Clinical Gait Analysis and Its Role in Treatment Decision-Making

Roy B. Davis, III, PhD, Sylvia Õunpuu, MSc, Peter A. DeLuca, MD, Mark J. Romness, MD

Disclosures

August 14, 2002

Which Patients Can Benefit from a Clinical Gait Analysis?

Computerized gait analysis techniques are appropriate for any adult or child who has a gait problem requiring treatment. Because of the complexity of gait abnormalities in neuromuscular disorders, gait analysis is most commonly performed in this patient population. Gait analysis is appropriate for guiding decision-making on management in such disorders as cerebral palsy, stroke, traumatic brain injury and myelomeningocele, among others. Because of the complexity and expense of the test, gait analysis is primarily used as part of the surgical decision-making process when all conservative treatments have been exhausted and surgical intervention is being considered. Gait analysis is not limited to only this application, however. Questions concerning bracing issues and medication efficacy can be addressed using gait analysis techniques. For example, is the brace performance or drug intervention (ie, Botulinum toxin, baclofen) consistent with the prescriptive objectives? Evaluation of the rate of deterioration in progressive disorders that affect gait can also aid in understanding a patient's abilities and directing countermeasures. As described above, another valuable function of gait analysis is assessing the efficacy of surgical intervention. Routine analyses of postoperative functional status provides the clinician with more objective information to evaluate the effects of treatment as well as a basis for determining the next steps in the treatment plan.

There are a number of factors to consider when referring a patient for gait analysis. At our institution, the patient must be ambulatory, with or without assistive devices, for at least 10 consecutive steps. A minimum height of approximately 100cm is necessary in order to achieve required measurement precision goals, particularly around the foot and ankle. The patient must be able to follow simple directions and can behaviorally tolerate the placement of reflective markers and EMG electrodes on the skin. The level of patient cooperation influences testability given the time required for a typical gait analysis, particularly in cases of severe cognitive impairment. If a patient has orthoses, testing with and without the devices may be required to address clinical questions concerning brace wear. Usually, testing is conducted with the patient using any necessary walking aids. A full gait analysis which includes all the above parameters takes approximately two to four hours.

Perhaps the most important consideration in using clinical gait analysis is the proper formulation of the specific questions to be addressed by the analysis. For example, what is the cause of the tripping/falling and what is the etiology of idiopathic joint pain? Such questions need to be asked in order to properly direct the application of the technology and the associated interpretation process. Certainly there is a temptation to believe that the technology, specifically, the computer, can not only aid in the analysis, but also direct the analysis. As illustrated throughout this article, the experience and knowledge of the professionals who collect and interpret gait data are essential to clinical gait analysis.

As previously mentioned, a referral for gait analysis is usually made when all methods of conservative treatment have been tried and surgical options are being considered. This typically occurs after the patient has reached an ambulatory plateau and/or when orthopedic concerns necessitate treatment (ie, hip subluxation or severe joint contractures). In patients with cerebral palsy, multi-level surgeries are now performed to address all dysfunction during one surgical intervention. This not only reduces a patient's exposure to anesthesia, but it also reduces the need for frequent hospitalizations and periods of rehabilitation. Gait analysis is invaluable in identifying the multiple areas of impairment that are difficult to understand by observation and clinical assessment alone. For example, when used as a preoperative tool, the child with cerebral palsy may often need only one surgical package of treatment during the growing years.

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