Sally Mallory, PT, ATP, CPST 214-763-9173 [email protected]
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2020-04-27 Gait Analysis and Equipment Selection 1 Sally Mallory, PT, ATP, CPST 214-763-9173 [email protected] 2 1 2 2020-04-27 Thank you to our contributors • All of the children and their families, caregivers and therapists • Missy Ball, PT • Sally Mallory, PT, ATP, CPST • Jo McConnell, PT • Bente Storm, PT • Helle Rasmussen, PhD, PT • Lynda Reagan, PT • Megan Salley, MOTR/L • Elaine Westlake, PT, DPT, MA • Julie Kobak, MA, CCC-SLP This webinar is being recorded 3 4 2 4 2020-04-27 5 5 Our family of products 3 6 2020-04-27 Course Outline Importance of independent mobility Gait analysis with instrumentation & case study Factors impacting functional mobility Analysis of gait cycle Phases of gait Shank & thigh kinematics Ambulation equipment types Considerations for equipment selection BWSTT treadmill training vs ground training 7 7 During Ambulation • The whole body is active • Bones, joints and muscles, nerves, senses, heart and lungs work together and movements are coordinated. • To be able to walk, head and trunk control together with balance and active use of arms and legs are needed. 8 4 8 2020-04-27 Importance of Independent Mobility Increases level of engagement in educational and recreational activities Promotes problem solving skills Enhances quality of interactive behavior with other children, adults Increases exploration of environment Promotes cognitive, perceptual and visual spatial skills by learning to navigate around obstacles, avoid stairs or other drop offs Promotes healthy functioning of physiological systems (heart, lungs, GI, bladder, bones) Increases self confidence Reduces learned helplessness 9 9 Importance of Early Mobility Immobility associated with “Learned Helplessness” Established by 4 years of age in children without functional mobility (Butler, 1991; Safford & Arbitman, 1975, Lewis & Goldberg ,1969) 10 5 10 2020-04-27 Research Real-World Performance: Physical Activity, Play, and Object-Related Behaviors of Toddlers With and Without Disabilities (Logan, et al, 2015) Less time in play Less engagement with peers Less interaction with environment Less variability of movement 11 11 Normal Motor Development 10 months Pulls up to stand Stands with support Cruises Stands unsupported Takes few steps 12 6 12 2020-04-27 Diagnoses Down Syndrome Developmental Delay Cerebral Palsy Spina Bifida Arthrogryposis Muscular Dystrophy (certain types) Mitochondrial Defects Metabolic Disorders impacting movement Genetic Disorders Head Trauma 13 13 Factors Impacting Functional Walking LIMITATIONS IN FORCE POOR ENDURANCE ABNORMAL MUSCLE TONE ABNORMAL SENSORY GENERATION & GRADING MOTOR SYNERGIES FOR OF MUSCLE STRENGTH MOVEMENT RANGE OF MOTION ISSUES SKELETAL DEFORMITY CARDIOPULMONARY BALANCE/COORDINATION ISSUES ISSUES 14 7 14 2020-04-27 Goals: Functional Mobility PROMOTE INDEPENDENT MOBILITY USE OF APPROPRIATE ASSISTIVE FOR ACTIVE CONTROL OVER ONE’S TECHNOLOGY TO IMPROVE EXPLORATION OF THE WORLD FUNCTIONAL MOBILITY AS NEEDED 15 15 Therapist’s Role in Functional Mobility Functional performance Therapy interventions assessment Gait analysis to Ambulatory equipment determine gait pattern selection if needed issues Body Weight Supported Orthotic Selection if Treadmill Training vs needed BWS Overground Training 16 8 16 2020-04-27 Assessment of Function and Mobility PEDI Pediatric Evaluation of Disability Inventory GMFM Gross Motor Functional Measure WeeFIM Functional Independence Measure PAMS Physical Abilities & Mobility Scale PMS Physical Mobility Scale CB&M Community Balance & Mobility Scale 17 17 Gait Analysis The systematic study of human motion, using the eye and the brain of observers, augmented by instrumentation for measuring body movements, body mechanics, and the activity of the muscle WITH THROUGH INSTRUMENTATION OBSERVATION 18 9 18 2020-04-27 Phases of Gait 19 19 Phases of Gait Creative Commons CC BY-NC-ND 3.0 20 10 20 2020-04-27 Gait Requirements To walk 3 tasks must be accomplished Weight acceptance by a limb Single limb support of body weight Swing limb advancement 21 21 Gate Cycle Summary Task: Weight Acceptance Phases of Gait: Initial Contact • Weight accepted while maintaining limb stability & forward momentum • Hip Flexion 30, Knee Ext 0, Ankle 0 (heel strike) Loading Response • Shock absorption & momentum preserved • Slight knee flexion at loading due to deceleration by Ankle DF to lower foot to floor; Hip ABD/Extensors Active 22 11 22 2020-04-27 Gate Cycle Summary Task: Single Limb Support Phases of Gait Mid Stance • Body advances from behind to ahead of ankle • Hip & knee extension concentrically extend limb then Ankle PF eccentrically control momentum • Ankle PF’s decelerate/counter knee extension & control tibia forward movement Terminal Stance • Extreme progression of body forward past MTP heads • Limb stability with active Hip ABD 23 23 Shank & Thigh Kinematics • Relationship of shank, thigh, pelvis, & trunk to segments in normal gait (Owen, 2010) 24 12 24 2020-04-27 Shank & Thigh Kinematics Relationship of shank, thigh, pelvis & trunk segments in standing Owen,2010 25 25 Shank & Thigh Kinematics During mid stance: Important for stability Owen,2010 Shank 10-12° inclined during midstance Knee over middle of foot 26 13 26 2020-04-27 Purpose of Orthotics Facilitate hip extension normal, or as close to normal as Replicate possible, shank and thigh kinematics Achieve stability Achieve balance account of the needs of bi-jointed and Take tri-jointed muscles 27 Wingstrand, 2014 27 Gait Cycle Summary Task: Swing Limb Advance Objective: Swing limb advances from behind to forward of body; foot clearance Phases of Gait: • Pre Swing • Foot still on floor, weight shifts to opposite limb • Initial Swing • Foot clearance as leg moves forward • Active Hip Flexors, Knee Flexors (& momentum) increase knee flexion • Active Ankle DF for foot clearance • Mid Swing • Limb continues forward with active Hip Flexors • Knee begins to extend as hamstrings turn off; Ankle DF become active • Terminal Swing • Knee extensors active to fully extend knee for full stride length • Ankle DF active to prepare for heel strike 28 14 28 2020-04-27 Equipment to Assist Ambulation Least to Most Assistance • Single point cane • Quad cane • Loft strand crutches • Posterior walker Independent Walker Gait Trainer Walking • Anterior walker • Posterior or vertical gait trainer • Anterior gait trainer 29 29 Types of Assisted Walking Equipment Walker: provides no unweighting of LE’s • Requires UE’s to push the walker and maintain upright torso with minimal postural supports R82 Crocodile, Mustang (basic) Kaye Posture Walker Rifton (basic) Gait trainer: offers both unweighted support and postural alignment to enable gait practice. • It provides more assistance for balance and weight-bearing, than does a traditional rollator walker, or a walker with platform attachments. Anterior (E8002) - Mustang, Pony, Rifton Vertical (E8001) - Mustang, Crocodile, Kaye with suspension Posterior (E8000) - Mustang, Kidwalk, Rifton, Kaye with suspension 30 15 30 2020-04-27 Considerations for Selection Stage of recovery: acute vs later rehab stage Head control Trunk control: upper or lower thoracic, lumbar spine UE function: active use of hands, limited dexterity or spasticity Ability to weight bear through LE’s (full or partial) LE stance & gait pattern Scissor pattern Endurance, cardiopulmonary status, balance Size of walker or gait trainer base of support Storage: collapsible or not Environment/setting: home, school, work, indoor or outdoor use 31 31 Acute vs Later Stage of Rehabilitation Acute or early stage: BWSTT • Debilitated patient: weakness, balance issues, fatigue, fear of falling • BWSTT (Body Weight Supported Treadmill Training) • Can provide good body alignment, partially unload LE’s, and provide repetitive stepping practice at different intensity for neuroplasticity to occur without fear of falling Later stage rehabilitation: Overground training • Stepping is more self generated, but gait pattern/speed may need work • Increase challenges (obstacles, inclines, different terrain) • Negotiate actual environment, self directed, problem solving 32 16 32 2020-04-27 BWSTT • Treadmill training vs traditional gait training equally effective • Definitely helpful with acute stage or debilitated patient • Eliminates falls • Reduces man power needed • Provides repetitive stepping practice with variations in intensity • Research has shown it can help attain walking, improve gait speed, and endurance for different types/degrees of CP.(Mattern-Baxter, 2009). Lite Gait 33 33 BWS Overground Training • R82 Mustang 34 17 34 2020-04-27 Types of Equipment: Posterior Walker Head Control Patient has head control Patient has upper trunk control Trunk Control Support around pelvis may be needed (back, side support) Patient able to bear weight through legs If good arm strength, some of weight bearing can be Active Weight Bearing through the hands or forearms May need flip down seat for rest or forearm supports Forearm support may be necessary if no active Active use of hands use of hands 35 35 Posterior Walker R82 Crocodile - Size 1 Size 2 Size 3 36 18 36 2020-04-27 R82 Crocodile • Posterior walker- height adjustable • GMFCS II-III • CP Type • Spastic Diplegia, Hemiplegia • Low Tone, Mild Ataxic • Accessories • Sling seat, flip down seat • Back, hip & trunk supports • Forearm support with handgrip 37 37 Gait: Spastic CP • Types: Quadriplegia, Diplegia, Triplegia, Hemiplegia • GMFCS: II-III (Posterior Walker) III-V (Ant./Post. Gait trainer) • Spasticity: varies per type • Hip: