/measure to use (eg, gait speed, gait endurance)
goal
_____ is common in children with CP, resulting in decreased _____ when walking
Co-contraction of muscles
neuromuscular control
