Primary, Secondary and Compensatory Deviations in CP

Disclosure Information AACPDM 71st Annual Meeting | September 13-16, 2017

Speaker Names: Sylvia Ounpuu, MSc and Kristan Pierz, MD

Differentiating Between Primary, Secondary Disclosure of Relevant Financial Relationships: and Compensatory Mechanisms in Gait in We have no financial relationships to disclose. Persons with Disclosure of Off-Label and/or investigative uses: We will not discuss off label use and/or investigational use in our presentation. Sylvia Õunpuu, MSc and Kristan Pierz, MD Center for Motion Analysis Division of Orthopaedics Connecticut Children’s Medical Center Farmington, Connecticut

Purpose Pathological Gait

To describe gait in CP in terms of primary, secondary and compensatory deviations. video

Compensation Objectives: Secondary Deviation • Define primary and secondary deviations and Primary compensations seen in gait Deviation Primary • Differentiate between primary deviations that Deviation need to be treated and other that Primary Deviation will resolve if the primary problem is addressed Primary Secondary • Understand common multi-level gait patterns in Deviation Deviation CP • Describe how motion analysis can help us Compensation understand primary vs. secondary gait deviations

Primary Deviation

AACPDM 2017 - IC #3 1 Primary, Secondary and Compensatory Gait Deviations in CP

Outline Angle definition

• Review of fundamentals for joint kinematics • The specific body including angle definitions and plotting segments that conventions. make up the angle • Review of typical joint kinematic patterns. • With consideration • Define, primary, secondary and compensatory for the orientation gait deviations. of the “viewer” • Case Examples when looking at the angle

Joint Angle Definitions What is this angle definition ? Which one?

105 deg 60 degrees 20 deg

210 120 degrees degrees

Joint Angle Definitions Trunk Motion

• Kinematics for the trunk, , , and / progression • Coronal, sagittal, transverse planes • Stance and swing phases of gait

AACPDM 2017 - IC #3 2 Primary, Secondary and Compensatory Gait Deviations in CP

Trunk Coronal Plane Trunk Sagittal Plane

• Angle Definition • Angle Definition – the lateral (side to side) – the forward inclination of the long inclination of the axis of the long axis of the torso relative to the lab relative to the lab coordinate system coordinate system – as viewed from the front and perpendicular – as viewed by an to the plane formed by observer looking the long axis of the along a line torso and the bi- connecting the clavicular line clavicles

Trunk Transverse Plane Trunk

• Angle Definition Direction of Progression – the motion of the bi- clavicular line relative to the lab coordinate system Bi-clavicular line – as seen by an observer looking down the long Coronal Sagittal Transverse C7 axis of the torso looking ( (range of motion (range of motion from above 1 degree) 3 degrees) 5 degrees)

Pelvic Motion Pelvis Coronal Plane

• Angle Definition – Angle of inclination of the right and left anterior superior iliac spine (ASIS) in relation to the horizontal – As viewed from the front of and in the pelvic plane

AACPDM 2017 - IC #3 3 Primary, Secondary and Compensatory Gait Deviations in CP

Pelvis Sagittal Plane Pelvis Transverse Plane

• Angle Definition • Angle Definition – inclination (typically – motion of the ASIS to ASIS line relative to the anterior) of the pelvic lab coordinate system plane with respect to (direction of the horizontal progression) – as viewed by an observer – as viewed by an whose site line is observer looking perpendicular to the along a line pelvic plane connecting the ASIS's

Pelvis Hip Motion

Coronal Sagittal Transverse (range of (range of (range of motion 8 motion 4 motion 8 degrees) degrees) degrees)

Hip Coronal Plane Hip Coronal Plane Kinematic

• Angle Definition • Stance – LR = adduction – relative angle – MST/TST/PS = between long axis of abduction the and a • Swing perpendicular to the pelvic plane – ISW = abduction – MSW/TSW = – as viewed from the adduction front of and in the ° pelvic plane • ROM = 13 (Add=adduction, abd=abduction)

AACPDM 2017 - IC #3 4 Primary, Secondary and Compensatory Gait Deviations in CP

Hip Sagittal Plane Hip Sagittal Plane Kinematic

• Angle Definition • Stance – relative angle – LR/MST/TST = between the long axis extension of the thigh and a – PS = flexion perpendicular to the • Swing pelvic plane – ISW/MSW = flexion – as viewed by an – TSW = minimal observer looking extension along a line • ROM = 43° connecting the (Flex = flexion, Ext = extension) ASIS's

Hip Transverse Plane Hip Transverse Plane Kinematic • Stance • Angle Definition – LR = internally rotates – motion of the thigh – MST/TST = internally (as defined by the rotated knee flexion – PS = externally rotates extension axis) • Swing relative to the ASIS - – ISW = internally ASIS line rotates – as viewed by an – MSW/TSW = observer in the pelvic externally rotates (Int = internal, Ext = External) plane • ROM = 8°

Knee Motion Knee Coronal Plane

• Angle Definition – relative angle between long axis of the shank and the long axis of the thigh – as viewed from the front of in the thigh plane

AACPDM 2017 - IC #3 5 Primary, Secondary and Compensatory Gait Deviations in CP

Knee Coronal Plane Kinematic Knee Sagittal Plane

• Angle Definition • Motion – relative angle – negligible between the long axis • Position of the thigh and – neutral shank segments – as viewed by an observer looking along the knee flexion/extension (var=varus=adduction, axis val=valgus=abduction)

Knee Sagittal Plane Kinematic Knee Transverse Plane

• Stance • Angle Definition – LR = flexion – motion of the shank (as – MST/TST = extension defined by the ankle dorsi/plantar flexion – PS = flexion axis) relative to the knee • Swing flexion extension axis – ISW = flexion line – as viewed by an observer – MSW = extension above the thigh plane – TSW = extension • ROM = 60° (Flex = flexion, Ext = extension)

Knee Transverse Plane Kinematic Ankle Motion/Foot Progression

• Stance – LR/MST/TST = progressive internal rotation • Swing – ISW/MSW/TSW = progressive external rotation • ROM = 11(5)°

AACPDM 2017 - IC #3 6 Primary, Secondary and Compensatory Gait Deviations in CP

Ankle Sagittal Plane Ankle Sagittal Plane Kinematic • Stance • Angle Definition – LR = plantar flexion – the relative angle – MST/TST = dorsiflexion between a perpendicular to the – PS = plantar flexion long axis of the shank • Swing and the plantar aspect – ISW = continued plantar of the foot flexion then dorsiflexion – as viewed by looking – MSW = dorsiflexion to along an axis neutral (Dors = dorsiflexion, perpendicular to the Plnt = plantar flexion) shank-foot plane – TSW = minimal plantar flexion • ROM = 30°

Foot Progression Foot Progression Kinematics • Stance • Angle Definition – LR/MST/TST = – angle between the long progressive external axis of the foot (ankle rotation center along to space – PS = internally rotates between 2nd and 3rd metatarsals) and the • Swing direction of progression – ISW/MSW = externally rotates – TSW = internally rotates (Int = internal, Ext = External) Foot progression angle • ROM = 6°

Pathological Gait • Trunk, pelvis, hip, knee and ankle/foot progression Can be very complicated! • Coronal, sagittal, transverse planes

CORONAL SAGITTAL TRANSVERSE

AACPDM 2017 - IC #3 7 Primary, Secondary and Compensatory Gait Deviations in CP

Compensation Definitions Secondary Deviation • Primary Deviation – kinematic abnormality Primary related to the impairment at the joint Deviation Primary • Secondary Deviation – kinematic Deviation Primary abnormality at another joint that is a direct Deviation result of a primary deviation Primary Secondary Deviation Deviation • Compensation – kinematic abnormality that is voluntary that helps reduce impact Compensation of primary deviation

Primary Deviation

Primary Deviation Secondary Deviation

• Kinematic abnormality related to the • Kinematic abnormality related to the impairment at the joint impairment at the joint • For example: • For example: – Impairment: Internal femoral torsion/femoral – Impairment: Internal femoral torsion/femoral anteversion (65 internal) anteversion (65 internal) – Associated kinematic abnormality – Primary – Associated kinematic abnormality – Primary Deviation: excessive internal hip rotation Deviation: excessive internal hip rotation – Secondary Deviation: excessive internal foot progression

Voluntary Compensation Case Examples

• Kinematic abnormality that is voluntary that helps reduce impact of primary deviation • For example: – Vault – early plantar flexion in mid stance to aid in clearance of the contralateral (swing) – Circumduction – hip abduction in swing to aid in clearance of the ipsilateral limb – Increased pelvic transverse plane range of motion over the full gait cycle to increase step length – Increased hip flexion in swing to aid in clearance of the ipsilateral limb

AACPDM 2017 - IC #3 8 Primary, Secondary and Compensatory Gait Deviations in CP

Pre-requisites of Typical Gait Primary Deviation - Increased Equinus in Swing Which are compromised? • Stance phase stability • Swing phase clearance • Appropriate pre positioning of the foot at initial contact • Adequate step length video • Energy conservation

(Perry, : Normal and Pathological Function, 1992)

Sagittal Plane Ankle Kinematic Impairment

• Ankle dorsiflexor weakness • Primary – Weakness of the ankle dorsiflexors during isolated deviation: voluntary dorsiflexion increased – No flexor synergy (negative confusion test) possible equinus in swing – More common in hemiplegia than diplegia

(gray band = reference data)

Primary Deviation – Increased Equinus in Stance & Swing Sagittal Plane Ankle Kinematic

• Primary deviations: increased video equinus in stance and swing

D87396 (gray band = reference data)

AACPDM 2017 - IC #3 9 Primary, Secondary and Compensatory Gait Deviations in CP

Primary Deviation – Impairment Increased Equinus and Knee Hyperextension in Stance

• Ankle plantar flexor contracture – Limited passive ankle dorsiflexion range of motion on clinical assessment – Example: video • -10 degrees with knee flexed • -20 degrees with knee extended equinus in weight – Typical value = 20 degrees bearing (Hoppenfeld, 1976)

E73834

Knee & Ankle Sagittal Plane Kinematics Impairment

• “Dynamic” ankle plantar flexor “contracture” – Typical passive ankle dorsiflexion range of motion on clinical assessment • Primary deviations: – Example: 20 degrees with knee flexed and increased equinus in extended stance & swing, – Increased spasticity of the ankle plantar flexors knee hyperextension – Sustained clonus (increased plantar – Positive confusion response (flexor synergy) flexion knee extension couple)

Primary Deviation: Increased Plantar Sagittal Plane Pelvis, Hip, Flexion-Knee Extension Couple Knee and Ankle

• Primary Deviation: increased equinus and knee extension in mid stance video • Secondary Deviation: increased anterior pelvic tilt

AACPDM 2017 - IC #3 10 Primary, Secondary and Compensatory Gait Deviations in CP

Primary Deviation: Increased Plantar Impairment Flexion/Knee Extension Couple • Increased ankle plantar flexor spasticity and tightness

video

Sagittal Pelvis, Hip, Knee and Ankle Impairment

• Primary Deviation: increased • Increased ankle plantar flexor tightness and equinus and knee hyper spasticity extension in stance (solid) • Secondary Deviations: ipsilateral increased anterior pelvic tilt in stance (solid), video increased contralateral pelvic anterior tilt and increased contralateral hip flexion in

A21910 swing (dashed)

Primary Deviation: Increased Plantar Sagittal and Transverse Kinematics Flexion-Knee Extension Couple

• Video 387121 – asked Jess • Primary Deviation: increased plantar flexion knee extension couple • Secondary Deviation: external pelvic rotation (retraction) in stance

(3 gait cycles left side)

AACPDM 2017 - IC #3 11 Primary, Secondary and Compensatory Gait Deviations in CP

Primary Deviation - Increased Knee Impairment Flexion/Ankle Dorsiflexion Stance • Increased plantar flexion knee extension couple – ankle plantar flexor tightness/spasticity video

Sagittal Plane Hip, Knee & Ankle Impairments

• Primary Deviation: • Impairment – issues related to crouch gait Increased ankle – tight/spastic hamstrings dorsiflexion and knee – knee flexion contracture flexion – ankle plantar flexor weakness • Secondary Deviation: Increased hip flexion

Right side – multiple gait cycles

Primary Deviation: Sagittal Knee and Ankle Increased Peak Dorsiflexion Stance • Primary deviation: increased ankle dorsiflexion in stance • Secondary deviation: video increased knee flexion in stance

AACPDM 2017 - IC #3 12 Primary, Secondary and Compensatory Gait Deviations in CP

Primary Deviation – Reduced Hip Impairments Range of Motion • Impairment – – Increased ankle passive dorsiflexion ROM: 20 degrees – Ankle plantar flexor weakness: 1/5 – No knee flexion contractures video – Popliteal angles: right -30 deg, left -40 deg

Sagittal Plane Pelvis and Hip Impairment • Primary Deviation: decreased hip sagittal • Reduced dissociation between pelvis and plane ROM (solid) • Secondary Deviations: increased ipsilateral anterior pelvic tilt and overall pelvic range of motion (solid) and increased contralateral hip range of motion (dashed)

Primary Deviation: Transverse Plane Pelvis, Internal Right Hip Rotation Hip, Knee and Ankle

• Primary Deviation: increased internal hip rotation • Secondary Deviation: video internal foot progression

(3 gait cycles right side)

AACPDM 2017 - IC #3 13 Primary, Secondary and Compensatory Gait Deviations in CP

Primary Deviation: Impairment Internal Right Hip Rotation • Internal femoral torsion

video

Transverse Plane Pelvis & Hip Impairment

• Primary Deviation: • Increased femoral anteversion in hemiplegia increased internal hip rotation (solid - right) • Example: 55 degrees of femoral anteversion on • Compensation: increased right side ipsilateral external pelvis rotation (solid) and increased contralateral internal pelvic rotation (dashed)

(right solid/left dashed)

Primary Deviation: Transverse Plane Pelvis, Transverse Plane Multiple Level Deformity Hip, Knee and Ankle

• Primary Deviation: internal hip rotation • Combination of internal Left femoral torsion and Side external tibial torsion mask multilevel rotational deformity

(3 gait cycles left side)

AACPDM 2017 - IC #3 14 Primary, Secondary and Compensatory Gait Deviations in CP

Primary Deviation: Impairment Internal Hip Rotation/Crouch • Increased femoral anteversion and increased external tibial torsion/forefoot abduction • Example: 55 degrees of femoral anteversion and 30 degrees of external tibial torsion on left side video

Coronal/Sagittal/Transverse Impairment Plane Kinematics • Increased femoral anteversion • Primary deviations: internal hip rotation • Increased hamstring tightness/spasticity and increased knee • Hip extensor/plantar flexor weakness flexion 100% gait • Example: 55 degrees of femoral anteversion, cycle knee flexion contracture 15 degrees • Secondary deviations: increased hip adduction 100% gait cycle

(3 gait cycles left side)

Primary Deviation - Increased Coronal Plane Pelvis and Hip Coronal Pelvic ROM • Primary Deviation: Increased hip adduction in loading response, bilaterally and increased pelvic range of motion video • Secondary deviation: increased hip abduction in swing

Right (solid) vs. Left (dashed)

AACPDM 2017 - IC #3 15 Primary, Secondary and Compensatory Gait Deviations in CP

Impairment Compensations

• Hip abductor weakness • Example: 3/5 on MMT

Compensation: Sagittal Pelvis, Hip, Increased Hip Flexion in Swing Knee and Ankle • Primary Deviation: increased equinus in swing (solid) • Compensation: video increased hip flexion in swing (solid)

A21910

Compensation: Impairment Typically Developing Side • Anterior tibialis weakness and plantar flexor tightness

video

AACPDM 2017 - IC #3 16 Primary, Secondary and Compensatory Gait Deviations in CP

Sagittal Plane Impairment

• Compensation: voluntary • Plantar flexor contracture on the involved (left) equinus through out stance side on the non-involved right • Confirmation of compensation: side (solid line) – Normal isolated voluntary control • Goal: provide in – Normal strength gait and reduced vertical – Ability to dorsiflex the ankle in swing displacement of the COM – Can “Dr. Walk” – contact gait possible from one gait cycle to the next

Compensation: Sagittal Plane Vault Typically Developing Side • Compensation: vault - voluntary equinus in stance on the non-involved right side (solid line) video • Goal: to allow clearance of the contralateral swing limb which has a) reduced/delayed peak knee flexion and b) increased equinus in swing

Sagittal Plane Impairments

• Gait issues on the • Plantar flexor contracture on the involved (left) side involved (hemi side) • Reduced peak knee flexion in swing on the involved that benefit from a vault (left) side on the typically • Confirmation of compensation: (on typically developing side developing side) – Normal isolated voluntary control at ankle – Normal strength at ankle – Ability to easily heel rise in single limb standing – Normal ankle dorsiflexion at initial contact and ability to dorsiflex in swing

AACPDM 2017 - IC #3 17 Primary, Secondary and Compensatory Gait Deviations in CP

Compensation: Coronal and Sagittal Increased Hip Abduction Swing Kinematics • Compensation: increased hip abduction in swing (circumduction) • Goal: to aid in clearance of video the ipsilateral limb during swing phase which shows limited and delayed peak knee flexion

(3 gait cycles left side)

Compensation: Impairment Increased Transverse Pelvic ROM • Delayed and reduced peak knee flexion in swing on the ipsilateral side due to rectus femoris activity in mid-swing video

Sagittal & Transverse Impairment Kinematics • Compensation: increased • Reduced knee extension at initial contact bilaterally transverse plane pelvic due to spasticity of the hamstrings and reduced range of motion passive range of knee extension • Goal: to increase step length and associated walking velocity that is limited due to decreased knee extension at initial contact

(right solid, left dashed)

AACPDM 2017 - IC #3 18 Primary, Secondary and Compensatory Gait Deviations in CP

How does one “differentiate” between Con’t primary and secondary deviations and compensations? • Development of a systematic approach to understanding this information • Knowledge of typically developing function and gait • Also include – Clinical exam (strength, ROM, etc.) – Pre versus post surgical data comparisons – Gait function (kinematics, kinetics, EMG, etc.) – Barefoot versus orthosis data comparisons – In the context of the phases of the gait cycle – Lift versus no lift data comparisons • Detailed understanding of he patient’s – Etc… impairments and gait – Using measures as above

Compensation Pathological Gait Secondary Deviation

Primary Deviation Primary Deviation Primary video Deviation Primary Secondary Deviation Deviation

Compensation

Primary Deviation

Thank You

AACPDM 2017 - IC #3 19