gait analysis at your fingertips - aacpdm · 2018-10-12 · gait analysis at your fingertips:...

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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


• 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


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


Observational Gait Analysis


• Prerequisites• Understand Normal Gait Cycle and Select Key Subphases• Recognition / Classification of Common Deviations

• Visual Assessment• Systematic• Forest / Trees

OptimizingObservational Gait Analysis


•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


Principles of Mobile Videography

20 feet

15 feet


• 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


../Videos/avi/2533830 sagittal pan.avi

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


Principles of Mobile Videography: Low-Cost Image Stabilization

•Gimbal•platform that maintains orientation in space despite inclines or rotation

•Nature Documentaries




•Drones•Geopolitical/ Personal





•Selfie Stick with 3 Axis Gimbal•$50-300 USD


Without Image Stabilization Hand-held Image Stabilization


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


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


Hudl Technique App: Features






Scale

•Case Example

Observational Gait Assessment Scoring Systems

Physician Rating Scale Salford Gait Tool Observational Gait Analysis

Observational Gait Scale

Edinburgh Visual Gait Score


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)


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


EVGS Scoring Six Stops in Gait Video


• 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






Scale

•Case Example

Right Spastic Hemiplegic Cerebral Palsy


Preop1 year post

Achilles + Plantar Fascia2 years post

Achilles + Plantar Fascia

Preop EVGS Grading: Right Mid Stance Sagittal


Preop EVGS Grading: Right Mid Stance Front Coronal



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



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


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


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


2

1

1

1

Trunk lean and vaulting resolve at 2 years

Total Body EVGS Grading


• 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.


• EVGS vs Kinematics• Cell Phone / Gimbel Platform• MAC System• Simultaneous Capture

• Refine Technique• Other Software Platforms• Additional Kinematic

Variables• Establish Clincial Boundries

Current Research


SimultaneousInstrumented Gait Capture

Sagittal Camera on Gimbal

Coronal Camera

Additional Markings

EVGS Set-Up


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.


Example EVGS Scoring Worksheet

Heart Function

Gait Function

Pulse RateStethoscope Echocardiogram

Hallway Examination

Observational Gait Analysis

3D Gait Analysis

Increasing Patient Complexity




•Modern Technology•Mobile Videography• Cell Phones and Tablets

• Image Stabilization


Scale

•New Possibilities!


• Full Handouts• Gait Scoring Sheets• Links to resources

….and more!• [email protected]

gait analysis at your fingertips - aacpdm · 2018-10-12 · gait analysis at your fingertips:...

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