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Purpose Pathological Gait Objectives Primary, Secondary and Compensatory Gait 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 Cerebral Palsy 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 pathology 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 gait deviations 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, pelvis, hip, knee and ankle/foot 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 torso 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 (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 thigh 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) limb – 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, Gait Analysis: Normal and Pathological Function, 1992) Sagittal Plane Ankle Kinematic Impairment • Ankle dorsiflexor weakness • Primary – Weakness of the ankle dorsiflexors during isolated deviation:
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