Kids are always on the move. Whether it's organized soccer matches, recess games of tag or chasing after younger brothers and sisters, children are wired to go, go, go. For some of them, though, simple everyday movements like walking are difficult - sometimes impossible. Whether they have a neurological or orthopedic basis, gait issues can be troublesome to kids, to both their bodies and their spirits.
There is a 21st century solution to this problem - the gait lab. At these state-of-the-art facilities, therapy and technology join together to analyze and diagnose young patients, getting to the bottom of the specific causes of their gait abnormalities and producing personalized treatment recommendations.
Mobility difficulties can stem from various root causes. "The most common diagnosis we see at the gait lab is children with cerebral palsy, which is one of the most common gait problems in general," said Amy Winter Bodkin, PT, PhD, PCS, Center for Gait and Movement Analysis, Children's Hospital Colorado, Aurora, Colo., and assistant professor, physical medicine and rehabilitation, University of Colorado School of Medicine.
Neurological issues, especially traumatic brain injury and brain tumors, can also cause gait problems. More recently, Bodkin and colleagues have evaluated patients who underwent a hemispherectomy to treat extreme seizure disorders.
Bodkin's counterparts at both the James R. Gage Center for Gait and Motion Analysis at Gillette Children's Specialty Healthcare, St. Paul, Minn., and the Center for Motion Analysis at Connecticut Children's Medical Center, Hartford, Conn., echo her experiences on the prevalence of cerebral palsy at their labs.
However, "We also see kids strictly with orthopedic issues," explained Jennifer Rodriguez-MacClintic, PT, DPT, PCS, C/NDT, physical therapist, Connecticut Children's. Some of those may include Blount's disease, clubfoot, and undefined musculoskeletal pain. "They come to the motion lab any time there's a question about their walking," summarized Sue Sohrweide, PT, physical therapist II, Gillette.
Gait analysis begins with a thorough physical exam, conducted by a physical therapist or kinesiologist, to evaluate range of motion, spasticity, strength, bony malalignment, motor control and other measures. At this point, the parents will have already completed an assessment, evaluating how well the child mobilizes around the home and community, and whether they rely on an assistive device, such as a walker, or help from other people
All Wired Up
While the specifics vary according to each gait lab, the overall progression of the analysis is similar. "The first thing we do is a video of them walking. We want to see how the children walk when they are not tired and without any of the equipment we later put on them," Bodkin said. In addition to walking, the child is videoed running, jumping and climbing stairs.
At Connecticut Children's, for instance, there are two cameras - one to capture anterior and posterior views, and one to capture side-to-side views. The clinicians get an idea of alignment from the different cameras, figuring out whether the knees and pelvis are level. Biomedical engineers are critical members of the labs; they operate the computers and cameras during the tests and download and distribute the ensuing data, making sure it's presented in an easy-to-read format.
Next, surface EMGs are attached to the child's legs, and reflective markers are placed on their feet, shins, knees, thighs, and pelvis. Explained Bodkin, "The child walks across the floor at the same time the computer collects information about their motion."
Force plates on the walkway provide information regarding where the forces created from walking are acting, and how the patient is able to respond to those forces. A plantar pressure mat embedded in the walkway gives information about the distribution of dynamic pressures on the plantar surface of the feet while walking.
The EMGs provide data on the timing of muscle firing. Their oxygen consumption during walking is also measured, in order to calculate the amount of energy required for walking.
At Children's Hospital Colorado, the first time children walk for an evaluation, they ambulate without any typically used orthotics or assistive devices. After, they are monitored using the devices. "The rule of thumb is that we want five good passes," noted Bodkin. The more data collected, the more comprehensive the picture of that child's gait.
Best Course of Action
After the gait study, the physical therapists analyze and then share the data with other members of the team, including engineers, orthotists, orthopedic surgeons and physical medicine and rehabilitation physicians. It's used to make recommendations for the patient's parents about the best course of action.
"We tease it apart and figure out exactly what's going on," said Rodriguez-MacClintic. The team can recommend anything from no interventions, to bracing, to medications, to physical therapy, to surgery. "We try to really be detailed on the recommendations we make," said Bodkin, sharing the giant report that is generated from the data with the families.
Thanks to the analysis, clinicians are better able to make a personalized plan for each patient. "Two kids can look like they walk the same way, but mechanisms behind it are totally different," said Jean Stout, PT, MS, physical therapist III, James R. Gage Center for Gait and Motion Analysis. Added Rodriguez-MacClintic, "When you watch someone walk, sometimes what you think you're seeing isn't true. With gait analysis we can look at it from every plane and get objective data."
On the low end of the intervention scale, the recommendation might be to add or subtract an assistive device, such as a shoe insert, walker, cane or ankle-foot orthotic. Sohrweide remarked, "We might recommend a different style of brace." A physician could prescribe Botox injections, which can be used to treat spasticity.
Sometimes starting physical therapy is recommended, but most often, the recommendation is for changes to the current regimen. "Most kids we see are already in the middle of a therapy episode of care," Stout said. "We usually suggest additions to their therapy or more emphasis on a certain area of care, like core strengthening or range of motion."
If orthopedic surgery is found to be the best course of action, the child is asked to return for another gait analysis one year after the procedure and for corresponding physical therapy. "We can compare pre- and post-gait analysis and really see the changes, both visually and objectively," said Rodriguez-MacClintic.
Looking to the Future
All three institutions interviewed by ADVANCE stress research as a major component of their gait labs. Rodriguez-MacClintic remarked, "Part of the reason I joined the team is that they are so involved with research, and I wanted to get my foot in the door." The Center for Motion Analysis at Connecticut has participated in a multicenter study with Shriner's Hospital, looking at how body structures impact activities and participation in children with cerebral palsy.
In a more immediate project, Connecticut Children's studied kids and teens that underwent ACL repair following a sports injury. They are determining whether 3D data can help determine the optimal return-to-play time.
"We do research all the time," said Bodkin of the Center for Gait and Movement Analysis at Children's Hospital Colorado. They use information from surgical outcomes research, such as a study of children who had hip flexor lengthening surgery, to determine best practices for future patients. Another study looked at outcomes of rectus femoris transfer, a procedure to help children with stiff legs swing their leg forward when they walk to achieve greater knee flexion. Personally, Bodkin noted, "I've done a lot of work on using a treadmill, with and without bodyweight support."
The thread of research continues in St. Paul. The gait lab at Gillette Children's Specialty Healthcare has been operational since 1987 and representatives have traveled the world teaching courses to physical therapists, physicians and engineers on how to use motion analysis technology and how to interpret the data.
In addition to the main gait lab, Gillette has an auxiliary research lab. They've developed a multi-segment foot model, which allows small, intricate movements within the foot to be analyzed during gait. "Advances in technology have really helped us in the lab. We can use smaller markers and capture smaller, more subtle movements because of these advances," Sohrweide noted.
Research into crouch gait, an issue with children with CP, led surgeons to adapt innovative procedures to restore upright walking. "Biomedical engineers work with us to model the biomechanics of crouch gait to help increase our understanding," said Stout.
One of the most lasting effects of motion analysis labs is the rise of single-event multi-level procedures - surgeries that correct multiple orthopedic problems simultaneously, often with more than one surgical team. "Gait analysis has changed the way our orthopedic surgeons treat children because of the three-dimensional analysis of the biomechanics that gait analysis provides," Stout explained. Bodkin added, "It's a lot easier to make those recommendations."
Whether they come because of orthopedic or neurological conditions, a visit to a gait analysis center is often the first step in getting these kids back into the motion of childhood.
Danielle Bullen is on staff at ADVANCE. Contact: firstname.lastname@example.org