Cerebral Palsy - gait exam

Question 1

Gait Tests & Measures

Participation and Activity ICF Level

Answer 1

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)

Question 2

Patient Specific Functional Scale (PSFS)

Answer 2

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

Question 3

Pediatric Evaluation of Disability Inventory (PEDI-CAT)

Answer 3

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

Question 4

Gross Motor Function Measure (GMFM) - Dimension E: Walking, Running, and Jumping

Answer 4

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

Question 5

Timed Up and Go (TUG)

Answer 5

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

Question 6

Dynamic Gait Index (DGI)

Answer 6

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

Question 7

Gait Tests & Measures

Body Function and Structure

Answer 7

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

Question 8

3D Gait Analysis

Answer 8

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

Question 9

Edinburgh Visual Gait Scale

Answer 9

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

Question 10

Endurance/Speed Tests

Answer 10

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.

Question 11

Motor Control Tests

Answer 11

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

Question 12

Range of Motion (ROM) and Strength

Answer 12

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

Question 13

*** gold standard for gait analysis =

Answer 13

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

Question 14

Edinburgh Visual Gait Score

Answer 14

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

Question 15

EVGS stance:
initial contact

Answer 15

peak hip flexion (S)
peak knee extension (S)
foot contact (S)

Question 16

EVGS stance:
midstance

Answer 16

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)

Question 17

EVGS stance:
terminal stance

Answer 17

peak hip extension (S)
peak knee extension (S)
max ankle DF (S)

Question 18

EVGS swing:
midswing

Answer 18

peak knee flexion (S)
max ankle DF (S)
foot clearance (S)

Question 19

Children with CP have increased co-activation of muscles disrupting the synergetic neuromuscular control needed for gait

Answer 19

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

Question 20

Ankle Lever Arm Dysfunction

Answer 20

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

Question 21

lever arm =

Answer 21

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.

Question 22

The longer the child walks
on their toes =

Answer 22

the more
at risk they are for 
developing a 
contracture

Question 23

Altered Propulsion:

Answer 23

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

Question 24

Joint and Bony Abnormalities

Answer 24

As the child grows and develops, muscle imbalances can lead to bony or positional deformities

Question 25

A set of conditions in which lever arms become distorted because of bony or positional deformities

Answer 25

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

Question 26

altered Force Capabilities

Answer 26

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)

Question 27

Complexity of Rotation:

Answer 27

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

Question 28

Femoral Anteversion

Answer 28

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

Question 29

External Rotation of the Tibia

Answer 29

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

Question 30

Equinovalgus

Answer 30

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

Question 31

Genu Recurvatum

Answer 31

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

Question 32

Gait Patterns in Cerebral Palsy

Answer 32

jump knee gait TRUE VS APPARENT EQUINUS GAIT crouch gait stiff-knee gait

Question 33

jump knee gait

Answer 33

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

Question 34

TRUE VS APPARENT EQUINUS GAIT

Answer 34

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

Question 35

CROUCH GAIT

Answer 35

Ankle in excessive dorsiflexion throughout stance, knee and hip in hyperflexion, pelvis in normal ROM, anterior or posterior tilt

Question 36

STIFF-KNEE GAIT

Answer 36

Reduction in knee flexion during swing is coupled by excessive hip circumduction

Question 37

Jump Knee Gait CHARACTERISTICS

Answer 37

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

Question 38

Equinus Gait CHARACTERISTICS

Answer 38

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

Question 39

Crouch Gait CHARACTERISTICS

Answer 39

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

Question 40

Stiff Knee Gait CHARACTERISTICS

Answer 40

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

Question 41

Consider the ---- before deciding which test/measure to use (eg, gait speed, gait endurance)

Answer 41

goal

Question 42

_____ is common in children with CP, resulting in decreased _____ when walking

Answer 42

Co-contraction of muscles neuromuscular control