Evaluation of Pathologic Gait in Children Flashcards
5 prerequisites of typical walking
- stability in stance
- clearance in swing
- adequate pre-positioning of foot for initial contact
- Adequate step length
- energy conservation
2 major factors that challenge stability in stance
- The body is top-heavy – The Center of Mass is above the Base of Support
- Walking continually alters segmental alignment – The COM is constantly moving forward and laterally relative to each support (foot)
For stability in stance, not only is a stable food requires, but the lower extremity segments must function to:
- Allow advancement of the limb in swing
- Maintain balance
- Provide propulsion
- Ensure appropriate position of the structures above
Sufficient foot clearance requires
- Appropriate position and power at the hip, knee and ankle on the stance side
- Adequate ankle dorsiflexion, knee flexion and hip flexion during swing
- Stability of the stance foot
- Adequate body balance
Appropriate pre-positioning of food for initial contact requires
- Appropriate body balance
- Stability, power and proper position of the stance limb
- Adequate ankle dorsiflexion, balance between foot invertors/evertors, and knee position
Adequate step length requires
- Appropriate body balance
- Stability and proper position of the stance limb
- Adequate hip flexion and knee extension
- Neutral ankle and foot position
Energy conservation includes:
a. Joint stability
b. Minimization of the COM excursion
c. Muscle forces optimized
Age of normal walking
9-15 months
mature, synchronous gait pattern
3.5 years
heel strike
between 2-3 years
reciprocal arm swing
2 years
mature arm swing
4 years
mature food angles (arches)
3 years
adult gait pattern
7 years
walking speed of average adult (above 13 yrs)
4.95 feet/sec
7 year old average walking speed
2.6 feet/sec (1.8 mph)
2 year old average walking speed
1.5 ft/sec (1 mph)
What is there a linear relationship between?
step length and leg length
duration of single limb stance increases as…
walking pattern matures
when does rapid change in single limb stance occur
between 1.5-3.5 years
standing energy expenditure rate decreases with…
age
at a high speed of walking, energy expenditure is…
70% greater for a 3-4 year old and 40% greater
in a 5-6 year old than adult energy expenditure at same speed.
Gait pathology - primary impairments
abnormalities that are a direct result of CNS injury
Gait Pathology- Secondary Impairments
compensations/mechanisms that are used by the child to
circumvent the primary abnormality
Why do abnormal gait patterns typically develop?
bony deformities, loss of ROM, muscle weakness, spasticity, and/or abnormal motor control.
Gait evaluation methods
-Observation (Edinburgh Visual Gait Scale)
- Efficiency and Practicality of Walking
- Footprint Analysis Method
- Gait Assessment tools
- Gait Analysis Laboratory
Video analysis falls into what category?
observation
what is the most common type of gait analysis?
observation
components of gait analysis
- Type of environment/Surface(s):
- Requirement of orthotics and ambulatory aids
- Length of observation (minutes) to assess typical household and community distances
- arm swing
- trunk position and sway
- compensated or uncompensated trendelenburg
- excessive hip flexion and rotation
- excessive knee flexion or hyperextension
- toe clearance
- foot position
- push off effectiveness
- foot progression angle
- coordination and fluidity of movement
Considerations for type of environment/surface
a. walking on level surfaces versus unlevel outdoor surfaces, carpet versus tile, hard wood floors
b. quiet versus busy, clinic versus school, home
How long should you assess gait?
AT LEAST TEN MINUTES
How to evaluate efficiency and practicality of walking
a. Calorimetry – Using oxygen consumption as an indirect measure of energy metabolism
b. heart rate – linear relationship of HR with O2 consumption,
c. EEI (energy expenditure index)
d. Velocity = distance/time
*need to normalize velocity for stature to compare over time. Divide velocity by leg length (best) or height (less precise).
e. 30 second walk test – measure of casual or comfortable walking speed; number of feet child can walk within 30 seconds
Standardized observational gait analysis tool
Edinburgh Visual Gait Score
Footprint analysis Methods
- Chalk, paint, water and paper
- Commercial paper/tools
Parameters of footprint analysis
- Velocity
- Cadence
- Foot progression angle
- Base of support
- Toe clearance
- Stride length
- Step length
There is a linear relationship between what and what
heart rate and oxygen uptake during walking for normal children and children with CP
Energy Expenditure index equation
EEI = (HR walking - HR resting) / average velocity
Supported walking ambulation performance scale (SWAPS)
method used to qualify video-taped observations of gait
Gait assessment tools
a. SWOC – Standardized Walking Obstacle Course
b. DGI – Dynamic Gait Index (modified version for children)
c. FMA - Functional Mobility Assessment tool
d. FMS – The Functional Mobility Scale
e. GOAL – Gait Outcomes Assessment List
f. Gaitrite
g. Write Step
Gait analysis laboratory
facility that uses specialized measurement technology to
provide objective data about a patient’s gait
Data collected by gait analysis laboratory
a. Kinematics – Motion of the patient’s individual body segments and joint rotations
b. Kinetics – Joint reactions including forces, torques (moments), and power
c. Electromyography (EMG) – Skeletal muscle on-off activity (i.e. timing), not strength
Standardized Walking Obstacle Course
Measures stability and speed of gait under difference circumstances
Measures: time, number of steps, and observation of stability
Designated path
Includes negotiating 3 directional turns and negotiation of barriers
Gait Outcomes Assessment List (GOAL)
Patient-reported outcome (PRO) for ambulatory children
with CP (GMFCS I-III)
Spans all domains of the ICF
Very helpful with goal setting
Ages: Child version for 13 y/o+ (or younger if they can complete on their own or give verbal responses) OR Parent version for younger
Subscales of Gait Outcome Assessment List
ADL
Gait function & mobility
Pain
Discomfort & fatigue
Physical activities
Sports & recreation
Gait pattern & appearance
Use of braces and mobility aids
Body image & self-esteem
Guidelines for 3 dimensional Gait analysis
Child’s age (typically around 3 years old)
Lack of progress in PT
Goals of Intervention
Changes in Intervention
Post Intervention Gait Analysis
Typical Diagnosis
Giat abnormalities in children with cerebral palsy
Bony Abnormalities
Inadequate ROM and Spasticity
Muscle Weakness
Abnormal Motor Control
Energy Expenditure
Gait abnormalities in children with myelomeningocele
typically results in hypotonicity/areflexia and sensory impairment
Bony Problems (hip instability and torsional malalignment)
Additional Areas of Weakness Resulting in Gait Abnormalities (glut med lurch or crouch)
Energy Expenditure
L1
weak hip movements (iliopsoas L1-L4)
L2
present hip flexors, adductors and hip rotators are grade 3 or better. Hip flexion and
adduction contractures. Dislocated hips common. Short distance household amb. Possible using
KAFO’s and UE support
L3
strong hip flexion and adduction. Weak hip rotators and anti-gravity knee extension. With
at least grade 3 quads, can ambulate with KAFO’s and forearm crutches, HH and short distance
community amb.
L4
anti-gravity knee flexion and grade 4 ankle df with inversion. Calcaneal foot deformities are
common. AFO’s and forearm crutches
L5
lateral hamstring muscle with at least grade 3 strength, grade 2 glut min, grade 3 post tib.
Gluteal lurch (trendelenburg) without assistive device, hindfoot valgus/calcaneal deformities
S1
gastroc/soleus grade 2, glut med grade 2 or glut max grade 2, no orthosis or assistive device
needed, mild/mod glut lurch, may require orthotics for medial/lateral stability
S2/S3
gastroc/soleus, glut med and glut max grade 4, decreased push off, decreased strike length, orthotics may be required to maintain subtalar neutral
Additional bony problems of myelomeningocele
a. talipes equinovarus – clubfoot
b. infant heel - atypical development of the calcaneus due to lack of weight bearing
Additional area of weakness resulting in abnormalities in posture/gait due to myelomeningocele
a. Excessive lumbar lordosis and anterior pelvic tilt
b. Exaggerated movement of pelvis and pelvic obliquity
c. Excessive hip, knee flexion and ankle dorsiflexion (crouched gait)
d. Genu Valgum alignment in stance phase due to the combination of internal hip and pelvic
rotation and knee flexion
e. Calcaneovalgus
Energy Expenditure with walking children with MM
a. HR higher than non-disabled peers during walking
b. May require shorter distance or rest periods to keep HR at a steady state.
