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Role of gait analysis in the process of clinical decision making concerning post-stroke patients.

Castagna A., Rabuffetti M, Montesano A., Ferrarin A.

Abstract

Quantitative gait analysis is recognised to be the most effective analytical method to study and assess locomotor functions, thus complementing clinical assessment based on scale rating. Therefore scientific research in the human movement field more and more relies upon these methods to produce scientific evidences concerning the pathophysiology of muscoloskeletal system and motor control. The introduction of these methods in clinical settings has not been so successful: besides cost-effectiveness concerns, it is apparent that we are currently lacking strong evidences about the usefullness of gait analysis in the management of clinical cases. The only set where gait analysis is unanimously recognised as appropriate and highly recommended is the design of complex multilevel orthopedic surgery in cerebral palsy The objective of the present work is to present preliminary data from an ongoing research on the assessment of the usefullness of gait analysis in the clinical decision making process of patients suffering motor disorders post-stroke in chronic conditions. The research requires that the clinical management of a poststroke patient is initially performed by traditional clinical approach leading to a clinical decision which is first classified according to general therapy types (surgery, neuromuscolar pharmacological block, orthotic treatment, physiotherapy) and then furtherly specified by the details (which surgery, which muscle, which orthosis, which physical therapy). Obviously a clinical decision cannot be restricted to a single type. Then, the results of a gait analysis (though no costraint are assumed on which protocol apply, in our activity we generally adopt the LAMB plus foot protocol and an 8-channels dynamic electromyography, asking the patient to walk at self-selected and increased speeds) are considered by the decision-maker who revise eventually his/her decision. Three alternative occurrences are expected about the comparison of pregait and post-gait decisions: no change, minor change (when the details of the decided therapy are modified), major change (when the considered therapeutic types are changed) (omitting or including or substituting, for example discarding the toxin option to indicate an orthotic project, or discarding the surgery for physical therapy and toxin). Both pregait and post-gait decisions were scored on a ten-points scale by the decision-maker according to his/her confidence in it. In the present work we consider 10 post-ictus patients referring for clinical decision making to the SAFLo lab of the IRCCS Don Gnocchi of Milano. The comparison of pre- to post-gait decisions evidenced, out of 10 patients, 5 confirmed decisions (all with a slight increase of A relevant percentage of patients (50%) has a modified treatment plan, and about half of them experience a major change in it Such impact, if confirmed on larger samples, substantially support evidence for the use of gait analysis in clinical decision making of chronic post-stroke subjects. A perusal of the final data set will allow to further evidence if some anamnestic data or clinical signs let to identify a post-stroke confidence, 3 minor changes and 2 major changes. The presented preliminary results confirm the gait analysis potential in a clinical setting for ictus patients A relevant percentage of patients (50%) has a modified treatment plan, and about half of them experience a major change in it. Such impact, if confirmed on larger samples, substantially support evidence for the use of gait analysis in clinical decision making of chronic post-stroke subjects. A perusal of the final data set will allow to further evidence if some anamnestic data or clinical signs let to identify a post-stroke patients subgroup in which GA is effective even in a larger percentage, thus allowing for an even more effective GA prescription. It is relevant to note that the proposed research design strictly allows to evidence if gait analysis influences clinical decisions. Therefore, though expected, it is to be demonstrated that a gait analysis-based decision may produce a better outcome for the patient and/or a reduced cost-effectivness ratio in the management of post stroke patients.

Research in Developmental Disabilities. 2011 Jan-Feb; 32(1):377-81

Use of the Gait Deviation Index for the assessment of gastrocnemius fascia lengthening in children with Cerebral Palsy.

Cimolin V, Galli M, Vimercati SL, Albertini G.

Abstract

Gait analysis (GA) is widely used for clinical evaluations and it is recognized as a central element in the quantitative evaluation of gait, in the planning of treatments and in the pre vs. post intervention evaluations in children with Cerebral Palsy (CP). Otherwise, GA produces a large volume of data and there is the clinical need to provide also a quantitative measure of the patient’s overall gait. Starting from this aim some global indexes were proposed by literature as a summary measure of the patient’s gait, such as the Gait Deviation Index (GDI). While validity of the GDI is demonstrated for the evaluation of the functional limitation of CP patients, no studies have evaluated with the GDI the pre vs. post surgery gaitcondition in children with CP. The aim of our study was therefore to investigate the effectiveness of the GDI in the quantification of gait changes occurring after surgical intervention (gastrocnemius fascia lengthening for the correction of equinus foot deformity) in patients with CP. 19 children with CP were evaluated pre-operatively (PRE session) and about 1 year (POST: mean 13.1 ± 5.1 months) after gastrocnemius fascia lengtheningusing 3D GA. From GA data the GDI was computed. The results evidenced that the GDI value in the PRE session was 70.4 ± 14.8, showing a moderate global disturbance of the gait patterns of the patients. After the surgical treatment a significant improvement of the GDI mean value was found (82.9 + 7.4; p < 0.05; CG ≥ 100) with an improvement of 18% respect to the PRE session. A strong correlation (ρ = 0.83; p<0.05) existed between the GDI value in the PRE session and the percentage of improvement. Our results demonstrated that GDI seems to be an appropriate outcome measure for the evaluation of the effects of surgical treatment in CP.

BMC Musculoskeletal Disorders 2012, 13:193

Effect of posture-control insoles on function in children with cerebral palsy: Randomized controlled clinical trial.

Neto H. P., Grecco L. A. C., Christovão T. C. L., Braun L. A., Giannasi L. C., Salgado A. S. I., Franco de Moura R. C., Camillo de Carvalho P. D. T., Corrêa J. C. F., Sampaio L. M. M., Galli M., Oliveira C. S.

Abstract

Introduction: Cerebral palsy (CP) is a posture and movement disorder and different therapeutic modalities, such as the use of braces, have sought to favor selective motor control and muscle coordination in such patients. The aim of the proposed study is to determine the effect of the combination of posture-control insoles and ankle-foot orthoses (AFOs) improving functional limitation in children with CP. Methods/Design: The sample will be composed of 24 children with CP between four and 12 years of age. After the signing of the statement of informed consent, the children will be randomly allocated to two groups: a control group using AFOs alone and na experimental group using both posture-control insoles and AFOs. Evaluations will be performed on five occasions: without any accessory (insoles or AFOs), immediately after, one month after, six months after and one year after AFOs or insole and AFOs use. The evaluation will involve the analysis of gait, static and functional balance, mobility and hypertonia. The three-dimensional assessment of gait will involve the eight-camera SMART-D SMART-D 140W system (BTS Engineering), two Kistler force plates (model 9286BA) and an eight-channel, wireless FREEEMGW electromyography (BTS Engineering). Static balance will be assessed using a Kistler force plate (model 9286BA). Clinical functional balance and mobility will be assessed using the Berg Balance Scale, Timed Up-and-Go Test and Six-Minute Walk Test. The posture-control insoles will be made of ethylene vinyl acetate, with thermal molding for fixation. The fixed orthoses will be made of polypropylene and attached to the ankle region (AFO). The results will be analyzed statistically, with the level significance set to 5% (p < 0.05).

Journal of Motor Behavior. 2012; 44 (3): 161-7.

Use of the Gait Deviation index for the evaluation of patients with Parkinson’s disease.

Galli M, Cimolin V, De Pandis MF, Schwartz MH, Albertini G.

Abstract

The authors aimed to determine whether the Gait Deviation Index (GDI) could be feasible to characterize gait in patients with Parkinson’s disease (PD) and evaluate outcomes of levodopa treatment. Twenty-two PD participants were evaluated with clinical examination and 3-D quantitative gaitanalysis (GDI was calculated from gait analysis) in 2 states (OFF and ON) after taking levodopa. Twenty age-matched healthy participants (CG) were included as controls. The GDI value in the OFF state was 83.4 ± 11.5 (statistically different from CG) while clinical scales demonstrated a moderate-severe gait impairment of these patients. Significant improvements are evident from clinical scores and by GDI values in the ON state. The mean GDI for the ON state (GDI(ON): 87.9 ±10.4) was significantly higher than in for the OFF state (GDI(OFF): 83.4 ± 11.5), indicating a globalgait improvement after the treatment. The results show that GDI has lower value as an indicator of pathology in PD patients than in quantifying the effects of levodopa treatment in PD state.

Research in Developmental Disabilities. 2013 Oct 1; 34(11): 4280-4285.

Use of the Gait Profile Score for the evaluation of patients with joint Hypermobility syndrome/ Ehlers-Danlossyndrome hypermobility type

Celletti C, Galli M, Cimolin V, Castori M, Tenore N, Albertini G, Camerota F.

Abstract

Gait analysis (GA) is widely used for clinical evaluations in various pathological states, both in children and in adults, such as in patients with joint hypermobility syndrome/Ehlers-Danlos syndrome hypermobility type (JHS/EDS-HT). Otherwise, GA produces a large volume of data and there is the clinical need to provide also a quantitative measure of the patient’s overall gait. Starting from this aim some global indexes were proposed by literature as a summary measure of the patient’s gait, such as the Gait Profile Score (GPS). While validity of the GPS was demonstrated for theevaluation of the functional limitation of children with Cerebral Palsy, no studies have been conducted in patients JHS/EDS-HT. The aim of our study was therefore to investigate the effectiveness of the GPS in the quantification of functional limitation of patients with JHS/EDS-HT. Twenty-one adult (age: 36.1±12.7 years) individuals with JHS/EDS-HT were evaluated using GA and from GA data the GPS was computed. The results evidenced that the GPS value of patients was 8.9±2.6, statistically different from 4.6±0.9 displayed by the control group. In particular, all values of Gait Variable Scores (GVS) which compose the GPS were higher if compared to controls, with the exception of Pelvic Tilt and Foot Progression. The correlations between GPS/GVS and Lower Extremity Functional Scale (LEFS) showed significant relationship between GPS and the item 11 (“Walking 2 blocks”) (ρ=-0.56; p<0.05) and 12 “Walking a mile”) of LEFS (ρ=-0.76; p<0.05). Our results showed that GPS and GVS seem to be appropriate outcome measures for the evaluation of the functional limitation during gait of patients with JHS/EDS-HT.