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www.shrinerschildrens.org/aacpdm2018
Gait Analysis at Your Fingertips:Enhancing Observational Gait Analysis Using Mobile Device Technology and the
Edinburgh Visual Gait Scale
Jon R. Davids, MD; Shriners Hospitals for Children – Northern California; Sacramento, CA
Disclosure Information
The following relationships exist:
•OrthoPediatrics–Consultant
•OrthoPediatrics Foundation for Education and Research
–Board Member
Presenter Disclosure Information
JON R. DAVIDS, MDEnhancing Observational Gait Analysis Using Mobile Device Technology
and the Edinburgh Visual Gait Scale
www.shrinerschildrens.org/aacpdm2018
• Full Handouts• Gait Scoring Sheets• Links to resources
….and more!
Decision-making in Gait Surgery
History & Physical, Patient Goals
Pre- & Intra-operative Physical Exams
Gait Analysis:Kinematics
KineticsEMG
Dynamic Pedobarography
Individualized Surgical Prescription to Improve Gait Radiographs:
Hip, Ankle, Foot
www.shrinerschildrens.org/aacpdm2018
Gait Analysis Without a Lab = Observational Gait Analysis (OGA)
• Role of Observational Gait Analysis:• No access to 3-dimensional gait lab
• Frequent documentation of gait pattern change
• Child that cannot cooperate with 3D Gait Study• Very young (less than 5)
• Behavioral or cognitive issues
www.shrinerschildrens.org/aacpdm2018
Observational Gait Analysis
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• Prerequisites• Understand Normal Gait Cycle and Select Key Subphases• Recognition / Classification of Common Deviations
• Visual Assessment• Systematic• Forest / Trees
OptimizingObservational Gait Analysis
www.shrinerschildrens.org/aacpdm2018
•Modern Technology•Mobile Videography•Cell Phones and Tablets
•Structured Analysis• Edinburgh Visual Gait
Scale
•Case Example
High Quality Video: Your Key to Observational Gait Analysis
•Good observations take time!
•Videos help take decision-making out of busy clinic
•Permanent record
www.shrinerschildrens.org/aacpdm2018
Principles of Mobile Videography
20 feet
15 feet
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• Lighting and Focus• Well-lit hallway or room with
minimal distractions in background
• Perspective• At least 20 feet distance for
coronal
• At least 10 foot distance for sagittal
• Quality sagittal video allows for objective observational gait• Anyone can get coronal in their
clinic!
Principles of Mobile Videography: High Quality Sagittal Video
•High Quality Sagittal Video = High Quality Observations
•Panning camera•Parallax Problems•Cannot see more than
1 stride in-plane
www.shrinerschildrens.org/aacpdm2018
Principles of Mobile Videography: High Quality Sagittal Video
•Camera moves with child with minimal motion artifact• Allows for in-plane visualization of
more than one stride• May require specialized
equipment
www.shrinerschildrens.org/aacpdm2018
Principles of Mobile Videography: Low-Cost Image Stabilization
•Gimbal•platform that maintains orientation in space despite inclines or rotation
•Nature Documentaries
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Principles of Mobile Videography: Low-Cost Image Stabilization
•Gimbal•platform that maintains orientation in space despite inclines or rotation
•Drones•Geopolitical/ Personal
www.shrinerschildrens.org/aacpdm2018
Principles of Mobile Videography: Low-Cost Image Stabilization
www.shrinerschildrens.org/aacpdm2018
•Gimbal•platform that maintains orientation in space despite inclines or rotation
•Selfie Stick with 3 Axis Gimbal•$50-300 USD
Principles of Mobile Videography: Low-Cost Image Stabilization
Without Image Stabilization Hand-held Image Stabilization
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Principles of Mobile Videography: Skin Markings to Improve Observation
• Optimal clothing and marking for gait analysis• Tight-fitting swimsuit
or bike shorts
• Marking of ASIS, Patella, TibialTubercle, and Achilles
www.shrinerschildrens.org/aacpdm2018
Technology to Improve Your Video Observations
• Sports Performance Video Analysis Apps• Allow for slow
motion analysis
• Zoom function
• Can annotate with angles, lines, or shapes
• Split Screen and Imaging Overlay Options
Hudl TechniqueFree
SlomoFree
Coach’s Eye$4.99
Dartfish Express
$6.99
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Hudl Technique App: Features
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OptimizingObservational Gait Analysis
www.shrinerschildrens.org/aacpdm2018
•Modern Technology•Mobile Videography•Cell Phones and Tablets
•Structured Analysis• Edinburgh Visual Gait
Scale
•Case Example
Observational Gait Assessment Scoring Systems
Physician Rating Scale Salford Gait Tool Observational Gait Analysis
Observational Gait Scale
Edinburgh Visual Gait Score
www.shrinerschildrens.org/aacpdm2018
Rathinam et al. Gait & Posture40 (2014) 279–285.
• 17 observations/limb
• 10 Joint Angle Measurements
• 7 Gait Phase Timing Assessments
• 6 anatomic levels scored:
• trunk, pelvis, hip, knee, ankle and foot
• 3 planes of motion
• 12 stance phase items and 5 swing phase items
The Edinburgh Visual Gait Score (EVGS)
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1. Terminal Swing/Initial Contact
2. Mid-Stance Sagittal3. Terminal Stance4. Mid-Swing
EVGS Scoring Six Stops in Gait Video
1. Mid-Stance Front2. Mid-Stance Back
Sagittal Video Coronal Video
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EVGS Scoring Six Stops in Gait Video
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• 3 point ordinal scale:• 0 – within normal range (mean ±1.5 SD)• 1 – moderate deviation (1.5 – 4.5 SD from mean)• 2 – marked deviation (> 4.5 SD from mean)
• Score total of 0-34 per limb; 0-68 per gait cycle• Lower is better!
Phase Trunk Pelvis Hip Knee Ankle Foot
IC
M St
T St
M Sw
M St Front
M StBack
Segment Total
LIMB TOTALS
EVGS Summary Scoring Worksheet and Grid
www.shrinerschildrens.org/aacpdm2018
OptimizingObservational Gait Analysis
www.shrinerschildrens.org/aacpdm2018
•Modern Technology•Mobile Videography•Cell Phones and Tablets
•Structured Analysis• Edinburgh Visual Gait
Scale
•Case Example
Right Spastic Hemiplegic Cerebral Palsy
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Preop1 year post
Achilles + Plantar Fascia2 years post
Achilles + Plantar Fascia
Preop EVGS Grading: Right Mid Stance Sagittal
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Preop EVGS Grading: Right Mid Stance Front Coronal
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Midstance Terminal Stance Mid-swingInitial Contact
2
1
1
2
1
1 2
1
2
EVGS: Right Limb
Right Limb EVGS Grading
Phase Trunk Pelvis Hip Knee Ankle Foot
IC 1 0 2
M St 1 0 2
T St 0 0 2
M Sw 1 2 0
M St Front 0 1 0 0
M St Back 1
Segment Total
1 1 1 1 6 3
LIMB TOTALS PREOP TOTAL = 13
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Midstance Terminal Stance Mid-swingInitial Contact
2 2 2 2
EVGS: Left Limb
1
Left Limb EVGS GradingPhase Trunk Pelvis Hip Knee Ankle Foot
IC 0 0 2
M St 1 0 2
T St 0 0 2
M Sw 0 2 0
M St Front 0 0 0 0
M St Back 0
Segment Total
1 0 0 0 6 2
LIMB TOTALS PREOP TOTAL = 8
www.shrinerschildrens.org/aacpdm2018
Right Limb EVGS Grading
PhaseTrunk Pelvis Hip Knee Ankle Foot
P 1 2 P 1 2 P 1 2 P 1 2 P 1 2 P 1 2
IC 1 0 0 2 0 0
M St 1 0 0 2 0 0
T St 2 0 0
M Sw 1 2 1 2 0 0
M St Front 1 0 0
M St Back 1 0 0
Segment Total
1 0 0 1 0 0 1 0 0 1 2 1 6 0 0 3 0 0
1 year
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2 11
2
2 yearPre
Resolution of Mid-Swing Stiff Knee at 2 years
Left Limb EVGS Grading
PhaseTrunk Pelvis Hip Knee Ankle Foot
P 1 2 P 1 2 P 1 2 P 1 2 P 1 2 P 1 2
IC 2
M St 1 1 0 2 1
T St 2
M Sw 2
M St Front
M St Back
Segment Total
1 1 0 6 2 1
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2
1
1
1
Trunk lean and vaulting resolve at 2 years
Total Body EVGS Grading
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• Proximal segments (hip, pelvis) are less accurate than distal segments (ankle, foot)
• Less experienced observers have lower inter-rater reliability• GMFCS III patients have lower scoring reliability than I or II• Agreement between observers between 64 – 92%• Agreement to 3D gait analysis is between 60 – 70%
Limitations of EVGS
Orozco et al. Gait & Posture 49 (2016) 14–18.
www.shrinerschildrens.org/aacpdm2018
• EVGS vs Kinematics• Cell Phone / Gimbel Platform• MAC System• Simultaneous Capture
• Refine Technique• Other Software Platforms• Additional Kinematic
Variables• Establish Clincial Boundries
Current Research
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SimultaneousInstrumented Gait Capture
Sagittal Camera on Gimbal
Coronal Camera
Additional Markings
EVGS Set-Up
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Terminal Swing/Initial Contact R
Peak Hip Flexion (EVGS #13)Markedly increased flxn (>60° ) 2Increased flxn (46°-60°) 1Normal flxn (25°-45°) 0Reduced flxn (10 °-24 °) 1Severely reduced flxn (<10 ° ) 2
Knee Position (EVGS #10)Severe flxn (>30 °) 2Moderate flxn (16 ° -30 °) 1Normal flxn (5 ° -15 °) 0Moderate extn (4 ° flxn - 10 extn) 1Severe hyperextn (>+10 ° extn) 2
Foot Position (EVGS #1)Heel Contact 0Flatfoot Contact 1Toe Contact 2
For EVGS #1 Foot Position: Look at foot inclination graph at Initial Contact, which is 0.0% of Gait Cycle:
If the value is positive, this equates to heel contact.If the value is zero, this equates to flatfoot contact.If the value is negative, this equates to toe contact.
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Example EVGS Scoring Worksheet
Heart Function
Gait Function
Pulse RateStethoscope Echocardiogram
Hallway Examination
Observational Gait Analysis
3D Gait Analysis
Increasing Patient Complexity
www.shrinerschildrens.org/aacpdm2018
OptimizingObservational Gait Analysis
www.shrinerschildrens.org/aacpdm2018
•Modern Technology•Mobile Videography• Cell Phones and Tablets
• Image Stabilization
•Structured Analysis• Edinburgh Visual Gait
Scale
•New Possibilities!
www.shrinerschildrens.org/aacpdm2018
• Full Handouts• Gait Scoring Sheets• Links to resources
….and more!• [email protected]