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Home , Gait deviations, Trendelenburg gait

Editor’s Note: Corrections to this article were published in the March 2010 issue of JAOA—The Journal of the CASE REPORT American Osteopathic Association (2010;110[3]:210). The corrections have been incorporated in this online version of the article, which was posted January 2011. An expla - nation of these changes is available at http://www.jaoa .org/cgi/content /full/110/3/210-a.

Use of Osteopathic Manipulative Treatment to Manage Compensated Trendelenburg Caused by Sacroiliac Somatic Dysfunction

Adam C. Gilliss, DO; Randel L. Swanson, II, OMS III; Deanna Janora, MD; and Venkat Venkataraman, PhD

Gait dysfunctions are commonly encountered in the pri - In the present case report, we provide evidence that com - mary care setting. Compensated Trendelenburg gait is a gait pensated Trendelenburg gait may represent a secondary gait dysfunction that was originally described in patients with dysfunction stemming from somatic dysfunction of the weakness of ipsilateral abduction. This condition is sacroiliac joints. We also describe evidence of osteopathic thought to result from neuronal injury or myopathy. No manipulative treatment (OMT) resulting in quantitative treatment modalities currently exist for compensated Tren - improvements in the gait cycle. delenburg gait. The authors present a case in which osteo - pathic manipulative treatment may have improved a Tren - Traditional and Osteopathic Gait Theory delenburg gait dysfunction in a man aged 65 years with The gait cycle is divided into two main phases—stance and . Evidence of this improvement was swing, each consisting of numerous subphases. 2,3 Traditionally, obtained with the GaitMat II system for measuring the human gait cycle is considered to have six determinants that numerous gait parameters. Based on the results reported in function independently, yet simultaneously, to generate the the present case, the authors propose that compensated Tren - normally fluid, continuous movements of ambulation. 4 The first delenburg gait may arise from somatic dysfunction and may two determinants of the gait cycle—pelvic rotation and pelvic be corrected by osteopathic manipulative treatment. tilt—involve the , including the right and left innominate bones and the sacrum. [Published correction appears in J Am Osteopath Assoc . 2010;110(3):210.] J Am Osteopath Assoc . 2010;110(2):81-86 During the swing phase of the gait cycle, the pelvis rotates forward on the side of the swinging leg about a transverse hysicians routinely encounter gait dysfunctions in the plane, with the hip joint of the stance leg serving as the axis of Pprimary care setting. Abnormal gait patterns have many rotation. In addition to this forward rotation, Trendelenburg causes and may represent either a primary or secondary tilt occurs on the side of the swinging leg, with the pelvis (ie, compensatory) gait dysfunction. Compensated Trende - dropping by approximately 5 degrees. 2 The degree of tilt is lim - lenburg gait, also known as compensated gait , was ited by contraction of the hip abductor muscles of the stance originally described in the late 1800s by German surgeon , primarily the gluteus medius. Also during Trendelenburg Friedrich Trendelenburg in patients with weakness of ipsi - tilt, there is a lateral shift of the pelvis toward the stance leg, lateral hip abduction. 1 This weakness is thought to typically resulting in a shift in the center of gravity. 2 result from injury to the superior gluteal nerve or from a In traditional gait theory, the pelvis is thought to function pathologic condition affecting proximal hip abductor muscles, and move as a single unit, with the individual components primarily the gluteus medius. Currently, no treatment modal - immobile relative to one another. 2,4 Osteopathic theory, how - ities exist for patients with compensated Trendelenburg gait. ever, holds that individual motions occur between the right and left innominate bones and the sacrum. 5-7 These individual motions arise when torsion forces are created within the pelvis during the gait cycle, leading to variations in the timing of From the Department of Osteopathic Manipulative Medicine (Dr Gilliss) and rotation, tilt, and lateral shift between the sacrum and innom - the Department of Cell Biology (Student Doctor Swanson and Dr Venkataraman) at the University of Medicine and Dentistry of New Jersey- inates. Studies have documented the and the School of Osteopathic Medicine in Stratford; and the JFK Johnson Rehabili - degree of rotation in these bones. 8,9 Thus, clinical gait anal - tation Institute (Dr Janora) at the University of Medicine and Dentistry of ysis must incorporate both traditional and osteopathic gait New Jersey-Robert Wood Johnson Medical School in Edison. This study was supported by intramural grants from the Osteopathic theory to arrive at the correct diagnosis. Heritage Foundations (V.V., R.L.S.). typically rely on visual observation alone to Financial Disclosures: None reported. assess both normal and pathologic gait. Gait disturbances may Address correspondence to Adam C. Gilliss, DO, 27 E Chestnut Ave, Mer - chantville, NJ 08109-2504. arise from pathologic conditions of the spinal cord and lower E-mail: [email protected] body, as well as from cognitive and neurologic disorders of the brain. 10-12 systems, such as GaitMat II (EQ Inc, Submitted August 22, 2008; final revision received April 13, 2009; accepted April 22, 2009. Chalfont, Pennsylvania), are now available for making reliable

Gilliss et al • Case Report JAOA • Vol 110 • No 2 • February 2010 • 81 CASE REPORT

measurements of numerous spatial and temporal gait param - occurred once before and once after OMT was administered eters as a patient walks across a mat, 12 feet in length, that has by the osteopathic . electronic sensors connected to a computer. These systems, Values derived from the GaitMat II analysis for step which can aid physicians in diagnosing gait pathologic con - length, stride length, stance time, double support time, number ditions, 13 are increasingly used in the clinical setting. 1,14-15 of steps, and velocity were recorded for the left and right sides, Although the GaitMat II system measures only con - and the averages of these values were calculated for pretreat - tact patterns recorded on the mat, these patterns arise from ment and posttreatment in both trials. We analyzed the fol - the collective motions of the individual musculoskeletal com - lowing four parameters: ponents that contribute to bipedal locomotion. 16 Therefore, GaitMat II can be used to assess normal and abnormal gait ▫ step length —distance along the mat from the “first switch patterns, as well as the effects of somatic dysfunction and closure” of one footprint to the first switch closure of the OMT on gait. We used GaitMat II in the present case report next footprint on the contralateral side, typically the dis - to evaluate a patient with Trendelenburg gait before and tance from the of one foot to the heel of the opposite foot after OMT. ▫ stride length —distance along the mat from the first switch closure of one footprint to the first switch closure of the next Report of Case footprint on the ipsilateral side, typically the distance from A man aged 65 years with a history of relapsing and remitting the heel of one foot to the heel of the same foot where it falls multiple sclerosis presented to the office of an osteopathic next physician (A.C.G.) in 1999 with a chief complaint of back and ▫ stance time —time during which a foot is in contact with hip pain. He had been diagnosed as having multiple sclerosis the mat in 1991 based on findings from a magnetic resonance imaging ▫ double support time —time during which both feet are in (MRI) scan. From 1991 to 1999, he was treated with standard contact with the mat medications for multiple sclerosis, including interferon beta- 1a and glatiramer acetate. The patient sought care from the Statistical analyses of all values were conducted initially osteopathic physician when he experienced marked deterio - with InStat software (version 4.0; GraphPad Software Inc, ration in ambulation in March 1999 resulting in the need for a La Jolla, California) and were repeated with SigmaStat (ver - walker and motorized wheelchair. sion 4.0; Systat Software Inc, San Jose, California) and Excel The patient’s comorbid conditions at presentation included (Office Professional 2007; Microsoft Corp, Redmond, Wash - rheumatoid and benign prostatic . The ington) software. patient’s surgical history was unremarkable. The osteopathic physician (A.C.G.) initiated OMT in 1999 Diagnosis of Somatic Dysfunction to manage somatic dysfunctions detected throughout the Video analysis of the patient demonstrated an patient’s body. This treatment has continued to the present day. with left lateral trunk lean and hip hiking to compensate For the present case, we focus on two OMT sessions con - for decreased clearance of the right leg in the swing phase of ducted in September and October 2006, during which gait the gait cycle. This pretreatment video was shown sepa - analysis and videotaping of the patient were conducted. rately to three physicians—two physiatrists (including D.J.) Medications used by the patient at the time of the present and one osteopathic family physician who was board certi - study included vitamin B 12 injections (1000 ␮g, intramuscular, fied in neuromusculoskeletal medicine and osteopathic once weekly); tamsulosin hydrochloride (0.4 mg daily) and manipulative medicine. Based on this video, all of these dutasteride (0.5 mg daily) for benign prostatic hyperplasia; physicians diagnosed the patient as having a compensated celecoxib (200 mg daily) and hydroxychloroquine sulfate Trendelenburg gait. (200 mg daily) for rheumatoid arthritis; and alprazolam (0.5 mg Biomechanical examination of the patient during the OMT three times daily, as needed) for anxiety. sessions revealed somatic dysfunction within the sacroiliac joints, in addition to other somatic dysfunctions throughout the Gait Analysis Before and After OMT body. The sacroiliac diagnoses in both trials were right-on- In the present study, the patient had two appointments right sacral torsion and posterior rotation of the left innominate. (ie, trials)—one in September 2006 and the other 1 month later, in October 2006—during which his gait was analyzed as he OMT Application walked across the GaitMat II mat. 13 (Weekly OMT sessions Osteopathic manipulative treatment was administered to the occurred between these two appointments as part of the patient in each of the two trials. For the right-on-right sacral tor - patient’s regular treatment.) Videotaped recording of the sion and the posterior rotation of the left innominate, the patient during ambulation was also performed. In each patient was treated with standard OMT muscle energy tech - appointment, the GaitMat II analysis and video recording niques. 16-18

82 • JAOA • Vol 110 • No 2 • February 2010 Gilliss et al • Case Report CASE REPORT

Trial 1 Trial 2

Pretreatment (18) (18)

Posttreatment (8) (7)

Left Right Direction of Motion

Figure 1. Step patterns of the patient in the present case—a 65-year- later—in trial 2. The number of steps is shown within parentheses old man with compensated Trendelenburg gait—as traced by the next to each tracing. This analysis revealed a 58% decrease in the GaitMat II (EQ Inc, Chalfont, Pennsylvania) gait analysis system before number of steps after treatment, indicative of an improvement in and after osteopathic manipulative treatment in trial 1 and—1 month the patient’s compensated Trendelenburg gait.

Briefly, the sacral torsion was addressed by manipulating This difference vanished after treatment (left, 0.50 [0.05] m; the left gluteus maximus muscle in an isometric contraction right, 0.51 [0.03] m; P=.691). These results suggest that analysis to pull the left sacral base posteriorly, and the posterior rota - of step length variation may serve as a diagnostic tool for tion of the left innominate was counteracted by manipulating Trendelenburg gait, as well as an evaluation method for gait the iliopsoas and rectus femoris muscles to rotate the innom - improvement after OMT. inate anteriorly during an isometric contraction. The Table provides numerical values for two additional parameters—stance time and double support time. Results Results showed statistically significant decreases after OMT for both Analysis of the posttreatment video showed substantial the left and right sides in stance time (left, -33%; right, -24%; improvement in the patient’s gait, with a dramatic decrease in PϽ.001) and double support time (left, -44%; right, -48%; the compensated gluteus medius pattern. Specifically, left lat - PϽ.001). These results are consistent with the observed increase eral trunk lean and hip hiking were noticeably decreased, in velocity and demonstrate that the OMT sessions resulted in indicating that the OMT was effective. improvements in ambulation. Posttreatment analyses using the GaitMat II system pro - vided quantitative evidence that supported the video-based Follow Up conclusions. Figure 1 shows the GaitMat II tracing of the The patient has not needed a walker or wheelchair or used any patient’s steps from both trials before and after OMT. This anal - multiple sclerosis–related medication since 2001. The patient’s ysis revealed a 58% decrease after treatment in the number of gait improvement was such that his neurologist questioned the steps taken across the mat, with a mean of 18 steps in the original 1991 diagnosis of multiple sclerosis and referred the pretreatment analysis and 7.5 steps in the posttreatment anal - patient to a multiple sclerosis specialist, who ordered a new ysis ( PϽ.01). MRI in 2006. Both the neurologist and a radiologist reviewed The changes in mean step length, stride length, and the results from this MRI and confirmed the diagnosis of mul - velocity after OMT in both trials are provided in the Table tiple sclerosis. Thus, despite having multiple sclerosis, the and Figure 2 . After OMT, analyses revealed significant increases patient appeared to benefit from OMT in terms of managing in both left and right step lengths (left, +85%; right, +216%; his compensated Trendelenburg gait. PϽ.001 for each) and left and right stride lengths (left, +136%; right, +128%; PϽ.001 for each). An increase of 193% was Comment observed in the patient’s velocity after OMT, with a pretreat - The normal gait of the patient in the present case had been ment value of 0.21 m per second and a posttreatment value of altered primarily through dysfunctions in the sacroiliac joint. 0.81 m per second ( PϽ.01). The diagnoses for this patient included right-on-right sacral tor - Consistent with a compensated Trendelenburg gait, a sion and left posterior innominate somatic dysfunctions. The statistically significant difference was observed between the sacrum and innominate bones are in these positions when mean (SD) right and left step lengths before treatment the left leg is moved forward during ambulation—providing (Figure 3 ), with the right step length 41% shorter than the left an explanation of why the patient’s left stride was longer at step length (left, 0.27 [0.04] m; right, 0.16 [0.06] m; PϽ.05). presentation.

Gilliss et al • Case Report JAOA • Vol 110 • No 2 • February 2010 • 83 CASE REPORT

Table Gait Parameters of Patient With Compensated Trendelenburg Gait Before and After Osteopathic Manipulative Treatment

Step Length, m Stride Length, m Stance Time, s Double Support Time, s Left Right Left Right Left Right Left Right Steps, No. Velocity, m/s Ⅲ Pretreatment, Mean (SD) * ▫ Trial 1 0.29 0.15 0.44 0.45 1.29 1.25 0.43 0.47 (0.04) (0.05) (0.06) (0.07) (0.41) (0.18) (0.03) (0.21) 18 0.26

▫ Trial 2 0.25 0.17 0.43 0.44 1.15 1.06 0.36 0.39 (0.05) (0.06) (0.07) (0.07) (0.31) (0.11) (0.02) (0.04) 18 0.29

▫ Both trials, 0.27 0.16 0.44 0.45 1.22 1.15 0.40 0.43 average (0.04) (0.06) (0.06) (0.06) (0.37) (0.18) (0.05) (0.16) 18 0.28

Ⅲ Posttreatment, Mean (SD) * ▫ Trial 1 0.47 0.51 0.98 1.00 0.84 0.87 0.23 0.23 (0.04) (0.04) (0.02) (0.06) (0.08) (0.07) (0.04) (0.01) 8 0.80

▫ Trial 2 0.53 0.50 1.07 1.03 0.80 0.89 0.21 0.22 (0.05) (0.03) (0.05) (0.03) (0.03) (0.11) (0.05) (0.03) 7 0.81

▫ Both trials, 0.50 0.51 1.02 01.01 0.82 0.88 0.22 0.23 average (0.05) (0.03) (0.05) (0.05) (0.06) (0.09) (0.04) (0.02) 7.5 0.81

Ⅲ Difference Between Averages ▫ Units 0.23 0.35 0.59 0.57 -0.40 -0.28 -0.18 -0.21 -10.50 0.53 ▫ Percent 85.19 215.63 135.63 128.09 -32.79 -23.81 -44.30 -47.67 -58.33 192.73 ▫ P value <.001 <.001 <.001 <.001 <.001 <.001 <.001 <.001 <.01 <.01

* All values in mean (SD) except for steps and velocity.

The right-on-right sacral torsion occurred in this patient lateral trunk lean and hip hiking. The observed decrease in with the left stride. With the left sacral base stuck forward in right-left variation and the observed increases in step and a rightward rotation about a right oblique axis, it was not able stride lengths provided quantitative measures of the beneficial to return to a neutral position. Because of this inability, the results of OMT. Furthermore, energy expenditure during gait left sacroiliac joint could not lock into position, and the right was reduced after treatment, allowing the patient to increase sacral base could not move forward in a leftward rotation his speed of . Consistent with this observation, an about a left axis—as is required for efficient forward movement increase in velocity and decreases in stance time and double of the right leg. Thus, a problem with the right stride resulted. support time were measured. Similarly, the left innominate in this patient was restricted in anterior rotation and, therefore, it was unable to allow the Conclusion left sacroiliac joint to close so that the patient’s weight could be For the patient in the present case, OMT resulted in improved balanced effectively on the left leg while the right leg was gait parameters that could be measured with the use of the swung forward. The patient compensated for this restricted GaitMat II system. Further research is being carried out motion by laterally flexing his trunk to the left. This flexing bal - (by A.C.G.) to clarify the relationship between somatic dys - anced the weight of the body on top of the femoral head, functions and gait deviations, as well as to investigate the through the acetabulum of the innominate. As a result, the effects of OMT in alleviating these conditions. right leg could be swung forward without striking the ground and without the patient falling. References After OMT, improved motion of the pelvis was observed, 1. Pomeroy VM, Chambers SH, Giakas G, Bland M. Reliability of measure - ment of tempo-spatial parameters of gait after stroke using GaitMat II. Clin including a more normal gait pattern with less evidence of Rehabil . 2004;18(2):222-227.

84 • JAOA • Vol 110 • No 2 • February 2010 Gilliss et al • Case Report CASE REPORT

Figure 2A Figure 2B Figure 2C

1.0 1.0 1.0

0.8 0.8 0.8 m

m ,

t , s t h / h g g m

0.6 n

0.6 0.6 , n e y e L t

L i

e c p d o i l e r t e t

S 0.4 0.4 0.4 S V

0.2 0.2 0.2

0.0 0.0 0.0 Posttreatment Left Right Left Right Pretreatment

Pretreatment Posttreatment

Figure 2. Step length, stride length, and velocity of the patient in the present case—a 65-year-old man with compensated Trendelen - burg gait—as revealed by the GaitMat II (EQ Inc, Chalfont, Pennsylvania) gait analysis system. After osteopathic manipulative treatment, analyses found significant increases in the left and right step lengths (PϽ.001 for both) (A) and left and right stride lengths (PϽ.001 for both) (B). An increase of 193% was observed in the patient’s velocity (C) after osteopathic manipulative treatment (PϽ.01). The bars indicate the mean for each parameter, and the error bars denote the standard error of the mean, calculated from the mean for the two trials.

Figure 3. The step length and stride length of the patient in the present case—a 65-year-old man with com - pensated Trendelenburg gait—as revealed by the GaitMat II (EQ Inc, Chalfont, Pennsylvania) gait analysis system. Consistent with a compensated Trendelenburg gait, a statistically significant difference was observed between the mean right and mean left step lengths before osteopathic manipulative treatment, with the right step length 41% shorter than the left step length ( PϽ.05). The pretreatment right stride length was slightly longer than the pretreatment left stride length. The difference was not statistically significant posttreatment.

2. Pease W, Bowyer B, Kadyan V. Human walking. In: DeLisa JA, Gans BM, 3rd ed. Philadelphia, PA: Butterworth-Heinemann; 2002:42-86. Walsh NE, Bockenek WL, Frontera WR, eds. Physical Medicine and Rehabili - tation: Principles and Practice . 4th ed. Philadelphia, PA: Lippincott Williams & 4. Saunders JB, Inman VT, Eberhart HD. The major determinants in normal and Wilkins; 2005:156-167. pathological gait. J Bone Joint Surg Am . 1953;35(3):543-558. 3. Whittle M. Normal gait. In: Whittle MW. Gait Analysis: An Introduction . 5. Heinking K, Kappler R. Pelvis and sacrum. In: Ward RC, ed. Foundations for

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Osteopathic Medicine . 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 14. Rosano C, Aizenstein H, Brach J, Longenberger A, Studenski S, Newman 2003:762-783. AB. Special article: gait measures indicate underlying focal gray matter in the brain of older adults. J Gerontol A Biol Sci Med Sci . 6. Mitchell FL. Structural pelvic function. In: Barnes M, ed. 1965 Year Book of 2008;63(12):1380-1388. http://biomed.gerontologyjournals.org/cgi/con - Selected Osteopathic Papers . Vol 2. Carmel, CA: Academy of Applied tent/full/63/12/1380. Accessed December 10, 2009. Osteopathy; 1965:178-199. 15. Rosano C, Brach J, Longstreth Jr WT, Newman AB. Quantitative mea - 7. Schiowitz S, DiGiovanna EL, DiGiovanna JA. Gait and postural considerations. sures of gait characteristics indicate prevalence of underlying subclinical struc - In: DiGiovanna EL, Schiowitz S, Dowling DJ, eds. An Osteopathic Approach to tural brain abnormalities in high-functioning older adults [published online Diagnosis and Treatment . Philadelphia, PA: Lippincott Williams & Wilkins; ahead of print October 25, 2005]. Neuroepidemiology . 2006;26:52-60. 2004:293-303. 16. Craik RL, Dutterer L. Spatial and temporal characteristics of foot fall pat - 8. Kissling RO, Jacob HA. The mobility of sacroiliac joint in healthy subjects. terns. In: Craik RL, Oatis CA, eds. Gait Analysis: Theory and Application . 1st ed. Bull Hosp Jt Dis . 1996;54(3):158-164. St Louis, MO: Mosby; 1995:143-158. 9. Jacob HA, Kissling RO. The mobility of the sacroiliac joints in healthy vol - 17. Apley G. Apley’s System of Orthopaedics and Fractures . 6th ed. unteers between 20 and 50 years of age. Clin Biomech (Bristol, Avon) . London, England: ELBS; 1986:243. 1995;10(7):352-361. 18. Dowling DJ. Muscle energy of the lower extremity. In: DiGiovanna EL, 10. Yogev-Seligmann G, Hausdorff JM, Giladi N. The role of executive func - Schiowitz S, Dowling DJ, eds. An Osteopathic Approach to Diagnosis and tion and attention in gait [review]. Mov Disord . 2008;23(3):329-342. Treatment . Philadelphia, PA: Lippincott Williams & Wilkins; 2004:506-513. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2535903/?tool=pubmed. Accessed December 10, 2009. 11. Boonstra TA, van der Kooij H, Munneke M, Bloem BR. Gait disorders and disturbances in Parkinson’s : clinical update and pathophysi - ology. Curr Opin Neurol . 2008;21(4):461-471. Editor’s Note: Video clips of the patient described in the present case walking before and after osteopathic manipulative treat - 12. Scherder E, Eggermont L, Swaab D, van Heuvelen M, Kamsma Y, de Greef M, et al. Gait in ageing and associated dementias; its relationship with cog - ment have been posted online to the JAOA ‘s Web site at nition [published online ahead of print February 15, 2007]. Neurosci Biobehav http://www.jaoa.org/cgi/content/full/110/2/81. Rev . 2007;31(4):485-497. 13. Barker S, Craik R, Freedman W, Herrmann N, Hillstrom H. Accuracy, reli - ability, and validity of a spatiotemporal gait analysis system [published online ahead of print August 24, 2005]. Med Eng Phys . 2006;28(5):460-467.

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86 • JAOA • Vol 110 • No 2 • February 2010 Gilliss et al • Case Report