Joint session ESPRM/ESMAC/SIMFER/SIAMOC Study of the Movement in clinic of the Rehabilitation Venice 25 May 2010

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1 Joint session ESPRM/ESMAC/SIMFER/SIAMOC Study of the Movement in clinic of the Rehabilitation Venice 25 May 2010 Gait Analysis in the Rehabilitation field M.G. Benedetti MD LAM Movement Analysis Laboratory Istituto Ortopedico Rizzoli, University of Bologna Dir. Prof. S. Giannini

2 GENERAL CAUSES OF ABNORMAL GAIT Arthritis of the leg or foot joints CAUSES OF SPECIFIC GAITS CAUSES OF SPECIFIC GAITS CAUSES OF SPECIFIC GAITS Propulsive gait: Spastic gait: Waddling gait: Chondromalaciapatellae Carbon monoxide poisoning Brain abscess Congenital hip dysplasia Conversiondisorder(a psychologicaldisorder) Foot problems (such as a callus, corn, ingrown toenail, wart, pain, skin ulcer, swelling, spasms) Fracture Manganese poisoning Brain tumor Muscular dystrophy Parkinson's disease Use of certain drugs including phenothiazines, haloperidol, thiothixene, loxapine, metoclopramide, and metyrosine (usually drug effects are temporary) Cerebrovascularaccident (stroke) Spinal muscle atrophy Head trauma Ataxic or broad-based gait Hemophilia Spastic and scissors gait: Multiple sclerosis Alcohol intoxication Injections into muscles that causes soreness in the leg or buttocks Cerebrovascularaccident (stroke) Steppagegait: Long term brain injury due to alcoholism Infection Cerebral palsy Guillain-Barresyndrome Neuropathy(aswithdiabetes) Injury Cervical spondylosiswith myelopathy(a problem with the vertebrae in the neck) Herniated lumbar disk Stroke Legs that are different lengths Multiple sclerosis Multiple sclerosis Use of certain medicines such as Dilantinand other seizure medications Myositis Pernicious anemia Peronealmuscle atrophy Shin splints Spinalcordtrauma Peronealnerve trauma Tendonitis Spinalcordtumor Poliomyelitis Tight or uncomfortable shoes Syphilitic meningomyelitis Polyneuropathy Torsion of the testis Syringomyelia Spinal cord trauma This list is not all-inclusive. Cerebral palsy

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4 Gait (motion) analysis Routine functional analysis for clinical decision making and outcome measure

5 Instruments & Measurements Gait Analysis Instruments: Position system Forceplates Electromyography Pressure platforms Basografy Digital Videograms Biomechanical information: Joint Rotations Ground Reaction Force Muscular Activity Plantar pressure distribution Temporal-Spatial parameters Joint Moments and Powers

6 Kinematics: all those variables describing movement of human body in the space without considering the forces acting during motion 20 Pelvic Tilt 20 Pelvic Obliquity 20 Pelvic Rotation Ant Up Int Pos Dw Protocols Flex Hip Flexion/ension Abd Hip Ab/Adduction Int Hip Rotation Add ASISr PSISr Zf Xf ASISl Flex Knee Flexion/ension Abd Knee Ab/Adduction Int Knee Rotation FH GT Yt Add Zt Xt Ankle Dorsi/Plantar Ankle Ab/Adduction Ankle Rotation Dors Abd Int LE HF ME Ys TT Plan Add Zs Xs CA LM L M Zf VM MM Xf Yf SM FM

7 Kinetics: all those variables describing parameters determining movement (ground rection forces, joint moments, joint power..) 10 Hip Flex/ Moment 10 Hip Ab/Add Moment 2.0 Hip Rotation Moment Flex Abd Int Nmm Nmm Nmm Add Knee Flex/ Moment 8 Knee Adb/Add Moment 2.0 Knee Rotation Moment Flex Adb Int Nmm Nmm Nmm Add Ankle Dors/Plan Moment 6 Ankle Ab/Add Moment Plan Abd Nmm Nmm Dor Add -5-6

8 Surface dynamic EMG: muscular activity in terms of pattern of activation during motion

9 RELEVANCE OF FUNCTIONAL GAIT ANALYSIS It allows to explore musculo-skeletal skeletal system in dynamic conditions It allows to explore biomechanical issues and determinants of motion otherwise not clinically undeterminable It is objective and quantitative Clinical assessment Gait analysis Dynamic! Dynamic!

10 . Gait analysis is the systematic measurement, description, and assessment of quantities that characterize human locomotion; more simply put, it is the evaluation of a subject's walking pattern. A standard physical examination cannot provide a complete description of the complex pathology of abnormal human gait. Gait analysis can.

11 The advent of gait analysis has enabled physicians and others to define, document, and analyze normal and abnormal human gait much more accurately and comprehensively than was previously possible. Gait analysis has been of great value for planning and documenting the outcome of one-stage corrective operations in patients who have cerebral palsy.. Restore the prerequisites of normal gait, in order of priority 1) stability of the foot, the ankle, and, in fact, the entire lower limb in stance phase; 2) clearance of the ground by the foot in swing phase; 3) proper pre-positioning of the foot in terminal swing; 4) adequate step length; 5) maximization of energy conservation Muscular function Role and relevance of bi-articular muscles Identification of coping responses Emerging homogeneus gait pattern

12 Pelvic Fixed obliquity Pelvic Obliquity Up Dw -20 Adductors retractions Spasticity/retraction lateral trunk muscles Leg length discrepancy

13 60 Hip Flexion/ension 100 Knee Flexion/ension 40 Ankle Dorsi/Plantar Flex Flex Dors Integrated kinematics/kinetics/ EMg graphs uv R_STEND R_BFLH uv -500 R_RF Pla uv -500 R_GASTMH uv Hip Flex/ Moment 10 Knee Flex/ Moment 15 Ankle Dors/Plan Moment Plan Nmm Nmm Nmm Flex Flex Dor R_RF* 500 R_STEND* 500 R_TA uv uv uv R_BFLH* uv R_GASTMH* uv Sagittal Hip Power 200 Sagittal Knee Power 500 Sagittal Ankle Power Gen Gen Gen W W W Abs Abs Abs

14 Instrumental semeiotics: single/multiple joint pattern Joint range of motion, muscular strength, selectivity, retraction Analysis of biomechanical events with respect to gait requirements CLINICAL GAIT ANALYSIS

15 CLINICAL ASSESSMENT

16 APPLICATIONS OF GAIT ANALYSIS Whittle, 1991 Clinical gait analysis : Involves performing gait analysis on a single person, with the aim of benefiting that person directly for clinical decision making Scientific gait analysis : To improve our understanding of some aspects of gait, either normal or pathological. Clinical research Research involving patients, which is not necessarily expected to benefit those patients directly, but hopefully other patients in the future. Fundamental research Research aimed to further our knowledge: Methods of measurements, Biomechanics, Human performance,physiology

17 Evidences for clinical gait analysis in rehabilitation

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20 Workshop Virginia, 1996

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22 FUTURE OF THE DISCIPLINE Partnership SIMFER- SIAMOC Partnership ESMAC- ESPMR Scientific and education activities SIAMOC CONSENSUS CONFERENCE : Minimal requirements for appropriateness of gait analysis in the rehabilitation field Reimbursement of exams by National Health System (LEA) New regulation of Schools of Specialization in Physical Medicine and Rehabilitation ( gait analysis exams included)

23 Thankyou