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Scoliosis: Lower Limb Asymmetries During the Gait Cycle Cassandra Kay Haber1* and Mark Sacco2

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Scoliosis: Lower Limb Asymmetries During the Gait Cycle Cassandra Kay Haber1* and Mark Sacco2 Haber and Sacco Archives of Physiotherapy (2015) 5:4 DOI 10.1186/s40945-015-0001-1 RESEARCH ARTICLE Open Access Scoliosis: lower limb asymmetries during the gait cycle Cassandra Kay Haber1* and Mark Sacco2 Abstract Background: Several studies indicate that the gait pattern of subjects suffering from scoliosis differs from the norm. However, there is conflicting evidence regarding the source of this discrepancy. Objective: To evaluate lower limb asymmetries in selected gait variables. Study design: A case–control study on lower limb asymmetries during gait which can be related to scoliosis. Methods: 31 subjects with scoliosis (Study Group - SG) and an equal comparative control sample (Control Group – CG) of subjects underwent objective gait analysis with the Vicon® motion caption system whilst walking at a comfortable speed along the gait laboratory walkway. Analysis was performed at three levels: (1) Asymmetry in the SG against asymmetry in the CG, (2) Difference in magnitude of asymmetry between the SG and CG, and (3) Global mean values in the SG vs. CG. The Paired Student T-Test was used for intra-group analysis whilst the Independent Student T-Test was used for inter-group analysis of the selected parameters, which include temporal parameters (stride length, stride time, step length, individual step speed, speed of gait, cadence, swing-to-stance ratio), ground reaction force (peak GRF values during Loading and Propulsion phases, vertical component only) and electromyography (peak EMG values and their time of onset, as a percentage of the gait cycle) of two lower limb muscles (Gastronemius and Vastus Medialis). Results: No intra-group variation was found to be significant. However, the speed of gait was found to be significantly slower (p = 0.03) in scoliotic subjects when compared to the norm, as a result of the shorter stride length (p = 0.002 and longer stride time (p = 0.001) in the SG. Furthermore, there was statistical significance in the time of onset of EMG peaks for the Lateral Gastrocnemius (p = 0.02) with regards to inter-group difference in magnitude of lower limb asymmetry and global mean values. Conclusions: Scoliosis is a tri-planar deformity which has some impact on the gait pattern. This research study concludes that scoliotic subjects have a slower speed of gait due to a shorter stride length and a longer stride time, together with variations in the timing of muscle activation. Keywords: Scoliosis, Gait analysis, Speed of gait, Ground reaction force, Electromyography Background is located in the spine, present literature suggests that the Scoliosis is a spinal deformity occurring in the frontal, sagit- step length [6–9], cadence [10] and velocity [11], hip, knee tal and transverse planes with multiple variations in presen- and ankle range of motion [7–9,12–14], loading and unload- tation. This deformity generates postural changes [1], ing [15], duration of trunk and gluteal muscle activation [6, sensory disturbance [1, 2], standing instability [1, 3, 4] as 7], magnitude of muscle force [15,16], energy cost and well as gait pattern modifications. Gait is the most common muscle efficiency [7–9, 11] are affected. However, there is of all human movements and it can be defined as a harmo- conflicting evidence regarding the effect of the condition on nious, energetically efficient activity resulting from a se- left and right lower limb asymmetries [3, 7, 15–17]. quence of alternate lower limb steps [5]. Although scoliosis There are several studies which analyse the asymmet- ries in muscles of the back [18, 19]. However, few studies have focussed on lower limb asymmetries and the need * Correspondence: [email protected] 1Department of Physiotherapy, Mater Dei Hospital, Msida, Malta for further research has been voiced by several authors Full list of author information is available at the end of the article © 2015 Haber and Sacco. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http:// creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Haber and Sacco Archives of Physiotherapy (2015) 5:4 Page 2 of 8 [4, 7, 8, 15]. A comprehensive evaluation of lower limb Thus, the size of the study group was determined by vol- asymmetries during the gait of individuals suffering from untary participation of the scoliotic individuals, consent scoliosis may help one appreciate the physical implica- of the legal guardians in the case of children, and the tions of this condition. Therefore, the aim of this re- availability of the gait laboratory. An appropriate CG of search is to analyse the effect of Idiopathic Scoliosis on subjects with no spinal deformity, matched by age and gait, through kinematic, kinetic and electromyographic gender to the study subjects, was acquired through ran- (EMG) analysis. Left and right lower limb asymmetries dom sampling from a school. The study was approved in EMG values, vertical ground reaction force (GRF) and by the University Research Ethics Committee and the temporal parameters will be evaluated in relation to the Data Protection Officer prior to commencement, and all side of spinal curvature occurring in scoliosis, taking ethical rules of conduct (including informed consent into consideration the concavity versus the convexity as- from all participants) were abided by throughout the pect relative to the erect vertical spine. The purpose of whole research process. unifying these variables is to obtain a generalised under- standing of gait with special emphasis on lower limb asym- Procedure metries, which may not be evident unless sophisticated gait Prior to gait analysis, the severity of the scoliosis was de- analysis technology is utilised [7, 15]. Differences and corre- termined via Scoliometer® measurements taken with the lations will be estimated between the variables of the Study subject in the Forward Bend Test position in standing. Group (SG) and the norm via a comparison Control Group Scoliometric readings were taken three times and the (CG) of non-scoliosis individuals. best readings were recorded. Subjects were only admit- In summary, it is hypothesised that (1) the direction of ted in the SG if they presented with Scoliometric reading the scoliotic curve will result in an asymmetrical gait of at least 5°, since lower curvatures are associated with pattern, (2) the extent of the asymmetry will be different non-scoliotic spines [20,21]. The objective gait analysis for the SG and the CG, and (3) there will be a difference was performed using the Vicon® motion capture system between the gait pattern of the SG and the CG. at a gait laboratory, which consists of: a 10 m walkway, six video cameras with infrared circular strobes, EMGs, Materials and methods and a force plate (AMTI) controlled by the Vicon Nex- Participants usTM Software. The Lower Body Plug-in Gait marker set, This case–control study follows a quantitative compara- which describes the lower half of the biomechanical tive research design, consisting of a total of 62 subjects: model and requires a total of sixteen markers (four on 31 scoliotic subjects in the SG and 31 non-scoliotic sub- the pelvis and six on each lower limb), was adopted for jects in the CG. Data collection took place at the Bio- this study. Marker data was collected at 100Hz, whilst medical Engineering Laboratory at the University of force plate and EMG data was collected at 1000Hz sim- Malta in the beginning of the year 2013. The subjects ultaneously. EMG data was rectified and smoothened, for the SG were selected from individuals with a re- but not normalised to MVC since peak values were one corded medical diagnosis of idiopathic scoliosis regis- of the analysed variables. ‘Surface Electromyography for tered in the database of a Maltese public hospital and the Non-Invasive Assessment of Muscles’ (SENIAM) referred to the Physiotherapy Department during the recommendations for the electrode size, electrode ma- year 2012. All individuals who met the inclusion criteria terial, sensor construction and electrode placement were set for the study (Table 1) were invited to participate. applied. The surface electrode location relative to the Table 1 The inclusion criteria of the research population Study group Control group Diagnosis of Idiopathic Scoliosis No diagnosis of scoliosis No surgical correction of the spinal deformity Male or female Age: 10–30 years Male or female Scoliometric reading of less than 2 Age: 10–30 years Scoliometric reading of at least 5° Symmetrical leg length Leg length discrepancy (LLD) less than 2 cm No relevant orthopaedic condition No relevant orthopaedic condition No concomitant diseases present which could influence the gait pattern No concomitant diseases present which could influence the gait pattern Voluntary participation Voluntary participation Haber and Sacco Archives of Physiotherapy (2015) 5:4 Page 3 of 8 target muscle was accurately determined by a palpable between the SG and CG, and (3) Global mean values in contraction during a low effort muscle test. In this study, the SG vs. CG. Table 2 and Table 3 present the results of the muscles chosen for investigation by the researcher this study. were Vastus Medialis (VM) and both lateral (GL) and The adopted speed of gait was found to be signifi- medial (GM) heads of Gastrocnemius. cantly slower in the SG compared to the CG. This is Once all preparations were complete, the subject was emphasised by the significantly shorter stride length and asked to walk a number of times along the walkway at a longer stride time of the SG. Furthermore, lower limb comfortable speed. Ten trials were collected with the asymmetry with regards to the individual step speed in right foot landing on a concealed force plate, and an- the SG tended towards being significantly different (p = other ten trials with the left foot landing on the force 0.07): the mean speed of stepping with the lower limb plate.
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