Disclosure Information AACPDM 69th Annual Meeting | October 21-24, 2015

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

Gait Analysis Data Interpretation: Disclosure of Relevant Financial Relationships:

Understanding Kinematic Relationships Within We have no financial relationships to disclose. and Across Planes of Motion in Persons with Physical Disabilities Disclosure of Off-Label and/or investigative uses:

Sylvia Õunpuu, MSc and Kristan Pierz, MD We will not discuss off label use and/or investigational use in my Center for Motion Analysis presentation Division of Orthopaedics Connecticut Children’s Medical Center Farmington, Connecticut

Purpose Outline

• To demonstrate the role of motion analysis in • Angle and segment definitions gaining an understanding of the relationship of • Definition of within and across plane joint and segment kinematics within and across interactions planes of motion for a variety of gait • Case examples of within and across plane pathologies interactions • Examples are of patients with CP unless otherwise noted

Objectives: Angle definition

• Understand the importance of knowing • The specific body angle definitions segments that • Define joint kinematic interactions within make up the angle and across planes • With consideration • Develop skills to separate primary for the orientation deformities vs. compensations in gait of the “viewer” pathology when looking at the angle

AACPDM 2016 Interactions Within and Across Planes – IC #5 1 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

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

AACPDM 2016 Interactions Within and Across Planes – IC #5 2 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

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

AACPDM 2016 Interactions Within and Across Planes – IC #5 3 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 – between long axis of MST/TST/PS = abduction the thigh and a • perpendicular to the Swing pelvic plane – ISW = abduction – – as viewed from the MSW/TSW = adduction front of and in the ° pelvic plane • ROM = 13 (Add=adduction, abd=abduction)

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

AACPDM 2016 Interactions Within and Across Planes – IC #5 4 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 above the externally rotates (Int = internal, Ext = External) pelvic 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 and in the thigh plane

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)

AACPDM 2016 Interactions Within and Across Planes – IC #5 5 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)°

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°

AACPDM 2016 Interactions Within and Across Planes – IC #5 6 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°

Definition: Coronal Sagittal Transverse Interactions within plane: • Evaluation of the relationships between motion from one joint or segment to another – Differentiate between primary and secondary gait deviations – Determine possible causes of gait abnormalities

Right = solid, Left = dashed

Definition: Coronal Sagittal Transverse Definition: Coronal Sagittal Transverse Interactions across planes: Sequence of data • Evaluation of the interpretation: relationships between 1. Individual joint motion from one plane kinematic – to another primary problem – Differentiate between 2. Joints and primary and segments within a secondary gait deviations single plane of – Determine possible motion that are causes of gait proximal or distal abnormalities

Right = solid, Left = dashed Right = solid, Left = dashed

AACPDM 2016 Interactions Within and Across Planes – IC #5 7 Definition: How does one “discover” interactions within and across planes? Sequence of data interpretation: • Pre versus post surgical data 1. Individual joint comparisons 2. Joints and • Barefoot versus orthosis data segments within a comparisons single plane of • Lift versus no lift data comparisons motion • Etc… 3. Joints and segments across • Any SYSTEMATIC DATA REVIEW of multiple planes of problems and possible causes motion

Case Examples Coronal Plane Terminology

Interactions within planes • Joint and segment angles – Up vs. down – Elevation vs. depression – Abduction vs. adduction – Varus vs. valgus

Pelvic Hiking in Swing Pelvic Drop in Swing

Hip Neutral Hip Abduction

• Visual assessment of hip angle = “typical” • Visual assessment = “circumduction” based on thigh position based on thigh position • Kinematic shows hip = abduction to keep • Kinematic shows hip angle = neutral thigh vertical

AACPDM 2016 Interactions Within and Across Planes – IC #5 8 Myelo - Lateral Trunk Lean DMD – Lateral Trunk Lean

• Primary impairment – • Primary impairment – hip abductor weakness hip abductor weakness • Associated gait issue – • Associated gait issue – increased hip abduction increased hip abduction and pelvic drop in and pelvic drop in stance stance • Mechanism – increased • Mechanism – increased lateral trunk lean in lateral trunk lean in stance stance Right side – Right side – multiple gait multiple gait cycles cycles

Increased Coronal Plane ROM Blount’s - Knee Varus

• Primary impairment – hip abductor weakness • Associated gait issue – increased hip adduction in loading response C89440 • Secondary deviation – increased coronal plane range of motion of the pelvis Right (solid) vs. Left (dashed)

Knee Varus Sagittal Plane Terminology

• Impairment – fixed knee • Joint and segment angles varus deformity – Forward vs. backward • Associated gait issue – – Anterior vs. posterior increased knee varus 389440 – Flexion vs. extension • Secondary deviation – – Dorsiflexion vs. plantar flexion hip abduction

Left side – multiple gait cycles

AACPDM 2016 Interactions Within and Across Planes – IC #5 9 Increased Knee Flexion Increasing Anterior Pelvic Tilt • Impairment – reduced • Impairment – issues dissociation between pelvis related to crouch gait and femur – tight/spastic hamstrings • Associated gait issue – – hip extensor and ankle plantar flexor weakness decreased hip sagittal plane – knee flexion contracture ROM (solid) • Associated gait issue – • Secondary deviations – increased knee flexion & increased ipsilateral anterior ankle dorsiflexion pelvic tilt and overall pelvic range of motion (solid) and • Primary/Secondary Right side – increased contralateral hip deviation-increased hip multiple gait cycles range of motion (dashed) flexion

Plantar Flex/Knee Ext Couple CMT - Equinus in Swing

• Impairment – increased • Impairment – anterior plantar flexion knee tibialis weakness extension couple • Associated gait issue – • Associated gait issue – increased equinus in increased equinus and swing knee extension in mid • Compensation – stance increased hip flexion in • Secondary deviation – swing increased anterior pelvic

tilt Right (solid) vs. Left (dashed)

Equinus in Swing Equinus in Stance • Impairment #2 – plantar flexor • Impairment #1 – anterior tightness tibialis weakness and • Associated gait problem – plantar flexor tightness increased equinus in stance (solid) • Associated gait problem – • Secondary deviations - increased equinus in swing ipsilateral increased anterior (solid) pelvic tilt in stance (solid), • Compensation - increased A21910 increased contralateral pelvic A21910 hip flexion in swing (solid) anterior tilt and increased hip flexion in swing (dashed)

AACPDM 2016 Interactions Within and Across Planes – IC #5 10 DMD –Forward Trunk Lean Transverse Plane Terminology

• Impairment – knee extensor • Rotations weakness – Internal vs. external • Associated gait impairment – – Protraction vs. retraction no knee flexion in loading or – Inversion vs. eversion stance • Compensation – increased forward trunk lean in stance • Knee extensor moment (internal) minimal

Internal Hip Rotation Pelvic Rotation Compensation

• Primary impairment – • Primary impairment – femoral anteversion increased femoral anteversion • Associated gait issue – • Associated gait deviation – increased internal hip increased internal hip rotation rotation (dashed) • Secondary deviation – • Pelvic compensation – internal foot progression increased ipsilateral external pelvis rotation (dashed) • Secondary deviation – Right side – increased contralateral multiple gait internal pelvic rotation cycles (solid)

Multilevel Transverse Plane Within Plane Interactions

• Primary Impairments – • Visual inspection is the first step increased femoral anteversion • Gait analysis allows identification of actual and increased external tibial torsion forefoot abduction joint and segment kinematics • Associated gait deviation – • Integration with clinical impairments allows internal hip rotation identification of primary gait issues and • Foot progression masks tibial secondary compensations torsion and foot problems

Left Side – multiple gait cycles

AACPDM 2016 Interactions Within and Across Planes – IC #5 11 Break Case Examples

Interactions Across Planes

Increased Increased Pelvic Hip Transverse Abduction Plane in Swing Motion  Secondary to • Secondary to Reduced Reduced Sagittal Knee Plane Knee Extension at Flexion in Initial Swing and Contact Equinus in Swing

Increased Increased Hip Coronal Abduction Plane Hip in Swing Abduction Initial • Secondary to Contact Reduced Sagittal • Secondary to Plane Knee increased Flexion in transverse Swing and plane internal Pelvic Drop pelvic rotation in Swing

AACPDM 2016 Interactions Within and Across Planes – IC #5 12 Increased Increased Asymmetric Coronal Plane Coronal Hip Adduction Plane Hip Loading Motion Response

• Secondary to • Secondary to Increased Transverse Transverse Plane Pelvic Plane Pelvic Asymmetry Rotation

Hip coronal plane position? Increased Hip Adduction in Stance

• Secondary to Knee Flexion & Internal Hip Rotation

Increased Pelvic Pelvic External Obliquity Rotation in Stance

• Secondary to  Secondary to a an Excessive Functional Leg Plantar Flexion Knee Length Extension Difference Couple (barefoot)

AACPDM 2016 Interactions Within and Across Planes – IC #5 13 Pelvic HSP – External Increased Rotation Hip in Stance Abduction Swing (reduced)

• Reduced • Increased excessive internal pelvic plantar rotation right flexion knee (solid) extension couple during AFO walk

HSP – Knee Valgus Thrust in Loading? Increased Pelvic Transverse Range

• Reduced knee extension initial contact

Apparent Neutral Knee Knee Valgus Moment Thrust • Secondary to increasing – internal pelvic rotation – internal hip rotation – knee flexion Coronal Plane Knee Moment

AACPDM 2016 Interactions Within and Across Planes – IC #5 14 Knee A closer look… Varus Moment (valgus thrust)

Coronal Plane Knee Moment

Summary: Summary:

Interactions within a plane: Interactions across planes: • Evaluation of the relationships between motion from • Evaluation of the relationships between motion from one joint or segment to another one plane to another – Differentiate between primary deviations and – Differentiate between primary deviations and compensations compensations – Determine possible causes of gait abnormalities – Determine possible causes of gait abnormalities • Sequence of data interpretation: • Sequence of data interpretation: – Individual joint – Individual joint – Joints and segments above or below within a single – Joints and segments within a single plane of motion plane of motion – Joints and segments across multiple planes of motion

AACPDM 2016 Interactions Within and Across Planes – IC #5 15