Faculty - AACPDM Sylvia Õunpuu MSc ... –Familial Spastic Paraplegia ... –Rectus femoris spasticity – clinical examination –Decreased peak knee flexion at in swing

GCMAS at the AACPDM, October 21, 2015 Lecture #1: Getting Started 1

New Frontiers: The Role of Motion Analysis in

“Other” Neuromuscular Disabilities

Faculty

Sylvia Õunpuu MSc and Kristan Pierz MD

Connecticut Children’s Medical Center, Farmington, CT

University of Connecticut, Farmington, CT

Haluk Altiok MD and Joseph Krzak PhD PT

Shriners Hospitals for Children, Chicago, Il and

Midwestern University, Downers Grove, IL

Kirsten Tulchin-Francis PhD

Texas Scottish Rite Hospital, Dallas, TX

Kent Heberer MS, Susan Sienko PhD and Michael Sussman MD

Shriner’s Hospitals for Children, Portland, OR and

University of California, Los Angeles, CA

Purpose

• Highlight the role of motion analysis in

understanding complex gait disorders

– Charcot-Marie-Tooth

– Myelomeningocele

– Familial Spastic Paraplegia

– Duchene’s Muscular Dystrophy

• Draw on the following – Clinical experience

– Research

– Case studies


Learning Objectives

• Appreciate limitations of a visual assessment

in understanding gait pathology

• Describe the typical gait patterns characteristic

of a variety of neuromuscular disorders

• Understand the gait indications for specific

treatment options

• Identify “new frontiers” in motion analysis and

how these may influence understanding and

treatment of neuromuscular disorders

Outline

• Setting the Stage

• Charcot-Marie-Tooth

• Myelomeningocele

• Familial Spastic Paraplegia

• Duchene’s Muscular Dystrophy

Setting the Stage

Sylvia Õunpuu, MSc

Center for Motion Analysis

Division of Orthopaedics

Connecticut Children’s Medical Center

Farmington, Connecticut


Disclosure Information

AACPDM 69th Annual Meeting | October 21-24, 2015

Speaker Name: Sylvia Õunpuu, MSc

Disclosure of Relevant Financial Relationships

I have no financial relationships to disclose.

Disclosure of Off-Label and/or investigative uses:

I will not discuss off label use and/or investigational use in this presentation.

Outline

• Definition of Gait Analysis

• Why we need Gait Analysis

• Orientation to Gait Data

Gait Analysis – what is it?

• Systematic and Objective Documentation of Human Locomotion

– kinematics/kinetics/EMG, etc.

• Why?

– Improve understanding of pathomechanics

– Determine causes of gait abnormalities

– Define treatment – based on objective data

– Evaluate treatment – based on objective data

– This level of documentation and understanding is NOT possible in the clinic


Why Important?

• We can be fooled by what we see…

• Provides us additional information we cannot

see…

• Efficient form of documentation

• Objective

• Outcomes evaluation tool

• Provides a systematic approach for treatment

decision-making

Is the clinic appointment enough?

• Pathological

gait =

atypical joint

motion and

position

• Assumption

= What

someone

looks like =

their joint

kinematics

Joint Motion = Visual Impression


Joint Motion vs. Visual Impression?

• Can be inconsistent

• One of the reasons why 3D gait analysis is

so important

Documentation of Change over Time

• Objective comparison of

kinematic, kinetic, EMG

and foot pressures

changes over time

• Provides evidence of

decline

• Provides further

evidence for need for

intervention

2007 2010

Treatment Decision-Making

• Framework

– Prerequisites of typical gait - which are

compromised? (discussed next lecture)

– Impairments – documented

– Link impairments to movement pathology

(kinematics and kinetics)

– Propose treatment

• Indications and expected outcomes

– Evaluate treatment outcomes objectively


Surgical Decision-Making

• Left rectus femoris procedure - indications

– Rectus femoris spasticity – clinical examination

– Decreased peak knee flexion at in swing – kinematics

– Delayed peak knee flexion in swing – kinematics

– Rectus femoris activity in swing – EMG data


• Left rectus femoris transfer - indications











149595M02 Left (10/2/1997) 149595M03 Left (10/2/1997) 149595M04 Left (10/2/1997)

Trunk Obliquity30

-30

Up

Dn

deg

Pelvic Obliquity20

-20

Up

Dn

deg

Hip Ab-Adduction20

-20

Add

Abd

deg

Knee Varus-Valgus

Gait Cycle

30

-30

Var

Val

deg

25% 50% 75%

Trunk Tilt40

-20

Ant

Pos

Pelvic Tilt40

-20

Ant

Pos

Hip Flexion-Extension60

-20

Flx

Ext

Knee Flexion-Extension80

-20

Flx

Ext

Plantar-Dorsiflexion

Gait Cycle

40

-40

Dor

Pla

deg

25% 50% 75%

Trunk Rotation40

-40

Int

Ext

Pelvic Rotation40

-40

Int

Ext

Hip Rotation40

-40

Int

Ext

Knee Rotation40

-40

Int

Ext

Foot Progression

Gait Cycle

40

-40

Int

Ext

25% 50% 75%

*








149595M02 Left (10/2/1997) 149595M03 Left (10/2/1997) 149595M04 Left (10/2/1997)

Trunk Obliquity30

-30

Up

Dn

deg

Pelvic Obliquity20

-20

Up

Dn

deg

Hip Ab-Adduction20

-20

Add

Abd

deg

Knee Varus-Valgus

Gait Cycle

30

-30

Var

Val

deg

25% 50% 75%

Trunk Tilt40

-20

Ant

Pos

Pelvic Tilt40

-20

Ant

Pos


-20

Flx

Ext


-20

Flx

Ext


Gait Cycle

40

-40

Dor

Pla

deg

25% 50% 75%

Trunk Rotation40

-40

Int

Ext

Pelvic Rotation40

-40

Int

Ext

Hip Rotation40

-40

Int

Ext

Knee Rotation40

-40

Int

Ext

Foot Progression

Gait Cycle

40

-40

Int

Ext

25% 50% 75%

*







* * * *

• Left rectus femoris procedure

• Pre-requisite of typical gait compromised

• Clearance in swing

• Surgical hypothesis

• Improved peak knee flexion in swing

• Improved clearance of swing limb


Next Step = Treatment Evaluation

• Standard of Care

• Repeat gait analysis one year post treatment

• Provides objective feedback

• Where lots of learning takes place!

Pre vs. Post

Operative

Kinematics

Left Barefoot

(pre – dashed

post – solid)

149595M25 Left (1/21/1999) 149595M02 Left (10/2/1997)

Trunk Obliquity30

-30

Up

Dn

deg

Pelvic Obliquity20

-20

Up

Dn

deg

Hip Ab-Adduction20

-20

Add

Abd

deg

Knee Varus-Valgus

Gait Cycle

30

-30

Var

Val

deg

25% 50% 75%

Trunk Tilt40

-20

Ant

Pos

Pelvic Tilt40

-20

Ant

Pos


-20

Flx

Ext


-20

Flx

Ext


Gait Cycle

40

-40

Dor

Pla

deg

25% 50% 75%

Trunk Rotation40

-40

Int

Ext

Pelvic Rotation40

-40

Int

Ext

Hip Rotation40

-40

Int

Ext

Knee Rotation40

-40

Int

Ext

Foot Progression

Gait Cycle

40

-40

Int

Ext

25% 50% 75%

Terminology

• Need to speak the same language

• Understand what we are talking about

• Facilitate communication

• Prevent errors


Gait Cycle • Period of time from one event (usually

initial contact) of one foot to the

subsequent occurrence of the same foot

• Represented as 0 to 100% of the gait cycle

• Allows comparison of multiple strides of

data

100% Gait Cycle

R R

149595M25 Right (1/21/1999) 149595M02 Right (10/2/1997)

Trunk Obliquity30

-30

Up

Dn

deg

Pelvic Obliquity20

-20

Up

Dn

deg

Hip Ab-Adduction20

-20

Add

Abd

deg

Knee Varus-Valgus

Gait Cycle

30

-30

Var

Val

deg

25% 50% 75%

Trunk Tilt40

-20

Ant

Pos

Pelvic Tilt40

-20

Ant

Pos


-20

Flx

Ext


-20

Flx

Ext


Gait Cycle

40

-40

Dor

Pla

deg

25% 50% 75%

Trunk Rotation40

-40

Int

Ext

Pelvic Rotation40

-40

Int

Ext

Hip Rotation40

-40

Int

Ext

Knee Rotation40

-40

Int

Ext

Foot Progression

Gait Cycle

40

-40

Int

Ext

25% 50% 75%

Phases of the Gait Cycle

• loading response (LR) / double support (0-10%)

• mid-stance (MST) (10-30%)

• terminal stance (TST) (30-50%)

• pre-swing (PSW) / double support (50-60%)

• initial swing (ISW) (60-73%)

• mid-swing (MSW) (73-87%)

• terminal swing (TSW) (87-100%)

(Perry, Normal and Pathological Gait, Slack, 1994)


Phases of the Gait Cycle

Loading Response

MidstanceT erminal Stance

PreswingInitial Swing

MidswingT erminal Swing

Stance (60%)

Swing (40%)

Stride (100%)

10% 30% 50% 70% 85%

T oe Off

Double Support (10%)

Double Support (10%)

Joint Kinematics

• Parameters used to describe the spatial movement of the body (segments and joints)

• Do not include the forces that cause the movement

• e.g. angular displacements or joint angles, angular velocities, angular accelerations

Knee Flexion-Extension

70

Flex.

40

10

Ext.

-200 25 50 75 100

% Gait Cycle

Joint Kinematics

• Joint angle

Knee Flexion-Extension

70

Flex.

40

10

Ext.

-200 25 50 75 100

% Gait Cycle

Timing


“Anatomy” of a Kinematic Plot

Left Right


Gait Cycle

40

-40

Dor

Pla

deg

25% 50% 75%

Left Right


Gait Cycle

40

-40

Dor

Pla

deg

25% 50% 75%

STANCE SWING DORSIFLEXION

PLANTAR

FLEXION

THE KINEMATIC PLOT

TOE OFF INITIAL

CONTACT

INITIAL

CONTACT

GAIT CYCLE

Right side =

green line

Left side =

red line *

* REFERENCE

DATA (N=580)

0 deg

Ankle Sagittal Plane Motion

• Angle Definition

– the relative angle between the long axis of the

shank and the plantar aspect of the foot

– as viewed by looking along an axis

perpendicular to the shank-foot plane




0 25 50 75 100 % Gait Cycle

Ankle Plantar-Dorsiflexion

30

Dors

10

-10

Plnt

-30

*


Joint Kinetics

• Description of the forces that cause motion

– Joint moments

– Joint powers

• Body’s response to external loads

• Two Questions:

– What muscles would need to contract?

– How are they contracting?

• What muscles would

need to contract?

• How are they

contracting?

– Isometrically?

– Eccentrically?

– Concentrically?

• Need kinematics do

know (joint angular

information)


Anatomy of

a Kinetic

Plot

Left Right

Plantar-Dorsiflexion40

-40

Dor

Pla

Deg

Ankle Moment2.0

-1.0

Ext

Flx

Nm/kg

Ankle Power3.0

-2.0

Gen

Abs

W /kg

JOINT KINETIC DATA

JOINT MOMENTS AND POWERS DURING MOTION

Left Right

Plantar-Dorsiflexion40

-40

Dor

Pla

Deg

Ankle Moment2.0

-1.0

Ext

Flx

Nm/kg

Ankle Power3.0

-2.0

Gen

Abs

W /kg

ABILITY OF THE

MUSCLES TO

GENERATE A

TORQUE

(MOMENT)

ABILITY OF THE

MUSCLES TO

GENERATE/ABSORB

POWER (con/ecc)

*

*

PLANTAR FLEXOR

MOMENT (strength plantar flexors)

DORSIFLEXOR

MOMENT (strength dorsiflexors)

POWER

ABSORPTION

(eccentric)

POWER

GENERATION

(concentric)

REFERENCE

DATA (N=580)

Dorsi

flexor

Plantar

flexor

Calculating Joint Kinematics/Kinetics

Left Right


Gait Cycle

40

-40

Dor

Pla

deg

25% 50% 75%

(joint angle plot)

Reflective joint/segment markers

(skeletal model – angle definition)


Summary

• Comprehensive motion analysis provides a

wealth of information to improve our

understanding movement pathology

• Gaining the knowledge needed to interpret

motion analysis data is worth the effort!

Benefits of this Approach

• Comprehensive and objective patient

assessment using motion analysis

• Treating all gait related issues at one point in

time

– Single surgery and rehabilitation (time/cost)

– Maximizing patient specific outcomes

• Ability to learn from experience and objective

documentation of outcomes

Thank You

Documents

Faculty - AACPDM Sylvia Õunpuu MSc ... –Familial Spastic Paraplegia ... –Rectus femoris spasticity – clinical examination –Decreased peak knee flexion at in swing