USE OF GAIT ANALYSIS IN TREATMENT PLANNING FOR PATIENTS WITH MYELOMENINGOCELE

Deirdre D. Ryan, M.D.

Childrens Orthopaedic Center Childrens Hospital Los Angeles

Assistant Professor, Department of Orthopaedic Surgery Keck-University of Southern California School of Medicine

Myelomeningocele

I. Overview

II. Functional Motor Levels

a. Thoracic-High Lumbar b. Low Lumbar c. Sacral i. High Sacral ii. Low Sacral

III. Expected Longterm Walking Ability

a. Walking ability depends on the functional motor level i. Thoracic-high Lumbar level 1-5% Community ambulators 10-15% Household ambulators 80% Non ambulators ii. Low Lumbar Level 80% Community ambulators 20% Household/nonambulators iii. Sacral Level 94% Community ambulators 6% Household/ nonambulators b.Walking ability is also affected by comorbidities i. Mental retardation ii. Obesity iii. Balance iv. Spasticity v. Contractures IV. Use Of Gait Analysis

a. Augments clinical assessment b. Provides an objective evaluation of gait patterns c. Brace selection d. Surgical planning e. Useful

i. Low Lumbar Level Lesion ii. Sacral Level Lesions

V. Typical Gait Patterns

a. Muscle weakness associated with the lesion determines the compensatory gait pattern. i. Pelvis and Hip ii. Knee and Ankle iii.Trunk iv. Crutch Walking v. Energy expenditure VI. Deformities affecting Gait

a. Increased Hip Flexion/ Contracture i. Treatment recommended >20 degrees Hip Flexor Lengthening Release of Tensor Fascia Transfer the Sartorius from ASIS to AIIS +/- proximal release rectus origin +/- intrapelvic lengthening of iliopsoas b. Hip Dislocation and Subluxation

i. Low Lumbar Level Do not relocate the hip due to high recurrence Address contractures with lengthening Adductor lengthening Intrapelvic iliopsoas lengthening Valgus Osteotomy if necessary Femoral derotation if indicated ii. Sacral Level

Walk without support dislocation leads to major asymmetry Relocate hip Femoral and acetabular surgery Soft tissue rebalancing c. Increased Knee Flexion/ Contracture

i. Ground Reaction Force AFO ii. Judicious Hamstring Lengthening(if tight) iii. Capsulotomy posterior Knee capsule iv. Guided growth d. Rotational malalignments

Lead to Valgus Knee Stress i. Pelvic obliquity/ rotation Crutches ii. Excessive Hip internal rotation during stance Derotational osteotomy femur iii. External tibial torsion > 20 degrees Derotational osteotomy tibia Internal tibial torsion i. Does not lead to abnormal knee stress

ii.Leads to intoeing Derotational osteotomy tibia

and Kay: JPO 33:4 22-430, 2013

Rethlefsen and Kay: JPO: JPO 33:422-430, 2013

References

. Asher M, Olson J:Factors affecting the ambulatory status of patients with spina bifida cystica. J Bone Joint Surg Am

1983;65:350-356.

.Bare A, Vankoski SJ, Dias L, Danduran M, Boas S: Energy expenditure in children with lumbosacral myelomeningocele:

Whats the cost of walking? Gait Posture 1997;5:142.

. Bare A, Vankoski SJ, Dias L, Danduran M, Boas S: Independent ambulators with high sacral myelomeningocele: The relation

between walking kinematics and energy consumption. Dev Med Child Neurol 2001;43:16-21.

.Bartonek A, Saraste H, Knutson LM: Comparison of different systems to classify the neurological level of lesion in patients

with myelomeningocele. Dev Med Child Neurol 1999;41:796-805.

.Barwood SA, Duffy C, Rodda J, Starr R, Nattrass G, Menelaus M, Graham HR: The means of progression in children with low

lumbar And sacral level spina bifida. Dev Med Child Neuro 1998;40(suppl 78):23-24.

.Brinker MR, Rosenfeld SR, Feiwell E, Granger SP, Mitchell DC, Rice JC: Myelomeningocele at the sacral level: Long term

outcomes in adults. J Bone Joint Surg Am 1994;1293-1300.

. Dobashi E, Dias L,Sarwark JF, Moore C, Vankoski S: Unilateral hip subluxation in the low lumbar level spina bifida child: A

gait analysis evaluation. Gait Posture 1994;2:60.

Duffy CM, Hill AE, Cosgrove AP,Corry IS, Mollan RA, Graham HK: Three dimensional gait analysis in spina bifida. J Peditr

Orthop 1996;16:786-791.

.Duffy CM, Hill AE, Cosgrove AP, Corry IS,Graham HK: The influence of hip abductor weakness on gait analysis in spina bifida.

Gait Posture 1996;4:34-38

.Duffy CM, Hill AE, Cosgrove AP, Corry IS, Graham HK: Energy consumption in children with spina bifida and cerebral palsy:

A comparative study. Dev Med Child Neurol 1996;38:238-243.

.Dunteman R, Vankoski S, Dias L: Abstract: Internal derotational osteotomy of the tibia:Pre and postoperative gait analysis

in lumbosacral myelomeningocele patients with external tibial torsion. Dev Med Child Neurol 1999;41(suppl 80):14.

.Eames M, Cosgrove A, Baker R: Center of mass excursion in children with myelomeningocele. Gait Posture 1998;8:70.

.Eames M, Baker R, Cosgrove A: The gait of people with myelomeningocele:How to abduct without abductors? Gait Posture

1999;9:110-111.

.Engel GM, Staheli LT: The natural history of torsion and other factors influencing gait in childhood: A study of the angle of

gait, tibial torsion, knee angle, hip rotation, and development of the arch in normal children. Clin Orthop 1974;99:12-17.

.Gage JR(ed): Gait Analysis in Cerebral Palsy. London, England, MacKeith Press, 1991

.Gage JR: Gait Analysis: An essential tool in the treatment of Cerebral Palsy. Clin Orthop 1993;288:126-134

.Gracovetsky S: The Spinal Engine. New York, NY, Springer-Verlag, 1988.

.Gracovetsky S: A hypothesis for the role of the spine in human locomotion: A challenge to current thinking. J Biomed Eng

1985;7:205-216.

.Gupta RT, Vankoski S, Novak RA, Dias LS: Trunk kinematics and the influence on valgus knee stress in persons with high

sacral level myelomeningocele. J Pediatr Orthop. 2005 Jan-Feb;25(1):89-94.

.Hoffer M, Feiwell D, Perry J, et al:Functional ambulation in patients with myelomeningocele. J Bone Joint Surg Am

1973;55:137-148.

Huff CW, Ramsey PL: Myelodysplasia: The influence of the quadriceps and hip abductor muscles on ambulatory function

and stability of the hip. J Bone Joint Surg Am 1978;60:432-443

.Hullin MG, Robb JE, Louden IR: Ankle-foot orthosis function in low-level myelomeningocele. J Pediatr Orthop 1992;12:518-

521.

.Krebbs D, Wong D, Jevsevar D, Riley PO, Hodge WA: Trunk kinematics during locomotor activities. Phys Ther 1992;72:505-

514.

.Lim R, Dias L, Vankoski S, Moore C, Marinello M, Sarwark J: Valgus knee stress in lumbosacral myelomeningocele: A gait

analysis evaluation. J Pediatr Orthop 1998;18:428-433.

.Lindseth RE: Treatment of the lower extremity in children paralyzed by myelomeningocele (birth to 18 months). Instr

Course Lect 1976;25:76-82.

.Mazur JM, Stillwell A, Menelaus M: The significance of spasticity in the upper and lower limbs in myelomeningocele. J Bone

Joint Surg Br 1986;68:213-217.

. McDonald CM, Jaffe KM, Mosca VS, Shurtleff DB: Ambulatory outcome of children with myelomenongocele: Effect of

lower extremity muscle strength. Dev Med Child Neurol 1991;33:482-490.

.McDonald CM, Jaffe KM, Shurtleff DB, et al: Modifications to the traditional description of neurosegmental innervation in

myelomeningocele. Dev Med Child Neurol 1991;33:473-481.

.Moore C, Nejad B, Novak, Dias L: The energy cost of walking in low lumbar myelomeningocele: A comparison between

reciprocal and swing through gait Gait Posture 2000;10:136-137

.Nazur JM, Thomas SS, Eberle C: The use of gait analysis in the evaluation of myelomeningocele patients. Orthop Trans

1990;14:299.

.Ounpuu S, Davis R, Bell K: Gait analysis in the treatment of children walking with or without support. Proceedings from the

7th Annual East Coast Clinical Gait Laboratories Conference. Richmond, VA, 1992

.Ounpuu S, Thomson J, Davis R: Understanding gait in persons with myelomeningocele: An evaluation of the upper body

and pelvic motion. Dev Med Child Neurol 1998;40(suppl 78):23.

.Ounpuu S, Thomson JD, Davis RB, Deluca PA: Abstract: The value of gait analysis in evaluation of knee function in persons

with myelomeningocele. Dev Med Child Neurol 1999;41(suppl 80): 13-14.

.Park BK, Song HR, Vankoski SJ, Moore CA, Dias L: Gait electromyography in children with myelomeningocele at the sacral

level. Arch Phys Med Rehab 1997;78:471-475

Perry J, Antonelli D, Ford W: Analysis of the knee joint forces during flexed knee stance. J Bone Joint Surg Am 1975;57:961.

.Perry J: Gait Analysis: Normal and Pathologic Function. New York, NY, McGraw Hill, 1992.

.Samuelsson L, Skoog M: Ambulation in patients with myelomeningocele: A multivariate statistical analysis. J Peditr Orthop

1988;5: 569.

.Schafer MF, Dias LS (eds): Myelomeningocele: Orthopaedic Treatment. Baltimore, MD, Williams and Wilins, 1983

.Selber P, Dias L: Sacral level myelomeningocele: Long term outcome in adults. J Pediatr Orthop 1998;18:423-427.

Sharard WJW: The segmental innervation of the lower limb muscles in man. Ann Royal College Surg 1964;35:106-122.

.Staheli LT, Engel GM: Tibial Torsion: A new method of assessment and a survey of normal children. Clin Orthop

1972;86:183-186.

.Staheli LT: Torsion-treatment indications. Clin Orthop 1989;247:12-17.

.Staheli LT, Corbett M, Wyss C, King H: Lower extremity rotational problems in children: Normal values to guide

management. J Bone Joint Surg Am 1985; 67:39-47.

.Stefko RM, de Swart RJ, Dodgin DA: Kinematic and kinetic analysis of distal derotational osteotomy in the leg of children

with cerebral palsy. J Peditr Orthop 1998;18:81-87

.Stillwell A, Menelaus MB: Walking ability in mature patients with spina bifida. J Pediatr Orthop 1983;184-190.

.Stokes VP, Andersson C, Forssberg H: Rotational and translational movement features of pelvis and thorax During adult

human locomotion. J Biomech 1989;22:43-50.

. Sutherland DH(ed):Gait Disorders in Childhood and Adolescence. Baltimore, MD, Williams and Wilkins, 1984.

Swank M, Dias L: Myelomeningocele: A review of the orthopaedic aspects of 206 patients treated from birth with no

selection criteria. Dev Med Child Neurol 1992;34:1047-1052.

.Thomas SE, Mazur JM, Child ME, Supan TJ: Quantitative evaluation of AFO use with myelomeningocele children. Z

Kinderchir 1989;44(suppl 1):38-40.

.Thomas SS, Wright N, Mazur JM: Abstract: Quantification of gait of children with myelomeningocele using motion analysis.

Dev Med Child Neurol 1988;30(suppl 57):41.

.Thomson J, OunpuuS, Davis R, DeLuca P: A comparison of barefoot and AFO walking persons with myelomeningocele: An

evaluation using 3-D gait analysis. Dev Med Child Neurol 1998;40(suppl I): 38-40

.Thorstensson A, Nilsson J, Carlson H, Zomlefer M: Trunk movements in human locomotion. Acta Physiol Scand 1984; 121:9-

22.

.Vankoski SJ, Moore CA, Statler KD, Sarwark JF, Dias LS: Abstract: The influence of external support on pelvic and hip

kinematic parameters in childhood community ambulators with low lumbar level myelomeningocele: Dont throw away the

crutches. Dev Med Child Neurol 1995;37(suppl 73):5-6.

.Vankoski SJ, Sarwark JF, Moore C, Dias L: Characteristic pelvic, hip and knee patterns in children with lumbosacral

myelomeningocele. Gait Posture 1995;3:51-57.

.Vankoski S, Moore C, Statler K, Sarwark JF, Dias L: The influence of forearm crutches on pelvic and hip kinematic patterns in

childhood community ambulators with low level myelomeningocele: Dont throw away the crutches. Dev Med Child Neurol

1999;41(suppl 80):4-5.

.Vankoski S, Mishaud S, Dias L: External tibial torsion and the effectiveness of the solid ankle-foot orthosis. J Pediatr Orthop

2000;20:349-355.

.Waters RL, Yakura JS: The energy expenditure of normal and pathologic gait. Critical Reviews in Physical and Rehabilitation

Medicine 1989;187-209.

.Wiet M, Vankoski S, Dias L: Temporal force characteristics of reciprocal four point crutch walking in children with spina

bifida. Dev Med Child Neurol 1999;41(suppl 80):4-5.

.Williams JJ, Graham GP, Dunne KB, Menelaus MB: Late knee problems in myelomeningocele. J Pediatr Orthop

1993;13:701-703.

.Winter DA: Kinematics and kinetic patterns in human gait: Variability and compensating effects. Hum Mov Sci 1984;3:51-

76.