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Analysis and Equipment Selection Sally Mallory, PT, ATP, CPST [email protected] Course Outline

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Analysis and Equipment Selection Sally Mallory, PT, ATP, CPST Sally.Mallory@Yahoo.Com Course Outline Gait Analysis and Equipment Selection Sally Mallory, PT, ATP, CPST [email protected] Course Outline Importance of independent mobility Factors impacting functional mobility Analysis of gait cycle Phases of gait Shank & thigh kinematics Considerations for equipment selection BWSTT treadmill training vs ground training Ambulation equipment types Gait analysis with instrumentation & case study 3 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. 4 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 5 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) • Decreased curiosity & initiative • Poor academic achievement • Poor social interaction skills (Kohn,1 977) • Passive, dependent behavior • Lack object permanence • Dependent on vision to control posture (Bai & Berenthal, 1992) • Poor visual spatial skills and memory (map testing difficult) 6 Research Real-World Performance: Physical Activity, Play, and Object-Related Behaviors of Toddlers With and Without Disabilities • Logan S, Schreiber M, Lobo M, Pritchard B, George L & Galloway J Pediatric Physical Therapy (2015) Volume 27 Issue 4:433–441 ➢Typically developing toddlers spend 1 hour/day in direct play with peers ➢Toddlers with disabilities spend less than 20 minutes & as few as 6 minutes/day in direct play with peers ➢Toddlers with disability: ➢Less engagement with peers ➢Less interaction with environment ➢Less variability of movement 7 Normal Motor Development 10 months Pulls up to stand Stands with support Cruises Stands unsupported Takes few steps 8 Diagnoses • Down Syndrome • Developmental Delay • Cerebral Palsy • Spina Bifida • Arthrogryposis • Muscular Dystrophy (certain types) • Mitochondrial Defects • Metabolic Disorders impacting movement • Genetic Disorders • Head Trauma 9 Factors Impacting Functional Walking • Limitations in force generation & grading of muscle strength in head, torso, and/or extremities • Poor endurance • Abnormal muscle tone • Abnormal sensory motor synergies for movement • Range of motion issues • Skeletal deformity • Cardiopulmonary issues • Balance/coordination issues 10 Goal • Promote independent mobility for active control over one’s exploration of the world • Use of appropriate assistive technology to improve functional mobility as needed 11 Therapist’s Role in Functional Mobility • Functional performance assessment • Therapy interventions • Gait analysis to determine gait pattern issues • Ambulatory equipment selection if needed • Orthotic Selection if needed • Body Weight Supported Treadmill Training vs BWS Overground Training 12 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 • Gait analysis with instrumentation • Observational gait analysis (without instrumentation) 13 Phases of Gait 14 Gait Cycle 15 Gait Requirements To walk 3 tasks must be accomplished: 1. Weight acceptance by a limb 2. Single limb support of body weight 3. Swing limb advancement 16 Gait 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 17 Gait 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 18 Shank & Thigh Kinematics Relationship of shank, thigh, pelvis, & trunk to segments in normal gait Owen, E (2010) The importance of being earnest about shank and thigh kinematics, especially when using ankle-foot orthoses. Prosthetics and Orthotics International 34(3): 254-269. 19 Shank & Thigh Kinematics Relationship of shank, thigh, pelvis & trunk segments in standing Owen,2010 20 Shank & Thigh Kinematics During mid stance: Important for stability Owen,2010 Shank 10-12° inclined during midstance Knee over middle of foot 21 Purpose of Orthotics Static Orthosis 1. Facilitate hip extension 2. Replicate normal, or as close to normal as possible, shank and thigh kinematics 3. Achieve stability 4. Achieve balance 5. Take account of the needs of bi-jointed and tri-jointed muscles 22 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 23 • Ankle DF active to prepare for heel strike Equipment to Assist Ambulation Least to Most Assistance • Single point cane • Quad cane • Loft strand crutches • Posterior walker • Anterior walker • Posterior or vertical gait trainer • Anterior gait trainer IndependentIndependent Gait Trainer Walker Walking Walking 24 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 25 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 26 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 27 BWSTT Lite Gait • 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 K (2009) Effects of Partial Body Weight Supported Treadmill Training on Children with CP. Ped 28 PT Journal 21(1):12-22 BWS Overground Training Mustang 29 Types of Equipment: Posterior Walker Head Control • Patient has head control Trunk Control • Patient has upper trunk control • Support around pelvis may be needed (back, side support) Active Weight Bearing • Patient able to bear weight through legs • If good arm strength, some of weight bearing can be through the hands or forearms • May need flip down seat for rest or forearm supports Active use of hands • Forearm support may be necessary if no active use of hands 30 Posterior Walker Crocodile 31 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 32 Gait: Spastic CP • Types: Quadriplegia, Diplegia, Triplegia, Hemiplegia • GMFCS: II-III (Posterior Walker) • III-V (Ant./Post. Gait trainer) • Spasticity:
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