CLINICAL GAIT ANALYSIS in Leuven
-
a crucial contribution from a multidisciplinary centre
By Kaat Desloovere, Guy Molenaers
and the team of the gait analysis laboratory of the University Hospital
of Leuven Belgium
Objective gait analysis
made (and continues to make) a significant contribution in improving the
outcome of interventions of children with cerebral palsy (CP). The use
of objective gait analysis and the change in surgical approach is a prime
example of how technology and open, inquiring minds came to interact for
the benefit of our patients.
The University Hospital of Leuven (Pellenberg) has seen rapid developments
in the area of clinical gait analysis since 1992, using a multidisciplinary
approach. For the past decade, the gait laboratory has been a centre for
the evaluation of children and adults with gait problems. In today's competitive
health care market, we cannot rely on traditional treatment theories without
rigid research to prove them. Therefore, apart from the individual clinical
gait evaluations, the gait laboratory has always been the heart of numerous
research projects.
The team of the gait analysis laboratory was honoured to receive the invitation
of the ESMAC committee to organize the eleventh annual meeting in Leuven.
We have the privilege of welcoming you to Leuven for the ESMAC gait courses
and conference, for the week beginning September 16.
History
The first steps towards a clinical gait analysis laboratory at the University
Hospital of Leuven were taken in 1992.
At that time, gait evaluations were performed using a set of normal video
cameras and a four camera automatic video system synchronised with a forceplate.
From these first evaluations, the use of objective gait analysis became
more and more obvious and crucial in defining an optimal treatment plan
for children and adults with spasticity.
After a training session with the group under the direction of Prof. Gage
at the Gillette Specialty Child Care Center in Minnesota, U.S.A in 1993,
Dr. Guy Molenaers, Paediatric orthopaedic surgeon of the University Hospital
of Leuven, was convinced of the need for an up-to-date three dimensional
gait lab, integrated within the multidisciplinary framework of the hospital.
However, lack of both budget and space prevented an immediate update of
the available gait lab facilities.
Finally, in July 1996, the gait lab was upgraded with a Vicon 370 system,
founded as a multidisciplinary service. This was the result of a joint
effort of three departments within the University of Leuven: the department
of paediatric orthopaedics under Prof. Fabry, rehabilitation, headed by
Prof. Lysens, and the child neurology department led by Prof. Casaer.
The Vicon 370 system with five cameras was synchronised with two AMTI
forceplates, four normal video-cameras and a 16 channel surface EMG system.
A typical data collection at that time involved kinematic and kinetic
data collection, sagittal, coronal and transverse plane split screen video,
and bilateral surface EMG of the rectus femoris, vastus lateralis, medial
and lateral hamstrings, tibialis anterior, gastrocnemius, soleus, and
for some patients gluteus medius, or other surface muscles of the lower
limb. The Vicon clinical manager was used to process the data.
The current gait
analysis laboratory
Since September 2001, the three-dimensional lab has been advanced further
by means of a Vicon 612 system with eight M-cameras, supported by three
AMTI force plates and a 16 channel surface EMG system (K-Lab). For most
routine gait analyses, the M-cameras are used at 120 Hz. Gait data are
now processed using Polygon, making use of the PluginGait marker set.
Bodybuilder software is available for special model development. Clinical
gait analysis is always combined with a thorough clinical examination,
assessing ROM, spasticity and muscle force and selectivity.
In young children (<4 years) gait analysis is limited to standardized
video recording, because of a lack of sustained concentration. The 2D
video laboratory runs in parallel with the Vicon 3D lab. The 2D laboratory
uses a standardized video protocol in order to characterize motor function,
including walking, in young children and adults that do not meet the inclusion
criteria for a 3D gait assessment. A video recording is taken in different
planes, including a close-up of the foot. Apart from five normal video
cameras, the 2D lab also includes a foot pressure system (RS-scan platform
and in-shoe pressure measurement system) in order to study pressure distribution
in patients with foot deformities. The 2D lab is also used for upper limb
evaluation. A standardized protocol for the evaluation of upper limb function
has recently been developed and is used with an adopted clinical examination.
A special trajectory in the 2D lab is used for energy measurements (Cosmed
b4).
Since the Vicon lab began in 1996, over 2500 full 3D gait assessments
have been performed according to the established protocol. At present
15 full gait evaluations and between eight and ten video analyses are
planned each week.
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Full gait analysis in the 3D gait laboratory. |
Clinical applications
From the start of the activities, the major field of interest was the
evaluation of gait deviation associated with neuromuscular disorders (mainly
children with CP, but also patients with spina bifida, Charcot-Marie Tooth,
arthrogryposis). Other evaluated patient categories are tip-toe walkers,
children with clubfeet and other lower limb deficiencies. Since 2000,
adults are more often evaluated in the gait lab (adults with CP, stroke,
craniocerebral trauma, incomplete paraplegia, post-polio gait difficulties,
foot problems with total gait involvement and other lower limb deficiencies).
The areas of application are continuously extending.
The use of gait analyses in our department serves several purposes:
- First gait evaluation (preferably at a young age)
- Follow-up gait evaluation (frequently throughout growing spurt)
- Evaluation and tuning of ankle foot orthoses
- Evaluation of assistive devices
- Pre-intervention screening (orthopaedic surgery, selective dorsal rhizotomy,
Botulinum toxin A treatment, intrathecal baclofen).
- Post-intervention gait analysis to evaluate the individual treatment
result and to evaluate the present treatment hypothesis.
The multidisciplinary
team
Gait analysis results are discussed during multidisciplinary review meetings.
As a result of this, recommendations for therapeutic interventions are
formulated and communicated to referring doctors or physiotherapists.
These can be a broad selection of either physiotherapy settings, orthoses,
surgical procedures directed to elongation or transfer of soft-tissue
or restoration of bone alignment, Botulinum toxin injections, selective
dorsal rhizotomy, baclofen treatment (oral or intrathecal administration).
For each of these interventions, a history exists within the University
Hospital of Leuven.
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The 2D gait laboratory. |
Initially the lab was equipped with a small team. The gait analysis data
was collected and processed by one kinesiologist, and discussed within
a team comprising a kinesiologist, a paediatric orthopaedic surgeon, a
neuro-paediatrician and a paediatric rehabilitation doctor. The laboratory
multidisciplinary team gradually expanded, co-ordinated by Dr. Guy Molenaers
(paediatric orthopaedic surgeon, clinical director of the gait laboratory),
by kinesiologist Kaat Desloovere (PhD in biomechanics, manager of the
gait laboratory) and by Professor Roeland Lysens (department director
of the rehabilitation division and of C.E.R.M.). The gait laboratory is
now a major part of C.E.R.M. (Centre of Evaluation en Rehabilitation of
Motor functions) of the University Hospital of Leuven. The gait analysis
laboratory team now includes:
Movement sciences:
- Three kinesiologists (with a PhD in biomechanics)
Kaat Desloovere (100 %)
Ilse Jonkers (50 %)
Louis Peeraer (20 %)
- One paediatric therapist (lab assistant)
Catherine Huenaerts (50 %)
- One podologist/therapist (lab assistant)
Barbara Callewaert (100 %)
Secretarial management
Ann Fort (50 %)
Medical staff :
- Two Paediatric orthopaedic surgeons
Dr. Guy Molenaers
Dr. Ludo De Borre
- One paediatric rehabilitation doctor
Dr. Petra Pauwels
- One neuro-paediatrician
Dr. Marijke Eyssen
Physiotherapist:
Jos De Cat (Lic. Physiotherapy - Bobath Instructor)
Students:
A group of students working on research projects
Apart from these core people of the multidisciplinary team, there is a strong interaction with other hospital departments. Multidisciplinary spasticity consultations are ongoing with colleagues of the child neurology department (Prof. De Cock), as well as the neurosurgery department (Prof. Nuttin). Furthermore, similar collaboration with the adult foot clinic (Prof. Dereymaeker) and the adult rehabilitation unit (Dr. Kiekens) has been established. A close cooperation with the orthotic workplace, located at the hospital site, exists to allow optimal orthotic management. There are also close links to the University (Faculty of Physiotherapy and Physical Education) through clinical and fundamental research projects.
Research in the
gait laboratory
Clinical gait analysis at the University Hospital of Leuven (Pellenberg)
has
seen rapid development in the six years since the opening of the Vicon
laboratory. Each patient needs to be evaluated individually, assessing
strengths and weaknesses. This is best done in a multi-disciplinary team
of health professionals with substantial input from the parents of the
patient. With the professional instrumentation and the expertise of the
team, we feel confident that we can help our patients to reach their full
potential. However, it is also extremely important for us, as health professionals,
to always examine the premises that we base our treatment interventions
upon. We are determined in the quest for quality improvement by the ethics
of our professional associations. We should always be evaluating to ensure
that our treatment is effective and constantly be looking for ways to
improve it.
Following this philosophy, the gait lab is also the heart of numerous
research projects including:
- Evaluation of the influence of integrated multilevel Botulinum toxin
A treatment on the gait pattern for children with CP
- Evaluation of the gait patterns of specific patient groups (CP with
hemiplegia, adults, clubfeet, etc)
- Evaluation of the influence of different types of orthoses on gait (for
different patient groups)
- Study of typical gait patterns (stiff knee, rotational problems)
- Longitudinal evaluations of gait pattern and study of the natural history
of children with CP
- Musculo-skeletal modeling (SIMM)
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Gait analysis begins in the 3D gait laboratory. |