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