Clinical Gait Analysis and Its Role in Treatment Decision-Making

Abstract and Introduction

Clinical gait analysis is the process by which quantitative information is collected to aid in understanding the etiology of gait abnormalities and in treatment decision-making. This process is facilitated through the use of technology such as specialized, computer-interfaced video cameras to measure patient motion, electrodes placed on the surface of the skin to appreciate muscle activity, and force platforms imbedded in a walkway to monitor the forces and torques produced between the ambulatory patient and the ground. Essential to the process is the interpretation of these data by an experienced, interdisciplinary team with substantial knowledge in normal and pathologic gait. This article introduces this clinical specialty and illustrates its applicability by addressing a number of frequently asked questions. What is involved in a clinical gait analysis test? That is, how is it performed? How are gait data interpreted? What additional information is provided through a clinical gait analysis that augments observational gait analysis? Which patients can benefit from a clinical gait analysis?

The goal of clinical gait analysis is to assist in treatment decision-making for the person with complex and not easily understood walking problems. Clinical gait analysis (sometimes referred to as "quantitative gait analysis") is a process whereby gait characteristics are measured, abnormalities are identified, causes are postulated, and treatments are proposed. The approach used most often today involves the placement of external markers or targets at specific points on the lower extremities and torso of the patient. These markers are then monitored by special video cameras as the patient walks along a straight, level pathway. The camera images are analyzed by a central collection computer with biomechanical programs to quantify the movement of specific body segments in space. For example, by measuring the thigh and shank simultaneously, one can appreciate knee motion. This analysis of motion is then combined with measures of muscle activity and the reaction forces between the patient's foot and the ground to provide a comprehensive assessment of the biomechanics of locomotion.

It is important to appreciate that while quantitative gait analysis does use technology to measure gait patterns, it does not replace the human observer (ie, the observational gait analysis approach that a clinician might employ in the clinic or office setting). Rather, clinical gait analysis serves as an adjunct to aid in understanding -- more precisely and at times more accurately -- visual impressions of a patient's gait impairment. Through the thoughtful use of technology, quantitative gait analysis provides an opportunity to appreciate the details of complex movement patterns that may involve a number of lower (and upper) extremity joints and segments simultaneously and include movements that occur in several planes of motion concurrently, as well as to understand and correlate the associated muscle activity.

It is also important to understand that while treatment decision-making is facilitated by clinical gait analysis, these decisions are always made in the context of the clinician's experience in gait analysis and in the management of the particular disorder presented by the patient. Quantitative gait analysis does not dictate clinical treatment. Although patients seen most often for gait analysis present with complex and sometimes subtle gait deviations that suggest surgical intervention is necessary, other recommendations for management may include physical therapy, bracing (orthoses), spasmolytic medications (such as, Botulinum toxin, baclofen), or "do nothing at present, but continue to follow."

The objectives of this manuscript are to illustrate the process of clinical gait analysis and to clarify when it might be of benefit for individuals with walking concerns. This discussion is based in large part on the experience and protocols developed and used at the Gait Analysis Laboratory at the Connecticut Children's Medical Center (formerly located at the Newington Children's Hospital, Newington, Connecticut). Several questions commonly asked about clinical gait analysis will be addressed, including:

What is involved in a clinical gait analysis test? That is, how is it performed?
How are gait data interpreted?
What additional information is provided through a clinical gait analysis that augments observational gait analysis?
Which patients can benefit from a clinical gait analysis?

Patient	Knee Position	Side	Passive Motion	Dorsiflexion Strength
1	fully extended	left	0°	2 out of 5
1	flexed to 90°	left	5°	2 out of 5
2	fully extended	left	5°	2 out of 5
2	flexed to 90°	left	10°	2 out of 5
3	fully extended	left	0°	1 out of 5
3	flexed to 90°	left	10°	1 out of 5

Patient	Muscle	Pattern of Activity
1	tibialis posterior	active in terminal swing with variable activity in stance
1	tibialis anterior	active in late stance, at toe off and in initial swing
2	tibialis posterior	negligible activity
2	tibialis anterior	active in late stance, at toe off and in initial swing with variable activity in late swing and from initial contact through mid-to-late stance
3	tibialis posterior	continuous activity in swing through mid-to-late stance depending on the gait cycle
3	tibialis anterior	variable premature activity of a late stance burst and normal activity in swing and prolonged activity through mid stance

Clinical Gait Analysis and Its Role in Treatment Decision-Making

Abstract and Introduction

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