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Gait Analysis at the Gait Lab

Introduction

Gait analysis involves computerised 3-D reconstruction of how a person walks by tracking information from electronic sensors placed on a person's body. The objective data provided by gait analysis enables doctors and surgeons to differentiate between a number of medical conditions which result in walking difficulties, to make confident recommendations for surgical and medical treatments and afterwards to monitor patient progress and objectively evaluate the different treatments. The benefits and use of this technology are well documented in the treatment of children with neuromuscular disorders such as cerebral palsy. Gait analysis has many other interesting and potential uses such as the assessment of abnormal back movements and arthritis of the hip, and the aetiology of some sports injuries.

The CRC provides the only clinical gait laboratory in the Republic of Ireland, and has offered this specialised service for the last fifteen years on a national level at the clinic's headquarters in Clontarf, Dublin.The CRC's gait laboratory team are internationally recognised leaders in their field. There have been numerous visits from foreign medical teams wishing to replicate the service in their own country.

The analysis involves a full clinical assessment, video recording, analysis of forces at the joints, measurement of muscle activity (electromyography) and three dimensional computerised analysis of the movements of the lower limbs and spine. The end product is a set of objective graphical data which along with relevant clinical data is interpreted by the medical team, and, based on this, treatment recommendations are made. This team is headed by Prof. Tim O'Brien, orthopaedic surgeon.

Recently, the gait laboratory has developed a mobile gait analysis service and provides outreach services to the Mid Western and South Eastern Health Executive Authorities. This means that children and their families from these regions no longer have to travel to Dublin for this particular service. The ability to perform gait analysis using a mobile system was a world first innovation pioneered by the CRC.

Research is also routinely carried out at the Gait Laboratory to improve knowledge and provide an evidence base for different management strategies. Such research has made unique contributions to the management of a number of different patient groups.

The laboratory regularly presents research topics at both national and international conferences.

Publications and presentations to date have considered topics such as; the classification of walking patterns in children with cerebral palsy, abnormalities and compensations of children with hemiplegia, the identification of idiopathic toe walkers, factors associated with internal hip rotation in cerebral palsy patients groups, a quality score in relation to walking, walking patterns in people with Charcot-Marie-Tooth and the effectiveness of Botulinum Toxin in spastic muscle groups.

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FAQ

Who refers to the gait lab?

  • Consultant Orthopaedic Surgeons / Paediatricians / Paediatric Neurologists
  • General Practitioners
  • Physiotherapists (special arrangement with consultants)

 

How do I get there? (click to see map)

DART

From the city or any southside station take the North-bound DART, disembark at Killester
- From the northside (except Clontarf) take the South-bound DART, disembark at Killester
- DART Times and Stations

 

Dublin Bus

Killester is the closest village to the CRC and it is served by a number of Dublin Bus routes, which include: 103 | 105 | 29A | 29N | 31 | 32 | 32A | 32B | 42A |
- See Dublin Bus for more information

 

Taxi

Taxis are generally available by on street hail or pre-booked
- (see Golden Pages.ie)

 

What do I bring?

Gait analysis requires an appropriate view of the movements of the body. This can only be achieved by exposure of an appropriate amount of the body. For this reason gait analysis is usually done in swim wear.

If you can, please bring your swim wear with you, if you can't some will be provided for you.

If you currently wear orthotics (splints or in-soles in your shoes) customised shoes, mobility aids (such as crutches, etc) or any other specialist equipment, please bring these with you.

What Can I Expect?

The analysis will take approximately 2½ hours to complete. This will include the following;
A video recording walking barefoot with swimwear.

  • A video recording walking barefoot with swimwear.
  • A full clinical assessment which will include measuring height, weight, joint ranges of movement, muscle control/strength and other appropriate measurements.
  • The 3-dimensional gait assessment will include walking while small electronic markers are placed on the pelvis and legs. Double sided sticky tape and Velcro straps are used to secure the markers in place. If there are allergies to sticky plaster/tape please let us know.
  • The subject will be videoed a second time (wearing the markers).
  • The subject will be asked to repeatedly walk up and down a 10m walkway. The number of repetitions will vary from person-to-person and care is taken not to over tax the subject. Rest breaks are provided as necessary.
  • The 3-dimensional gait assessment may assess different walking conditions, such as barefoot, wearing AFO, using different mobility aids, etc.
  • Before the subject goes home functional tests are commonly conducted and these include, a balance test (consisting of 11 simple tasks) and a 10-minute endurance walk outside the laboratory. These tests are performed while wearing regular clothes and footwear.

Who do I contact?

In relation to gait laboratory reports, the policy is to endeavour to send these out within two weeks of the assessment date. Sometimes this can be a little longer due to various circumstances but on average it is two weeks or less. The report is sent to the original referrer or anybody at the written request of the client or parent of client. If you want to know the status of your report you can contact the gait laboratory secretary. (Contact Number).

 

Who works there?

A photo of the Gait Lab Team.
Top row from left: Damien Bennett, Ann Jenkinson, Rory O’Sullivan, Colin Dunlevy
Bottom row from left: Mike Walsh, Prof. Tim O’Brien, Niamh Kavanagh

Directorship of the Gait Laboratory:
Professor Tim O'Brien (consultant orthopaedic surgeon)

Manager:
Mike Walsh, MMedSc, MISCP

Staff:
Ann Jenkinson, MSc, MISCP (Senior Physiotherapist)

Niamh Kavanagh, (Gait Laboratory Secretary)

Rory O'Sullivan, MSc (Senior Physiotherapist)

Colin Dunleavy, PhD, MISCP (Senior Physiotherapist)

Damien Bennett, PhD (Clinical Engineer)

 

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Equipment Used

Both the mobile and fixed location laboratories use Coda technology and equipment. These systems are active marker instrumented equipment and are supplied and developed by Charnwood Dynamics (UK).

The system uses specialised hardware and software to build and analyse 3-dimensional body movement.

Joint kinetics are calculated using ground reaction vectors (GRV) and an inverse dynamic mathematical model. The GRVs are collected using embedded forceplates on the laboratory's walkway. The forceplates used are manufactured by Kistler Instruments Ltd. and AMTI .

Muscle activity and timing are also collected as part of a routine gait analysis. This data is gathered using one of two surface electromyographic (EMG) systems.

A foot pressure (pedobarograph) system (RS Scan) is integrated into the walkway and is used to present information regarding foot pressures, timing and progression.

Video assessments of gait are gained using high quality cameras and digital video equipment.

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Professional Issues

Gait analysis can be described as the systemic study of human walking. The biomechanical and physiological feature of gait cycle have been of interest since the earliest days of science and medicine. The modernisation and development of exact scientific instrumentation for the specific purpose of gait analysis has only recently come of age (Whittle, 2002).

We are now armed with scientific terminology and well defined fields of gait analysis that enable professionals to communicate and discuss pathological gait features in a precise and scientific way. This medical, engineering and scientific study is still developing at pace, with multiple international conferences taking place annually.

There are numerous books and periodical publications that are of significance to the science of gait analysis. There are a number of publications and abstracts produced by the Gait Laboratory at the CRC. In addition, a sample of other significant publications are given below.

Recommended Literature Regarding Gait Analysis (below)

  • Gage, JR. (1991). Gait Analysis in Cerebral Palsy. MacKeith Press. Oxford Blackwell Scientific Publications Ltd. New York.
  • Gage, JR. (2004). The Treatment of Gait Problems in Cerebral Palsy. MacKeith Press, London.
  • Inman, Verne T., Ralston, Henry J., Todd Frank, (1981). Human Walking. Williams and Wilkins, Baltimore/London.
  • Perry Jacqueline, (1992). Gait Analysis, Normal and Pathological Function. Slack Incorporated, NJ.
  • Saunders, J.B. Dec.M., Inman Verne T., Ebenhart, Howard D., (1983). "The Major Determinants in Normal and Pathological Gait". The Journal of Bone and Joint Surgery, Vol 35-A No. 3 July 543-558.
  • Sutherland David H. (1984). Gait Disorders in Childhood and Adolescence. Williams and Wilkins, Baltimore/London.
  • Sutherland, D.H.,"The evolution of clinical gait analysis. Part II Kinematics", J. Gait and Posture, Vol 16, #2, pp 159-179, 2002
  • Whittle MW. (2002) Gait Analysis, an introduction. 3rd ed. Butterworth Heinemann, Oxford.
  • Winter D.A., (1990). Biomechanics and Motor Control of Human Movement 2nd Edition. Publisher: John Wiley & Sons.

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Mobile Lab

World's First Mobile Gait Analysis Service, Central Remedial Clinic, Ireland

The Central Remedial Clinic (CRC) in Ireland is a national centre for the assessment and treatment of adults and children with physical disabilities. All services required by a person with a physical disability, ranging from medical to social and technical are provided from CRC's main centre in Ireland's capital city, Dublin. CRC also provides disability services locally in the South East of Ireland and some specialized services in the Mid West. One of the specialized services offered at the CRC is clinical gait analysis. Gait analysis involves computerised 3-D reconstruction of how a person walks by tracking information from electronic sensors placed on a person's body and also embedded in a walkway. The objective data provided by gait analysis enables doctors and surgeons to differentiate between a number of medical conditions which result in walking difficulties, to make confident recommendations for surgical and medical treatments and afterwards to monitor patient progress and objectively evaluate the different treatments. The benefits and use of this technology are well documented in the treatment of children with neuromuscular disorders such as cerebral palsy. The CRC gait laboratory team is headed by Prof. Tim O'Brien, orthopaedic surgeon and medical director of the gait laboratory.

A photo of the CRC Mobile Gait Laboratory set up in Mid West of Ireland

CRC Mobile Gait Laboratory set up in Mid West of Ireland

The CRC provides the only clinical gait laboratory in the Republic of Ireland, and has offered this specialised service for the last fifteen years on a national level from its centre in Dublin. Almost 50% of clients attending the gait laboratory live outside the capital city and its surrounding regions. Up to recently children from all over Ireland had no choice but to travel to Dublin to access this service. This often involved an arduous and expensive journey for children and their families, which sometimes posed problems with compliance and obtaining accurate data. These problems were unacceptable in some cases especially when surgical decisions were being made based on the data. Establishing permanent gait laboratories in remote regions to make this specialized service more accessible would have been extremely difficult and economically unjustifiable. As a solution, CRC established what is believed to be the world's first truly mobile gait analysis service.

To date, a comprehensive 3-dimensional gait analysis service could only be provided from a permanent laboratory set-up. As a result of recent developments in the infra-red based Coda motion analysis system used at the CRC, which is manufactured by the UK based company Charnwood Dynamics, a new system called CX1 has been developed. This system was developed in conjunction with a project for NASA where portability of equipment was essential. As a result the CX1 is very small, easily transportable and can work from a laptop. CX1 has been integrated with portable force and EMG measurement systems to provide a complete human movement analysis system that can be taken to different locations as required. A lightweight fiber-glass walkway was also designed by the CRC team. All equipment is transportable in a saloon car and the full 3-D kinematic, kinetic and EMG analysis assessment of the permanent laboratory is replicated in the mobile service. Another element of the mobile service is in the area of telemedicine. Through the use of video-conferencing the gait laboratory team can link in to the medical consultant's clinic (Prof. Tim O'Brien) in Dublin to present patients for review. This novel use of telemedicine means that these children can now receive their specialised assessment with full medical recommendations from an expert team without having to travel out of their local region.

Regular outreach clinics were quickly established and are now provided in the Mid Western and South Eastern regions of Ireland. The adaptability of the mobile service is reflected in the diversity of locations where the gait laboratory is set up. In the Mid Western region, clinics are conducted in a special education and therapy centre for children with physical disabilities, and, in the South Eastern region, clinics are conducted in the middle of a large and busy acute hospital.

The most immediate and real tangible effect of the mobile gait laboratory is the abolition of the need to travel to Dublin for children and their families. This fact has been acknowledged and praised by the Irish Health Services Executive through a spokesperson in the Mid West. Feedback from parents of children has been very positive and overwhelming so far and they are absolutely delighted at not having to travel to the capital city. Parents have commented on the costs involved in obtaining babysitters, taking time off work, travel costs to Dublin, accommodation costs as well as negotiating traffic in the city etc.

A second and very real effect of the mobile service has been the linking in with local clinicians and therapists. Whilst the service was always available at a national level it was seen as something difficult to access due to its centralised location in the capital city. In addition gait analysis was viewed as a complex new technology which required great effort to develop an understanding of the output. As part of the mobile gait analysis service the gait laboratory team has presented lectures and workshops to local therapists and clinicians, some via videoconference. This has resulted in an upsurge in enthusiasm and a development of understanding amongst local clinicians and therapists in relation to the usefulness of the gait analysis reports in the management of their patients. The net effect has been an increase in referrals from these regions and a noticeable improvement in the reasoning process behind the clinical questions being asked in the referral letters. The gait laboratory recently delivered a one day course in the Mid West at the request of local therapists. Many therapists are now visiting the mobile clinics when their patients attend and one potential use of the videoconference aspect of the mobile lab is for local therapists to be able to sit in on Prof. O' Brien's clinic and partake in the discussions on their patients. This increased communication with local therapists and clinicians in the regions allows a dissemination of the specialized knowledge base which has built up in the CRC gait laboratory over the last sixteen years and can only result in an improvement of the quality of health care delivery for local patients.

The mobile gait laboratory has also resulted in benefits for CRC's medical team in the area of clinical research and there are other as yet untapped benefits for this and other areas of the medical service provided at the clinic.

In terms of cost the mobile gait analysis represents very good value for the Irish Health Care system. Children and adults with disabilities are approaching a time when they will have rights to have services provided locally. Currently the only gait laboratory in the country is located in Dublin. There is a demand for the service all over the country. To set up even one more gait laboratory in the country would cost 500,000 Euro and to staff it would cost in the region of 300,000 Euro annually. CRC made a once off capital investment of 200,000 Euro in the equipment for the mobile gait laboratory. Spread over the lifetime of the equipment this represents very good value (lifespan is indefinite, current systems in the lab have lasted 10 years so far and are still operating perfectly with no problems in the interim). There has been no increase in staffing levels for the mobile service as current staff numbers are providing the service in the Mid West and South East. The ongoing cost of the mobile clinic is very low.

The next step for the mobile gait laboratory is to consolidate the service now established in the Mid West and South East of the country and to provide more educational workshops and lectures to the clinicians and therapists in these regions. There have been some informal inquiries from clinicians on the ground in the North West of the country this would be the next natural region in which to develop a mobile gait analysis service.

The Irish Minister for Defence, Willie O' Dea, has praised the project for finding a low cost solution to providing a specialized medical service locally to the regions and wished that it could be replicated in other areas of medicine such as cancer services.

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Awards

Gait Laboratory wins Special Merit Award from the HSE

Congratulations to CRC's gait laboratory team who were recently presented with a Special Merit Award by An Tánaiste and Minister for Health and Children, Mary Harney at the HSE Innovation Awards ceremony in Dublin Castle on October 18th. This award for "Innovations in Management and Administration of Services/Support, including Innovative Use of Technology/Communications" was presented for the Mobile Gait Laboratory service developed last year. The National Health Innovation Awards are designed to reward innovation in the health services, and are sponsored by the Health Service National Partnership Forum. Over 250 entries were received this year from organisations and teams throughout the country including most of the large teaching hospitals. The scheme is a critical promoter of change that leads to the emergence of new concepts and practices which benefit the clients and their families as well as other healthcare staff.

 

A photo of staff members been presented with the Special Merit Award by An Tánaiste and Minister for Health and Children, Mary Harney at the HSE Innovation Awards ceremony

From Left: Ann Jenkinson, Dr. Davida de la Harpe, An Tánaiste and Minister for Health and Children, Mary Harney, Damien Bennett, Mike Walsh, Manager of Gait Laboratory, Colin Dunlevy, Niamh Kavanagh, Rachel Eggington. Missing from Photograph: Prof. Tim O'Brien, Director of Gait Laboratory, Rory O'Sullivan.

The Mobile Gait Laboratory utilises cutting-edge technology developed for a project funded by NASA to analyse movements of astronauts in a weightless environment on the International Space Station. This technology is lightweight, portable and works off a laptop computer. CRC's gait laboratory team recognised the potential of this technology for clinical application and developed a mobile 3-D human movement analysis service. The net result was the ability to bring the gait laboratory's unique and specialised clinical service outside of the permanent laboratory in Dublin for the first time. The immediate effect of this is that clients and their families from more remote parts of the country are saved the expense and huge effort involved in the long and arduous trip to Dublin. Another innovative aspect of the service is the utilisation of video-conferencing technology which allows the gait lab team to link in live with Prof. Tim O'Brien's clinic in Clontarf from the outreach clinics. This effectively means that a client receives their specialised medical assessment and expert surgical opinion without ever travelling out of the local region. Clinical outreach services are now up and running in the Mid West and South East. This service is the first of it's kind in the world and the gait laboratory were invited earlier this year to present their work at Guy's Hospital in London and later this month will present an abstract at the European Academy of Childhood Disability in Monaco. Their development has attracted interest from all over the world and this innovation has now been recognised by the HSE with the awarding of this Special Merit Award.

 

A Photo of the Gait Lab in Clontarf

Gait Lab in Clontarf

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Publications

 

  • Newman CJ MD, Kennedy A PT, Walsh M MSc PT, O’Brien T MD, Lynch B MD, Hensey O MD. A pilot study of delayed versus immediate serial casting after botulinum toxin injection for partially reducible spastic equinus. Journal of Pediatric Orthopaedics. Vol. 27, No. 8, December 2007.
  • Bennett D, Walsh M, O’Sullivan R, Gallagher J, Newman C, O’Brien T. Use of a dynamic foot pressure index to monitor the effects of treatment for equinus gait in children with cerebral palsy. Journal of Pediatric Orthopaedics 2007; 27(3):288-94.
  • Newman CJ, Walsh M, O'Sullivan R, Jenkinson A, Bennett D, Lynch B, O'Brien T. The characteristics of gait in Charcot-Marie-Tooth disease types I and II. Gait Posture.  2007; 26(1):120-7.
  • O’Sullivan R, Walsh M, Jenkinson A, O’Brien T. Factors Associated with Pelvic Retraction during Gait in Cerebral Palsy. Gait & Posture, 2007 Mar;25(3):425-31.
  • O’Sullivan R, Walsh M, Hewart P, Jenkinson A, Ross LA, O’Brien T. Factors Associated with Hip Internal Rotation Gait in patients with cerebral palsy. Journal of Pediatric Orthopaedics 2006;26(3):1-5
  • Rice J, Kaliszer M, Walsh M, Jenkinson A, O’Brien T. Kinematics of the toe touching test. Clinical Anatomy 2004;17:130-138
  • Rice J, Kaliszer M, Walsh M, Jenkinson A, O’Brien T. Movements at the low back during normal walking. Clinical Anatomy 2004;17:662-666
  • Rice J, Walsh M, Jenkinson A, O’Brien T. Measuring movement of the low back. Clinical Anatomy 2002;15:88-92
  • O'Brien T. Understanding Human Walking: A Manual of Gait Analysis. © 2001 TM O'Brien. 
  • Allen PE, Jenkinson A, Stephens MM, O'Brien T. Abnormalities in the Uninvolved Lower Limb in Children with Spastic Hemiplegia: The Effect of Actual and Functional Leg-Length Discrepancy. Journal of Paediatric Orthopaedics, Vol 20, No1, January/February 2000, 88-92.
  • Walsh M, Connolly P, Jenkinson A, O'Brien T. Leg Length Discrepancy - An experimental study of compensatory changes in three dimensions using gait analysis. Gait & Posture, Vol 12, 2000, 156-161.
  • O'Byrne j,  Jenkinson A, O'Brien T. Quantitative analysis and classification of gait patterns in cerebral palsy using a three-dimensional motion analyser. Journal of Child Neurology, Vol 13, No3, Manual 1998, 1-7.
  • Kelly I, Jenkinson A, Stephens M, O'Brien T. The Kinematic Patterns of Toe-Walkers. Journal of Pediatric Orthopaedics, Vol 17, No4, July/August 1997, 478-480.
  • Kelly I, O'Regan M, Jenkinson A, O'Brien T. The Quality Assessment of Walking in Cerebral Palsy. Gait & Posture, Vol 5, No1, February 1997, 70-74.
  • O'Bryne J, Kennedy J, Jenkinson A, O'Brien T. Split Tibialis Posterior Tendon Transfer in the Treatment of Spastic Equinovarus. Journal of Paediatric Orthopaedics, Vo 17, No4, July/August 1997, 481-485.
  • O'Brien T, Broderick A. The Technique of gait analysis using a Coda-3 motion analysis system. Irish Medical Journal, Volume 83, No.2, June 1990, 79-80.

 

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Abstracts

  • Egginton R, Newman C, Walsh M, Jenkinson A, Bennett D, O’Brien T. Kinematic Charcteristics Of Achondroplasia. JEGM (2006) - The First Joint Meeting of the European Society of Movement Analysis for Adults and Children (ESMAC) and the Gait and Clinical Movement Analysis Society (GCMAS).
  • Walsh M, Bennett D, O’Sullivan R, Jenkinson A, Dunlevy C, O’Brien T. Mobile Gait Analysis – A Low-Cost Solution To Provision Of This Specialised Service To A Large Geographical Area. JEGM (2006) - The First Joint Meeting of the European Society of Movement Analysis for Adults and Children (ESMAC) and the Gait and Clinical Movement Analysis Society (GCMAS).
  • O’Malley N, Dunlevy C, Kelly P, Walsh M, Bennett D, O’Brien, T, Moore D. Gait Alterations After Knee Arthrodesis. JEGM (2006) - The First Joint Meeting of the European Society of Movement Analysis for Adults and Children (ESMAC) and the Gait and Clinical Movement Analysis Society (GCMAS).
  • Taylor C, Walsh M, Bennett D, Brady P, O’Meara A, Fogarty E, O’Brien T. Gait In Hurler Syndrome. JEGM (2006) - The First Joint Meeting of the European Society of Movement Analysis for Adults and Children (ESMAC) and the Gait and Clinical Movement Analysis Society (GCMAS).
  • O’Sullivan R., Walsh M., Bennett D, O’Brien T. Effects of surgery on pelvic retraction gait in diplegic cerebral palsy. European Society of Movement Analysis in Adults and Children, Annual Meeting 2004, Barcelona, Spain.
  • Bennett D., Newman C., O’Sullivan R., Walsh M., Gallagher J., Dunlevy C. O’Brien T. A new method or measuring equinus using foot pressure measurements in CP children pre and post Botulinum toxin injection
    European Society of Movement Analysis in Adults and Children, Annual Meeting 2004, Barcelona, Spain.
  • O’Sullivan R, Walsh M, Jenkinson A, O’Brien T. Factors Associated with Pelvic Retraction during Gait in Cerebral Palsy. European Society of Movement Analysis in Adults and Children, Annual Meeting 2004, Warsaw, Poland.
  • O’Sullivan R, Hewart P, Walsh M, Jenkinson A, O’Brien T. The Incidence of an In-toeing Gait Pattern in Cerebral Palsy. European Society of Movement Analysis in Adults and Children, Annual Meeting 2003, Marseille, France.
  • O’Sullivan R, Hewart P, Walsh M,  Jenkinson A, Ross L-A, O’Brien T. The Incidence Of And Factors Which Influence Internal Hip Rotation Gait In Patients With Cerebral Palsy. European Society of Movement Analysis in Adults and Children, Annual Meeting 2002, Leuven, Belgium.
  • Walsh M, Jenkinson A, O’Brien T. Equinus Deformity – An Experimental Study Of Compensatory Mechanisms In Three Dimensions Using Gait Analysis. European Society for Movement Analysis in Adults and Children (ESMAC).  Annual meeting, Lund, Sweden, September 2000.
  • McKenna J, Walsh M, Jenkinson A, Hewart P, O’Brien T. Leg Length Discrepancy And Equinus Deformity In The Hemiplegic Cerebral Palsy Patient. Irish Orthopaedic Association Meeting, 2000.
  • McKenna J, Rice J, Walsh M, Jenkinson A, Hewart P, O’Brien T. Assessment Of Functional Anteversion Of The Femur And It’s Relationship To Kinematic Assessment. European Society for Movement Analysis in Adults and Children (ESMAC).  Annual meeting, Lund, Sweden, September 2000.
  • Connolly P, Walsh M, McCormack D, O’Brien T. The Effects Of A Simulated Hip Arthrodesis – A Study Using Gait Analysis. Irish Orthopaedic Association Meeting, Co. Cavan, May 1999.
  • Connolly P, Vedova PD, Jenkinson A, O’Brien T. Calcaneal Gait And Heel Walking In Patients With Spina Bifida. Poster Presentation. Irish Orthopaedic Association Meeting, Co. Cavan, May 1999.
  • Connolly P, Walsh M, McCormack D, O’Brien T. The Effects Of A Simulated Hip Arthrodesis – A Study Using Gait Analysis. Swedish Paediatric Orthopaedic Society Meeting, CRC, Dublin, September 1999.
  • Connolly P, Walsh M, Jenkinson A, O’Brien T. Paradoxical Movement Of The Tibia In Patients With Cerebral Palsy. Swedish Paediatric Orthopaedic Society Meeting, CRC, Dublin, September 1999.
  • Connolly P, Walsh M, Jenkinson A, O’Brien T. Paradoxical Movement Of The Tibia In Patients With Cerebral Palsy. European Society for Movement Analysis in Adults and Children (ESMAC).  Annual meeting, Heidelberg, Germany, September 1999.
  • Walsh M, Connolly P, Jenkinson A, O’Brien T. An Experimental Study Of Compensatory Mechanisms In Three Dimensions Using Gait Analysis. European Society for Movement Analysis (ESMAC).  Annual meeting, Heidelberg, Germany, September 1999.
  • Walsh M, Jenkinson A, Connolly P, O’Brien T. Hamstring Clonus – A Description Of The Three Dimensional Kinematic, Kinetic And EMG Patterns. European Society for Movement Analysis (ESMAC).  Annual meeting, Heidelberg, Germany, September 1999.
  • Cowman JP, Jenkinson A, O’Connell P, O’Brien T. A Model Of Establishing Reliability And Quantifying Error Associated With Routine Gait Analysis. European Society of Movement Analysis in Adults and Children, Annual Meeting 1998, Belfast, Northern Ireland.

Factors Associated with Pelvic Retraction during Gait in Cerebral Palsy.

O'Sullivan R, Walsh M, Jenkinson A, O'Brien T. Gait Laboratory, Central Remedial Clinic, Clontarf, Dublin 3, Ireland.

SUMMARY AND CONCLUSION

Static and dynamic measures thought to be associated with pelvic retraction were investigated in patients with cerebral palsy. Gait laboratory data of 233 patients with cerebral palsy were studied retrospectively. Two groups were selected; those who demonstrated pelvic retraction during gait >6.85° and those with <4.83°. Of 233 patients, 37.77% showed pelvic retraction of >6.85°. While differences were seen between hemiplegic and diplegic subjects, static and dynamic tightness of the gastro-soleus and internal rotation of the lower limb were the most significant features associated with pelvic retraction. This study suggests that pelvic retraction is multifactorial in origin and secondary to both static clinical measures as well as dynamic features during gait.

INTRODUCTION

Pelvic retraction during gait is common in children with cerebral palsy and can lead to cosmetic and functional concerns due to an asymmetric gait pattern. Studies have shown that pelvic retraction is associated with internal rotation1-2 and it is thought that static or dynamic tightness of the gastro-soleus may contribute to this gait pattern. The purpose of this study was to compare the measurement of both static and dynamic variables in two groups of patients: those with and without excessive pelvic retraction during gait.

METHODOLOGY

Excessive pelvic retraction during gait was defined as > 6.85° (average value) based on a previous study of normal subjects, (mean + 2 SD, n=59, age range 5-32yrs). 233 patients with cerebral palsy (diplegia-53.65%, hemiplegia-46.35%, age range 4-39) with no previous surgical history and who had undergone gait analysis using the CODA mpx30 system from 1998 to 2004 were reviewed. Two distinct groups were selected: those with pelvic retraction of >6.85° and those with <4.83° (mean + 1 SD from normal study). Each group was further subdivided into patients with hemiplegia or diplegia. Measures of eight clinical variables and eight gait variables thought to contribute to this gait pattern were compared in the two groups for hemiplegia and diplegia.

RESULTS Of 233 patients, 88(37.77%) patients walked with pelvic retraction >6.85°. 101 (43.35%) patients had pelvic retraction <4.83°. Using two-tailed t-tests, the p-values for each variable and group were calculated and are shown in the tables below. Significance level was set at p<0.05.

Static Measures Hemiplegic Diplegic
TA-Knee extended p=0.01* p=0.02*
TA- Knee flexed p=0.02* p=0.13
Popliteal angle p=0.26 p=0.33
Hip Flexion Contracture p=0.40 p=0.01*
Femoral Anteversion p=0.66 p<0.001*
Tibial Torsion p=0.98 p=0.67
External Rotation p=0.47 p=0.02*
Rectus Tightness p<0.001* p=0.46
*p<0.05

 

Dynamic Measures Hemiplegic Diplegic
Mean Hip Rotation p=0.002* p<0.001*
Mean Knee Rotation p=0.51 p=0.39
Mean Ankle Rotation p=0.005* p=0.95
Mean Foot Progression p=0.80 p=0.60
Max Hip Extension p=0.011* p<0.001*
Max Knee Flexion p=0.18 p=0.57
Max Knee Extension p=0.40 p=0.009*
Max Ankle dorsiflexion p=0.009* p=0.27

 

DISCUSSION

Factors contributing to excessive pelvic retraction were examined in children with cerebral palsy. Causes of such a gait pattern are multifactorial and there are important differences between patients with diplegia and hemiplegia. Static and dynamic tightness of the gastro-soleus and rectus tightness are the most significant features in hemiplegics while internal rotation of the hip and hip flexor tightness were the most significant factors in diplegics with a pelvic retraction gait. Further study is needed to determine if these factors are causal or compensatory.

REFERENCES

[1] Aminian A, Vankoski SJ, Dias L, Novak RA. J Paediatr. Orthop. 2003 p.314-320
[2] Kay RM, Rethlefsen S, Reed M, Do KP, Skaggs DL, Wren TA. J Pediatr Orthop. 2004 May;24(3):278-282

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The Incidence Of And Factors Which Influence Internal Hip Rotation Gait In Patients With Cerebral Palsy.
O'Sullivan R, Hewart P, Walsh M, Jenkinson A, Ross L-A, O'Brien T.Gait Laboratory, Central Remedial Clinic, Clontarf, Dublin 3, Ireland.

Summary and Conclusion

The incidence of internal hip rotation gait and factors, which are considered to influence this walking pattern, were investigated in patients with cerebral palsy. Gait laboratory data of 258 patients with cerebral palsy were studied retrospectively. Two groups were selected; those who demonstrated maximum dynamic hip internal rotation >27° and those with <20°. Of 258 patients, 29% (diplegia-68%, hemiplegia-32%) had at least one hip with dynamic internal rotation of >27°. The most significant differences in clinical measures between the groups were in the values of passive hip external rotation range, hip flexor contraction and femoral anteversion, particularly in patients with diplegia. This study suggests that excessive dynamic hip internal rotation is multifactorial in origin.

INTRODUCTION

Internal rotation of one or both limbs is common in children with cerebral palsy. Possible causes of an internal hip rotation gait pattern and the relationship between static clinical measurements and dynamic hip internal rotation values have been investigated1/2/3. Some factors thought to contribute to increased dynamic hip internal rotation are increased femoral anteversion, hip flexor tightness, imbalance of the hip rotators, weak abductors and tight hamstring and adductor muscles. The purpose of this study was 1) to establish the incidence of excessive maximum hip internal rotation during gait in patients with cerebral palsy and 2) to compare the measurement of some of the above factors in two groups of patients: those with and without excessive internal hip rotation during gait.

METHODOLOGY

Excessive dynamic hip internal rotation was defined as > 27° (peak internal rotation value) based on a previous study of normal subjects, (mean + 2 SD, n=50, age range 5-32yrs). 258 patients with cerebral palsy (diplegia-57%, hemiplegia-43%, age range 4-51) who had undergone gait analysis using the CODA mpx30 system from 1998 to 2001 were reviewed. Two distinct groups were selected: those with maximum dynamic hip internal rotation of >27° and those with <20° (mean + 1 SD from normal study). Each group was further subdivided into patients with hemiplegia or diplegia. The incidence of six clinical variables thought to contribute to this gait pattern was compared in the two groups for hemiplegia and diplegia.

RESULTS

Of 258 patients, 76 (29%) patients walked with at least one hip demonstrating dynamic internal hip rotation of >27° (hemiplegia 32%, diplegia 68%). 145(56%) patients had at least one hip demonstrating dynamic internal hip rotation of <20° (hemiplegia 34%, diplegia 66%). Using one-tailed t-tests, the p-values for each variable and group were calculated and are shown in Table 1. Significance level was set at p<0.05.

Variable Hemiplegia Diplegia
Popliteal angle p=0.34 p=0.04
Hip flexor contraction p=0.02 p < 0.001
Abduction –long lever p=0.26 p=0.09
Passive internal rotation p=0.01 p= 0.05
Passive external rotation p=0.009 p < 0.001
Femoral anteversion p=0.02 p< 0.001

 

Table 1. p values for each variable comparing groups with dynamic hip internal rotation <20 degrees with >27 degrees (peak value)

DISCUSSION

In this study, the incidence of dynamic internal hip rotation gait was defined in children with cerebral palsy. It would appear that the causes of such a gait pattern are multifactorial and vary in patients with diplegia and hemiplegia. Passive external rotation range, hip flexor contraction and femoral anteversion were the most significant clinical factors in determining the difference between internal and non-internal rotators. Prospective studies of gait development in younger children are recommended to define whether these factors are causal or consequential.

REFERENCES

[1] Aktas S et al. J Paediatr. Orthop. 2000 p.217-220
[2] Arnold A S et al. Dev.Med.Child Neurol. 1997, 39:1, p.40-4
[3] Delp S et al. J Biomechanics 1999, 32: p.493-501

 

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The Incidence of an In-toeing Gait Pattern in Cerebral Palsy.
O'Sullivan R*, Hewart P, Walsh M, Jenkinson A, O'Brien T. Gait Laboratory, Central Remedial Clinic, Clontarf, Dublin 3, Ireland.

 

INTRODUCTION

Children with cerebral palsy often walk with an in-toeing gait pattern. In the normal population the incidence of in-toeing has been documented 1and the three most common causes of this pattern have been identified as internal tibial torsion, metatarsus adductus and femoral neck anteversion2. The incidence of an internal hip rotation gait and the possible causes of this gait pattern have been investigated in the cerebral palsy population3. However, the incidence of an in-toeing gait pattern due to rotation at any level in the lower limb has yet to be examined. The purpose of this study was 1) to establish the incidence of in-toeing gait in patients with cerebral palsy, and, 2) to examine where (hip-femur, knee-tibia or ankle-foot) the excessive internal rotation was occurring in this group.

MATERIALS AND METHODS

Based on a previous study of normal subjects (n=33, age range 5-14) excessive average dynamic in-toeing (foot rotation relative to pelvis) was defined as –4.3o (mean+ 2SD). Three hundred and sixty nine patients with cerebral palsy (diplegia-58%, hemiplegia-42%, age range 4-51) who had undergone gait analysis using the CODA mpx30 system from 1998-2003 were reviewed. The overall incidence of in-toeing was calculated in the cerebral palsy population. This group was subdivided into patients with hemiplegia or diplegia and their gait data were studied to identify at which level (hip-femur, knee-tibia or ankle-foot) the excessive internal rotation was occurring based on data (mean+2SD) from the normal group.

RESULTS

Of 369 patients, 149 (40.4%) patients walked with at least one lower limb demonstrating excessive dynamic in-toeing with a higher incidence among diplegics (47.2%) compared to hemiplegics (31.0%). In the hemiplegic group the incidence of in-toeing was more common among those with left sided involvement (left 40.5%, right 18.2%). In diplegics in-toeing was a unilateral feature in 80.2% of cases with the left leg being the most commonly affected (left-side 69.5%, right-side 30.5%). In-toeing was secondary to a single primary deformity (average internal rotation>2SD normal) in 57.5% of diplegics and 37.5% of hemiplegics with the problem found to be multi-level in the remainder. The incidence of the primary deformity at each anatomical level is outlined in table 1.

 

Level of Primary deformity Hemiplegia(n=18) Diplegia(n=69)
Hip-femur 34.4%(n=8) 46.4%(n=32)
Knee-tibia 27.8%(n=5) 23.2%(n=16)
Ankle-foot 27.8%(n=5) 30.4%(n=21)
Table 1. Level of primary deformity in hemiplegia and diplegia

 

DISCUSSION

In this study, the incidence of dynamic in-toeing was defined in children with cerebral palsy. This was found to be a significant problem affecting 40.4% of the population. It is a multi-level problem occurring at the level of the hip-femur, knee-tibia and ankle-foot. While the hip-femur is the most common primary cause both in hemiplegics and diplegics the incidence of primary deformities at the knee-tibia and ankle-foot is significant. Further studies are needed to identify factors contributing to internal rotation at these levels.

CONCLUSION

In-toeing gait is a significant problem in Cerebral Palsy affecting 47.2% of diplegics and 31% of hemiplegics. The most common level of primary deformity occurs at the hip-femur (34.4% in hemiplegics, 46.4% in diplegics) with significant primary deformities also occurring at the knee-tibia (27.8% in hemiplegics, 23.2% in diplegics) and ankle-foot (27.8% in hemiplegia, 30.4% in diplegia).

 

Footnotes

  1. Aktas S et al. JPO 2000 p.217-220
  2. Aston JW. In-toeing gait in children. Gait Posture 1979 p.111-117
  3. O'Sullivan et al. Gait and Posture 2002 p.119 (abstract)

Communicating author. E-mail - rosullivan@crc.ie, Tel- 00-353-1-8542531, Fax- 00-353-1-8335496

 

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Relevant Links

 

Logo of The European Society of Movement Analysis for Adults and ChildrenThe European Society of Movement Analysis for Adults and Children (ESMAC)

 

Logo of The Clinical Movement Analysis Society UK and IrelandThe Clinical Movement Analysis Society UK and Ireland (CMAS)

 

 

Logo of Gait and Clinical Movement Analysis Society (of USA)Gait and Clinical Movement Analysis Society (of USA) (GCMAS)

 

 

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Public Relations

The Gait Laboratory at the CRC has featured in numerous national and international print and broadcast media. Recent published features have been run by both the Irish Times (21st December 2004, 19th April 2005), the Irish Examiner (14th April 05), and the Limerick Leader (13th April 05).

The development of the mobile gait analysis, as a world first, presented much interest on the international stage. The Motion Times UK (motiontimesPDF Document) ran a front page feature regarding this welcome innovation.

The national broadcasting agency of the Republic of Ireland, RTE, used the Mobile gait laboratory as the main feature for current affairs programme "Nationwide". The show was available for public view throughout Ireland on the DD/MM/05.

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Contact Us.

The laboratory is open weekdays from 9am to 5pm.
Contact can be made either by contacting the main CRC reception:

Phone: (01) 8542200
Fax: (01) 8336633

Or
Direct to the Gait Laboratory secretary: Phone : (01) 8542237

Our Address is:
The Gait Laboratory,
Central Remedial Clinic,
Vernon Avenue,
Clontarf,
Dublin 3.

 

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14th April 2005 Irish Examiner

 

Photo of an article from The Irish Times, April 19th 2005

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Photo of an article from The Irish Examiner, April 14th 2005

21st December 2004 Irish Times

Photo of an article from The Irish Times, Dec 21st 2004

 

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