‫بسم هللا الرحمن الرحيم‬

Sudan University of Science & Technology

College Of Engineering
MSC BIOMEDICAL ENGINEERING
Assignment in: biomechanical
ABOUT:

Gait Analysis for Surgical Planning Benefits & Limitations

BY:

MARWA AHMED ABDELWHAB MOHAMMED

Abstract

The technology supporting the analysis of human motion has advanced

dramatically. Past decades of locomotion research have

Provided us with significant knowledge about the accuracy of tests

performed, the understanding of the process of human Locomotion
and how clinical testing can be used to evaluate medical disorders and
affect their treatment.

Gait analysis is now Recognized as clinically useful and financially

reimbursable for some medical conditions. Yet, the routine clinical use
of gait analysis

Has seen very limited growth. The issue of its clinical value is related to
many factors, including the applicability of existing

Technology to addressing clinical problems; the limited use of such

tests to address a wide variety of medical disorders; the manner in

which gait laboratories are organized, tests are performed, and reports
generated; and the clinical understanding and expectations of

laboratory results. Clinical use is most hampered by the length of time

.and costs required for performing a study and interpreting it

A ‘‘gait’’ report is lengthy, its data are not well understood, and it
includes a clinical interpretation, all of which do not occur with
other clinical tests. Current biotechnology research is seeking to
address these problems by creating techniques to capture data

rapidly, accurately, and efficiently, and to interpret such data by an

assortment of modeling, statistical, wave interpretation, and

artificial intelligence methodologies. The success of such efforts rests

on both our technical abilities and communication between

engineers and clinicians

Introduction

Has clinical gait analysis come of age? The technology that supports
human motion analysis has advanced dramatically in the past two
decades. Motion systems are of many varieties including infrared
reflective light, refractive light, digital video camcorders,
electromagnetic sensors, and accelerometers. Software is abundantly
available for measuring and recording particular body areas or ‘‘whole
systems’’ during a variety of activities. These programs may be obtained
commercially from a variety of companies and no longer are the
proprietary production or use of a single lab. We now have choices
about measurements of multiple limbs over relatively large areas or the
measurement of small areas, e.g. the foot in many cases the same
instrumentation can be used for both. We can now choose between
system that record and represent the date in real time or in delayed time ;
if the latter , turnaround time is quick. Detection still requires the use of
markers that are (either active (radiating sound, light, or electrical waves
or passive (reflecting infrared, refracting real light, or electromagnetic
waves). However, research is beginning to show the promise of the use
of edge detection to eliminate the requirement for markers. Software
now allows us to choose between a variety of marker locations with
which to calculate body movements from individual joints and body
segments, assuming rigid segments. The ability to accurately acquire
ground reaction forces has been available as force plat forms allow us to
choose between varieties of marker for some time. Now, however, in
addition to metallic plates, there are non-metallic plates that prevent
interference with electromagnetic motion measuring systems. Floor mats
encompassing more than a small area can record multiple footfalls and
provide not only ground reaction forces but also stride length and
cadence to allow overall performance measures of time–distance to be
recorded. Measuring devices available as in-ground thin plates or as in
shoe inserts recording compressive and not shear-type forces have been
used to determine the pressure distribution under the foot during a
variety of locomotors activities. The recording of dynamic
electromyogram (EMG) signals is now relatively noise free and un
encumbering due to the miniaturization of the pre amplification devices
and newer cable or telemetry signal transmission systems .Perhaps most
significantly, the advances in computer technology with faster
processors, greater memory, and vastly miniaturized components allow
more information from a larger number of parameters to be recorded and
processed faster and more efficiently in a minimum amount of space.
Finally, the advent of the Internet and the worldwide web allows for
limitless communication possibilities.
With these technological advances, instrumentation and recording are
no longer limitations to the clinical use of gait analysis Clinical
relevance of gait analysis.
Gait analysis consisting of joint kinematics, kinetics
and dynamic EMG data, performed and properly interpreted by
experienced individuals, is now recognized as a clinically useful tool.
Rarely is gait analysis Used to make a medical diagnosis. Most
commonly, it is requested to quantities the mobility state of a medical
disorder and determine the neuromuscular–skeletal Contributions to that
state. As such, it provides quantitative information to ‘‘help’’ prescribe
treatment and assess its outcome To date gait analysis has had its
greatest clinical value as a test for individuals with central nervous
disorders associated with spasticity, especially children with cerebral
palsy (CP). To prevent deformity and increase mobility, various
medications, non-surgical therapy regimens, bracing, assistive devices,
and/or orthopedic and neurosurgical procedures are prescribed for these
children. In the past, many orthopedic procedures were performed
separately during a child’s growing years.

Problem statement
the understanding of the process of human Locomotion and how
clinical testing can be used to evaluate medical disorders and affect
their treatment.

THE PROCESS
What to capture on video

Different planes of motion with and without orthoses

With and without assistive devices some basic clinical
Examination

But it is far more desirable to perform these multiple orthopedic

procedures at a single surgical session.
This Approach avoids the psychological impact of multiple separate
procedures, optimizes functional improvement by using a single
operation, and reduces the total medical costs of performing each
procedure separately. Gait analysis affords the confidence not provided
by
clinical examination that the correct number and selection of surgical
procedures can be chosen In 15 children with spastic diplegia CP
monitored for years after staged operations, the staged operations gave
unpredictable results in the surgical correction of contractures of the
three most common muscle–tendon complexes (hamstrings, Achilles
tendon, and iliopsoas muscles) (Fabry et al., 1999). This conclusion was
based on the objective data derived from sequential gait studies and
caused a change in approach to favor multi level simultaneous
corrections. In 91 children with CP having surgery, experienced
clinicians who examined the gait analysis data of each subject changed
their initial opinions (based on a review of walking video and clinical
examination data) in about half (52%) the cases (DeLuca et al., 1997). In
general, this led to a reduction in the number of procedures performed
and an associated reduction in the cost of the surgery. In another study
(Kay et al., 2000a), the ultimate surgical procedures were changed in
89% of the individuals after data derived from the preoperative gait
study were reviewed. In the 97 children with CP in this study, 1.6
additional procedures per patient were added to the surgical
recommendations made purely from a clinical standpoint, while 1.5
procedures that were planned were subsequently not recommended. In
38 consecutive subjects with a static encephalopathy who had a gait
study averaging 16.7 months after multiple procedure (average 6.1)
orthopedic surgery to assess outcome, a recommendation of a change in
care in 84% of the cases was suggested that was not given prior to
evaluating the gait study (Kay et al., 2000b). These recommendations
included further surgery in 42%, bracing in 53%, and a change in the
specific physical therapy regimen in 21%. Changes were recommended
in at least two of the three areas in 29%. When surgical
recommendations were made based on a gait study on each of 23
children with spastic CP, 14 of the 16 children showed improved
walking parameters 1 year later, while only two of the seven whose
surgical procedures did not follow the recommendations improved (Lee
et al., 1992). Gait studies performed preoperatively and 1, 3, and 10
years after dorsal rhizotomy surgery on each of 11 children
With spastic diplegia (Subramanian et al., 1998) showed that the
children had increased ranges of motion of the lower-extremity joints,
and used the movement within a normal midrange point. The authors
concluded that lasting function al benefits, as measured by improved
gait, could be obtained from a dorsal rhizotomy Clinical gait research
has shown many other ways to properly use gait laboratories to obtain
valuable clinical information. For locomotors disorders having a
neurological origin, monitoring the variability of gait itself is an
indication of the severity of the disease (Hausdorffet al., 1997a, b, 1998,
2000, 2001). Quantitatively knowing an individual’s ‘‘locomotion state’’
can then be used to evaluate the effects of medications, or other forms of
treatment. At times, not all the parameters of an individual’s gait need to
be examined; determining quantitatively, only a single or at most several
of these can be used to select the best treatment for a specific gait
abnormality. For example, the degree of peak swing phase knee flexion
is often decreased in children with spastic CP. This condition limits the
foot clearing the ground and can be a cause of tripping. In able-bodied
individuals knee flexion is a result of early swing-phase hip flexion
producing sufficient momentum of the thigh
to cause the knee to passively flex. In children with CP the lack of
adequate swing-phase knee flexion can
directly be the result of abnormal quadriceps (vast us lateral is and/or
rectus femora’s) muscle activity (often known as a stiff-knee gait), or
can indirectly be caused by reduced early swing-phase hip flexion.
Rectus femora’s transfer surgery has been reported to improve this
abnormality (Chambers et al., 1998). However, the effectiveness of this
treatment depends on identifying the appropriate abnormality. The
presence of preoperative gait analysis-noted abnormal swing-phase
rectus EMG activity alone or combined with abnormal vast us lateral is
activity, or a physical examination demonstrating a positive Ely test or
knee range of motion does not influence the results. Rather, the rectus
femora’s should be transferred when maximum knee flexion in swing is
less than 80% of the normal maximum swing-phase
Value (Ounpuu et al., 1993a). The choice of rectus femora’s transfer site
did not affect gait abnormalities
observed in the transverse plane (Ounpuu et al., 1993b). The indication
for rectus femora’s transfer would thus seem very clear and requires
examining only sagittal plane knee motion, a measurement with little
error and variability from lab to lab. Other parameters may be measured
if other procedures are contemplated or outcome improvement other
than swing-phase knee flexion is questioned Clinical locomotion
research has justified its wider potential use not only in these disorders
but also in a variety of other medical conditions in the fields of
rheumatology, orthopedics, endocrinology, and neurology
(Benedetti et al., 1999; Catani et al., 1999;
Ebersbach et al., 1999; Hillmann et al., 2000; Kutz-
Buschbeck et al., 1999; Melis et al., 1999; Nadeau et al.,
1999; Oeffinger et al., 2000; Stolze et al., 2000).
Optimism for the expanded clinical use of gait laboratories is enhanced
by the ability to assess walking ‘‘out - of-the lab’’ during activities of
daily living. In its current state, a gait analysis does not measure
everyday actual walking performance. Recent instruments now enable
this aspect of locomotion also to be examined (Coleman et al., 1999;
Maluf et al., 2001; Shepherd et al., 1999). Such devices are relatively
simple to use, easy to interpret, and relatively inexpensive. The
incorporation of such instruments into the armamentarium of a gait
laboratory should greatly enhance its clinical value
Limitations of gait laboratories—variability in gait measurements
Clinically, how the locomotors disorder of a particular individual differs
from normal or is altered with treatment must be recognized. Variability,
inaccuracy , and lack of reproducibility due to technical factors, test
subject factors, or subjective clinical
interpretation factors must be minimized for gait analysis to be valuable.
Almost all motion measurement, EMG, and force platform systems in
association with digital recording hard are and software accurately
record multichannel electrical signals in almost any frequency domain
with high-enough data sampling rates and sufficient resolution. The
technical problem is that the desired parameters are calculated from the
recorded data based on certain assumptions and are not the data
measured. From the positions of the body’s surface tracked and recorded
from markers over time, the kinematic data related to bony limb
segments and joints are calculated. These data are combined with those
obtained from force platforms to yield kinetic data (joint moments and
forces). Lastly, EMG recordings produce accurate signals of muscle
electrical activity; they do not directly yield the internal forces of
muscles, joints, and bones. In the past, much engineering effort has been
spent on determining the degree of error in these calculated parameters
and maximizing their accuracy. Varying segment parameter values in
the determination of the mass and moment of inertial values by up to
740% of the baseline value significantly (Po0:05) affects most of the hip
kinetic estimates, but by only less than 1% of body weight (Pearsall and
Costigan, 1999). A more significant error affecting both the estimates of
angles and resultant moments of the lower-extremity joints is the
prediction or calculation of the location of joint centers or joint axes
from surface markers. Altering the coordinates of a hip joint center by
730mm can affect the angles and moments at both the hip and the knee
joints by up to at least 25% (Stagni et al., 2000). Regardless of whether
inter subject scaling reduces coordinate differences, the accuracy of skin
marker placement is improved, and better fixation methods are used to
minimize marker vibration, inherent errors remain.
These errors are related to anatomic variability in bony contours and
muscle attachments (White et al., 1989); multiple small bone/joints
assumed to be rigid bodies, e.g., the foot; and inherent cross-talk about
joints where a single axis throughout the range of functional motion
cannot be identified, e.g., the knee and ankle/subtalar/talar joints.
It is argued that a gait study does not accurately represent the actual
everyday activity pattern of the person. A gait laboratory measures only
the potential walking ability of a subject and only at a given time.
Functional subject variability exists from step-to-step, walk-to-walk,
hour-to-hour, day-to-day, and month-to month (Steinwender et al., 2000;
White et al., 1999).
For all these reasons, a variety of statistical approaches as well as
growing knowledge of the degree of variability presented by this factor
have permitted a representative walk to be used to compare gait studies
at different times. Lastly, it is recognized that the interpretation of the
data varies from clinician to clinician and institution to institution
(Skaggs et al., 2000).
 However, such variability is little different from that seen with other
tests. The inter observer variability reported is similar to that reported
for established classification systems of various orthopedic conditions
(Skaggs et al., 2000).
Despite measurement and subject variability, the use of gait laboratories
for routine tests should not be negated. No medical laboratory test is
without inherent errors and variability Limitations of gait laboratories—
time and expense of gait studies The most common gait study protocol
uses a standard
set of instruments (motion detection, EMG signals, and foot-floor
reaction forces) in a standard manner, and produces a standard set of
time–distance, kinematic and kinetic data.
Occasionally other tests are performed, e.g., energy consumption and
pressure distribution
under the foot. A history and clinical examination of the patient are first
obtained (20–30 min). Then appropriate sensors (markers) are placed on
the person and calibrated for motion detection and muscle activity
monitoring(30–60 min). Testing itself lasts 5–30 min depending on the
number of conditions examined, e.g., with/without braces or assistive
devices. This lengthy process limits the number of tests performed in a
day, thereby frequently impeding a timely response to clinical requests
the length of the process minimizes revenue.
Although the charge for a gait study can be as high as $2000, the
average reimbursement is $500 or less. The establishment of a gait
laboratory requires equipment purchases that average $300,000
excluding facility renovations. With technological advances, hardware
costs have decreased, new markets to use such equipment have emerged,
and more products and vendors are available. All these factors are likely
to lower the purchasing consists of new equipment and increase the
feasibility of establishing gait laboratories. Excluding normal space costs
(rent, heat, and electricity) and a minor cost for supplies, there are two
additional yearly expenses. These are the maintenance contracts for
hardware and software ($30–$50,000) and full-time laboratory personnel
consisting of a bioengineer, physical therapist, and secretary/receptionist
(direct)

6. Recommendations for change—increasing subject testing efficiency

Personnel are the single most costly item to a gait laboratory, and this
expense per gait study must be
reduced. Clinical tests must be performed in less than 30 min by
ancillary health technicians rather than by highly skilled professionals.
Minimizing all preparatory activities can reduce the time involved. A
pertinent history (including physical examination) and requested test
information should be part of the physician referral process. Specially
trained ancillary health personnel, similar to radiology technicians,
should perform the study, and the test should include only those
conditions, measuring instrument s, and parameters required to answer
the question. These changes require a better informed and educated
medical staff. Bioengineering research focusing on computerized
teaching and ‘‘condition testing’’ templates could greatly assist clinicians
and technicians in optimizing this process.
Eliminating the need for markers would also greatly reduce patient
preparatory time. Such an approach now appears feasible. One example
that shows promise is by ‘‘LegSilhouet te Contour Extraction’’ from
video images (Legrand et al., 1998; Parent et al., 1999; Varadarajan et
al., 1999).
Standard high-resolution video cameras can obtain front and side views
of an individual walking
The contour silhouettes of individual body segments are identified with
edge detection methods and
Contrasting colors to distinguish each leg. Contour