Perfect. Thank you. All right. Let's go ahead and get started. Again, welcome everybody to our AAP virtual didactics for today. My name is Sterling Herring. I'm PGY3 at Vanderbilt. We will skip through the goals, but we will address some of these housekeeping issues. We're going to keep everybody video and audio muted except for our presenter. If you have any questions, my name is Sterling Herring. If you click on your participant list, you shouldn't see my name on there. You can double click my name, send me questions, and I can pass them along to our presenter at appropriate times. Often that is at the end of the lecture or as invited by our presenter. If you have any big questions, concerns, suggestions, you can reach out to me directly or Candice's email is right there on the screen, candice.aapcst.org, or you can track us down on Twitter. Without further ado, we're excited to have our next presenter today, Dr. Inanoglu from UT Southwestern. Thank you for joining us today. Thank you. Let me see if I can do this correctly, share. Do you see my slides? Yes. Looks great. Okay. Here I am. Well thank you for having me. I love talking about pediatric gaits, so I'm hoping today I will be covering some what I would call bullet points for the attendees. I'm a pediatric rehab medicine physician, so when I talk about gait, I will be talking about some basics, but at this point, this lecture is more tailored towards how we evaluate gait in the pediatric age group. With the objectives today, we will be explaining the requirements for successful gait or locomotion. We will be describing phases of the gait cycle. We will define some key parameters of gait. We will talk about the important elements of a gait evaluation or examination. I will also go over how the adult gait pattern is developed, so the maturation of pediatric gait patterns. Then lastly, I will focus on cerebral palsy, which is one of the most common etiologies of physical disability in our age group and talk about the gait deviation seen in cerebral palsy. So do you see my slides okay? Because there's been… Hello? Okay. Yes, we can see your slides. Sorry about that. Okay, here we go. So let's talk about gait. Sterling, do you want to do this or can I just control the slides myself? Yes, absolutely. Okay. So gait in the basic definition is a form of upright mobility where the lower extremities are used to transport the individual between two points in space. Now gait itself is a very complex movement and it involves multiple interactions, bony alignments, joints, range of motion, neuromuscular activity. These are different components that we will be assessing when we talk about gait. Of course, like anything else we do, the gait examination requires a very systematic approach. So what is it that we're trying to get out of a gait exam, of a patient's evaluation? So of course we want to know how far can a patient walk and how long does it take to accomplish this distance? What are the patterns? What are the body segments looking like? Is there coordination? Is there balance? Is there adaptive or maladaptive patterns? How safe is the walk? Is there any assistive device needed or manual assistance needed to make the walk safe? And then again, is there any adaptation, correct, precise adaptations or maladaptations that would enable the patient to, for example, overcome obstacles or negotiate different surfaces or change speed or direction? Like walking on a straight line is different than turning. So these are all the considerations when we look at a patient's gait. Gait cycle is the largest unit we use to describe gait and this model was initially presented by Perry in the 1990s and this is a slide that kind of summarizes the basics of a gait cycle. So the definitions are one gait cycle is also a stride cycle and stride is the distance or time from one initial contact of the foot to the next initial contact of that same foot. Whereas a step is the initial contact of one side, let's say the right foot, to the initial contact of the opposite side to the left foot. So basically one stride is equal to two steps. When we look at the gait cycle, time-wise or distance-wise, we divide it into two periods, the stance phase and swing phase. We all know stance phase is the support phase and that makes up the most of this one unit, this gait cycle with 60%. So the division of stance is 60% of the cycle, swing is 40%. During these two periods, there are some goals, some functions that need to be achieved and those are the tasks defined as weight acceptance, single limb support, and then of course during the swing phase, it's the limb advancement. So smooth forward progression of that central mass and we want to make this at a minimal metabolic cost. So those are our tasks or functions during this gait cycle and the two periods, stance and swing, is further divided into eight phases so we can analyze and measure the gait cycle precisely. So the goals of the two phases, the swing phase is basically to reposition the limb for continued forward progression and the idea is of course making sure the toe clears the ground. Most of the muscle activity during the swing phase takes place at the very beginning or at the end of the swing phase. So in between, it's almost like a free fall and please remember at this point that gait in itself is just an alteration of losing balance and recovering from the loss of balance where the center of mass moves in a vertical plane and also at a horizontal plane and the end result is the smooth forward progression. With the stance phase, the goal is a little different. It's stabilization for the limb so that the limb can absorb the shock and accept the weight and while doing all that, it's also generating a propulsive force for continued motion. So the muscles in the stance phase activate and support the posture, the control of the posture, and while doing that with the shock absorption, it helps propel the body forward, the forward progression. So this is another visual representation of the gait cycle and we're pretty much all familiar with this I'm hoping or if not, we will be throughout our training years and this is to summarize the stance phase taking up the 60% while the opposite, the contralateral leg is in the swing phase for the 40% of the gait cycle and then one section of the gait cycle I'm going to point out which is important is the double limb support which may change in a normal steady state gait. We say it's 20% but when we have an underlying diagnosis or neurological disorder, this double support phase may increase just like any other gait parameters that may change. So basically when we analyze gait, we talk about time-based or temporal parameters like the stride time or the swing time or stance time. We talk about the distance covered, the length of the stride or width of the step or the base of support which is again a very helpful metric in the gait analysis and then of course there is the composite parameters, more advanced parameters that take some calculation. Velocity is one of them. The speed of the gait is important and then the cadence, the number of steps covered per minute is also important and these can all vary based on the underlying conditions. So when we talk about gait, of course we have some tools to measure gait, to analyze gait and become or derive some precise outcomes. The most common one is what we do in our clinic settings every day, the observational gait analysis. There are some good examples of this, but one common one is the Ranchos Los Inigos gait analysis form and every clinic or every provider may use their own subjective way too, but these are all validated and reliable measures. Then the most advanced one at the bottom of the list is the instrumentational or motion or three-dimensional gait analysis and in between the two there are so many different scales or rating systems or metrics that can be used. In the pediatric world, I like Gillette's gait deviation index, but there are different ones that can be used in the practice setting or also in research. One important thing to mention is when we're trying to measure gait, we don't always or we don't actually have the gait analysis available to us for our patients in every facility, so we still have to rely on our clinical examination, which means the impairment level tests are still very crucial, just like the range of motion or muscle strength or sensation or posture or whatever else we do on our musculoskeletal or neuro exams. So now how do we decide which tool to use? What is the most appropriate method or way of measuring or analyzing gait? To be able to do this, we need to be familiar with different types of analysis or options or tools if you like. We need to understand if they're valid or reliable. We need to understand if they apply to our patient population, so for example in the pediatric world it may be different than the adult age group. We must know what is a typical gait pattern, what is a normal pattern across the lifespan, so that's why we're going to be mentioning the maturation of gait too. Then of course we need to be familiar with different specific conditions or disorders of movements or neurologic conditions. In the pediatric world, for example, a kid with low tone, for example, trisomy 21 and this patient, a trisomy patient's gait is very different than a kid with stroke or cerebral palsy where we have upper motor neuron signs or spasticity or dystonia. Of course a kid with trans-tibial amputation will be exhibiting different patterns when they walk, so we again need to be very familiar with the specific presentations. As a clinician, we need to remember walking is a big component of quality of life and when we evaluate patients for gait or for walking we need to remember the systems within the individual that contribute to this gait. When we talk about systems, we need to remember how they help or inform the balance or postural control and how they inform the gait patterns. These systems, I'm sorry I keep saying symptoms, systems include postural control, the motor control, the neuromuscular systems, musculoskeletal systems with all the bones and joints and the muscles, the internal representation, the cognitive abilities that contribute to gait patterns, the sensory symptoms, and then of course the adaptive mechanisms that rely on the prior experience or practice of the individual. The musculoskeletal assessment is very important. In the pediatric age group, we see a lot of different deformities and one major group under this is the rotational deformities, but before I go into that, I just wanted to briefly mention when we look at every patient for their gait, we need to have the systematic approach and we need to remember to look at the whole body or the whole kinetic chain. So we start with the head or go down or maybe we start at the bottom with the feet and then go up, but however we do it, we need to examine the neck, the spine, the lower extremities, the pelvis, the lower extremities with their symmetry if there is a leg length discrepancy. We need to look at each segment, each joint level, hips, knees, ankles, midfoot joints, and then of course we need to decide if the deformities or the deviations we see are flexible or fixed. Now talking about rotational deformities, these are very common in our pediatric age group patients and the way to differentiate what the etiology is or which level it's coming from is very important because this will eventually inform our decision making in treatment. Femoral antiversion is when this internal rotation is coming from the hip or femur level. We see the kids walking with their patella and feet both pointing inward and this is a very common finding between the ages 3 and 8 years old. When there's femoral antiversion, usually the internal rotation is more than 70 degrees, so it is increased and the external rotation is reduced to less than 20 degrees. These children are the ones that like W sitting and they usually present with more exaggerated internal or in-toeing when they're running or fatigued. Now the next level of rotation may happen at the tibia level and it's important to differentiate this from femoral antiversion. Usually it's the lower leg and the child walks with patella facing forward, but the toes are pointing inward. So they're still in-toeing, but when you look at the patella, they're straight. And this is a common finding from the onset of walking to 3 years age and the way we evaluate is we look at the thigh foot angle, usually it's more than 10 degrees internally. Some cases are due to the positioning in utero, but really it is just a variation of the typical anatomy seen in young children, so it's important to remember this could be a normal variation or variation of the normal. Now the most distal level to look at for rotational deformities is the foot, the metatarsus, and metatarsus adductus is one other reason or etiology for in-toeing when we look at gait of our kids and this is usually characterized by medial deviation of the forefoot. So it's a C-shaped lateral border and when we look at the heel bisector line, we see the abnormality very clearly. This deformity could be flexible and most children that have this, they resolve by the age of 6. So again, it's important to remember if this is the normal finding or a finding that the kid will outgrow. So looking at the exam, the femoral should be differentiated from tibial. With the femoral we said we would look at the hip rotational range of motion and now with the tibia we use the thigh foot angle when the patient is prone and we're measuring these two lines and it gives us some confirmation. And then with the metatarsus adductus we see the bisector line here, the normal line, and then the degree of curvature will give us the degree of the severity. Now one other measure or metric we like to use when we talk about rotational deformities in gait exam is the foot progression angle and then the transmodular axis. These are all additional tools to use in clinic to help us confirm the etiology. Now let's go back to gait and how we talk or classify gait. We mentioned the instrumental or motion analysis which uses advanced technology and the idea is to better characterize the pathology of the abnormal gait, particularly when there is an underlying condition that results in deformities or changes in multiple planes and multiple segments. For example, when we talk about planes in the gait lab or when we do observational gait we need to be doing this too, we look at the kid from the lateral, from the side view, which we call the sagittal plane and the things to look for at that point would be the pelvic tilt. Is there an anterior or posterior tilt? We look at the hip flexion or extension, the knee flexion extension, and then we also look at the ankle whether there is equinus or plantar flexion or dorsiflexion. When we watch them from the front or back view, posterior, anterior view of the coronal plane we evaluate for pelvic elevation or depression. So this would give us the pelvic obliquity commonly mentioned in gait exams and then we would be looking for hip abduction or adduction. For example, if there is scissoring we would like to be looking at the coronal plane. Now the transverse plane is the least reliable plane used in motion analysis, but it may still be helpful when there is internal or external rotation deformities at the hip level or if there is any changes, deviations with the foot progression angle. So this is just a picture of one of our patients we tested or examined in our own motion analysis. I just wanted to give you an idea how advanced it is. This is a spatial floor panel mounted and has sensors. The kid has the skin markers. We had 10 cameras with the Bicon system and what we do is we capture all these views and then use a software to derive some graphs, some outcome analysis. So when we talk about motion analysis we talk about kinematics, which is the study of the joint position or motion and then we also talk about the muscle forces or moments or torques derived from the motion, so the kinetics. When we study both, we know the kinematics can also be to a certain degree observed with the gaits or seen with the observational gait analysis when we inspect the kids we can tell which direction, which plane the joints are moving and usually the kinematics is very consistent so for example on the left upper hand you see this average joint angle graph that tells you the ankle plantar flexion, the coefficient of variation is around 9% and it's very similar to the knee and hip flexion or extension degrees so when we look at the joint motions it is pretty consistent throughout that gait cycle whereas when we look at the kinetics, the muscle forces at different joint levels for example the plantar flexion moment created at the ankle versus the hip extension or flexion moment created there's a big variability there and this explains why there's individual differences from person to person or from step to step due to underlying neurological conditions. At that lower graph at the very top you see the support moment basically that means it's the sum of all the moments below from the hip, knee, and ankle joints that gives that net extensor moment that keeps the limb from collapsing when we take a step. So I'm not going to go into any more detail with the gait analysis, but this is just to give you an idea about how advanced or how precise it can be in terms of outcomes or etiology or the data we obtain from motion analysis. Now going back to the clinical model as clinicians as pediatric physiatrists or physiatrists we always need to remember how to assess function and how to analyze the impact of gait on function and independence or activity participation. So I kind of included this here, this is the ICF International Classification Function Model endorsed by World Health Organization. This is the basis of what we try to do when we step back and look at our patients, try to come up with care plans or treatment decisions, we need to consider body impairments or structural changes for example in the CP as a health condition we may have muscle contractures or shortening or we may have spasticity, but just saying it's spasticity and trying to come up with a treatment is not good enough. We need to look at how that relationship works with functional motor abilities and how that impacts the kid's activity level and how that limitation may translate into restriction and participation in the school environment or home environment or on the playground. Of course there are specific personal factors and some environmental factors that also contribute to all these limitations or impairments, but at the end we need to remember the relationship between impairments and activity limitations or restrictions for participation, it's not a very clear relationship. So it's important to keep this in mind. Now I'm going to step back and go back to gait, gait patterns and how we develop this mature adult gait. When we see young kids starting at infancy, we see certain gait patterns emerging. At age 8 to 10 months is the first time we see this supported walking, which is basically cruising or walking while you're holding onto furniture or objects. The gait pattern is totally different at this stage, there is a lot of flexion at the hip and ankle level. The knee is also flexed so there is decreased knee extension. Of course it's a very slow walking speed and it's very variable from cycle to cycle or step to step and it's a very clumsy way of walking. By the age 12 months or one year, the independent walking usually starts emerging and we call this pattern of walking the toddler gait, which is a very wide-based support, there is increased hip flexion. With the uppers there is no swinging of the arms, there is the high guard position with the shoulders abducted, elbows flexed. The hips usually remain externally rotated, keeping that base of support kind of wide and the knees are in a relative extension. There is also toe strike at the initial contact, meaning there is a whole extensor pattern instead of the mature flexion control. So to clear this extended, very extended limb, at this age we see a lot of circumduction so that there is no toe dragging or toe catching or tripping. At the age two years, now we start having a reciprocal pattern with the upper extremities and the heel starts the initial contact with a strike. So now instead of the toe strike we have better dorsiflexion to help with the heel first initial contact and this helps clear the foot so there is no more circumduction at this stage and also during stance phase there is greater stability and the duration of single-limb stance is increased so these kids do better taking turns, reciprocal steps. By age three years, most of the adult kinematic patterns are present so the joint alignments, the movements of joints in different planes are somewhat similar to adult patterns. However, the maturation still continues until about age seven when the adult gait pattern is developed. Now I will now focus on cerebral palsy as a very common finding in our pediatric rehab clinics and most of the gait literature, gait work we have is based on cerebral palsy cohorts. So I just wanted to remind you the basics on this. Cerebral palsy is a very typical movement disorder that also involves postural changes and this happens early on to the brain and I'm sure you all know this. It's the most common cause of spasticity in the pediatric age group and it's also the most common cause of physical disability in children. The prevalence is pretty high, 3.6 cases per thousand kids in eight-year-old age group whereas with the premature births if the gestational week is less than 28 weeks then the incidence increases to 4,200 per thousand live births. So we said cerebral palsy is a motor disorder. What are the common findings that would translate into abnormal gait in cerebral palsy? So we have some negative findings. For example, the muscle weaknesses we see with kids with cerebral palsy. There is impaired or poor selective control meaning these kids they can't isolate and recruit muscles one at a time. There are some postural or synergy patterns that we see in these kids. There are definitely sensory deficits in addition to the motor disorders with cerebral palsy population. Balance and coordination is usually impaired and this contributes further to the gait abnormality. The positive findings are the hyperreflexia. They may have clonus. They may have startle reflexes. They have involuntary movements. So they have a component of abnormal movements whether it's chorea or apoptosis or dyskinesia in general or dystonia and they also have high tone. And lastly, they have deformities, musculoskeletal deformities resulting from multiple factors and these deformities most commonly present as rotational deformities or torsions like I mentioned before, the femoral anteversion or tibial torsions or foot progression angle changes. Also, with the deformities we see a lot of contractures with growth and we see dislocations and the most common of that would be the hip dislocations. But also we see dislocations or subluxations with the distal joints like the midfoot joints, sub-tailor shifts or deformities are a common finding under CP umbrella. I just wanted to throw the slide in there. I know you all know the definition of hypertonia. In the adult world, when we talk about tone, high tone, we always think of spasticity. In the pediatric world, we would like to emphasize dystonia is as common as spasticity and we need to be able to differentiate dystonia or rigidity or spasticity in kids with cerebral palsy or kids with high tone because that impacts our treatment plans for sure. So when we have spasticity and cerebral palsy is a good example of this, we commonly see it in the plantar flexor group and this leads to some very abnormal gait deviations in the stents and swing phase. So both phases of the gait cycle are affected. With the quadriceps spasticity, we know there's excessive knee extension and this usually is observed in the stents phase and sometimes with the quadriceps firing out of phase with dynamic tone that may also impact the swing phase and we will talk about that briefly too. Hamstring spasticity is the most frequent problem with cerebral palsy. It leads to excessive knee flexion. Hip adductor spasticity definitely is a common finding and that leads to contralateral drop in the pelvis during stents phase. So it's not only scissoring when they try to swing through their gait cycle, but it's also during the stents phase that adductor spasticity may play into. One other point I wanted to mention talking about spasticity, cerebral palsy, hypertonia, core contraction is a big component of high tone in our population with CP and what that means is there is an inappropriate activation of two different muscle groups, the agonist and antagonist muscles during voluntary activity. So what this means is for example when you ask a patient, an ambulatory CP patient to walk they may be contracting their hamstrings and quadriceps at the same time and this leads to a different outcome or different abnormality with their gait pattern than just pure hamstring spasticity or pure quadriceps spasticity. The picture is even more complicated when we look at our CP cohort. Now we talked about the negative findings. Weakness is the biggest contribution to abnormal gait in cerebral palsy. When we say muscle weakness we mean the ability to generate force is reduced and this is important especially with those stabilizing muscles. When we have the hip muscles weak, the hip extensor muscles weak, we will compensate by leaning forward and this is a typical finding in our CP population too. When our hip abductors are weak, the drop of the pelvis on the opposite side leads to the stranded lumbar or lateral verge or sway. Of course the muscle weakness will impact the speed or will impact how the kids navigate different terrains or planes of movement. For example when they're turning, their weaknesses will be more exaggerated. It's a good idea to watch a kid walking on a straight line but also asking them to turn so we can watch and see if there's any changes in their gait patterns. And then we talked about the effect of control of movement. We need to remember during gait cycle there are a lot of muscle groups that get activated sequentially and they have different functions or goals so there are different types of contractions that the weakness, muscle weakness may contribute to. It's not only the concentric contractions where the muscles shorten, the weakness may also impact the loss of or cause the loss of eccentric contractions and stability or smoothness of the gait pattern. Now with cerebral palsy gait, I will be talking about how the gait pathology is developed. I just wanted to mention depending on the distribution of findings or the type of cerebral palsy, their gait patterns will be different. We all know with the CP patients, the hemiplegic patients, they all walk eventually. Diplegics, they need assistive devices and some orthotics, but they usually end up walking too. Cardioplegics, they may or may not walk. And then there's some other classifications where we talk about mixed CP and depending on its dystonia and spasticity in the same muscle groups or in the same distribution or we talk about double hemiplegia where the upper extremities are more involved with the lower. But this is a general idea to help us determine where the gait deviations are coming from. So when we talk about CP, we know the gait development relates to the topographical type of CP and also the gross motor functional classification system. So let me briefly show you what the gross motor functional classification system is unless you're already aware of this. So when we talk about ambulatory CP kids, we're referring to the first three kids that have the potential to walk whether with assistive devices or partial or community or household distances. Those are the ones that we need to be very careful evaluating their gait and trying to understand the underlying pathology. So for example, children with mild spastic diplegia fall under gross motor functional classification level one or two and they typically achieve independent walking between the ages of two to four. Yes, they're delayed, but they do arrive at that final outcome which is what we're targeting with our treatment plans. So gait abnormalities in CP often include multiple deviations at multiple joints and it also is seen in multiple planes. So this makes the picture really complicated especially when we're looking at a patient and talking about treatment decisions. So when we see patients, let's say they have spasticity around their knee joint in their hamstrings or quad muscles. So just assessing that particular segment and then not assessing or evaluating the proximal or the distal muscle groups or joints or bony alignment is not going to help us understand the gait abnormality because they all relate to each other and altogether with the very complex relationship we have these limitations in the gait patterns. So the best way to isolate or differentiate the different segments, different joints, different planes of motion abnormalities is of course the 3D instrumental gait analysis and so far with all the high quality evidence or research we have, we know that there is a functional decline in our CP population that is ambulatory if there's no intervention. If you don't plan any interventions, if you don't do surgeries or spasticity care or whatever else we choose to do for our CP populations, the natural course of things is they will decline with their function and some of these changes we see with age includes walking speed which is very reduced with age. It also is leading to increased duration of double support. So now the time spent with both feet down on the ground is longer. The range of motion in the sagittal plane is decreased because there's some stiffness when we watch the hip go through flexion or extension. When we look at the knee joint going through flexion extension movements, there's a lot of stiffness there. And then there's a gradual shift from equinus to neutral to calcaneus at the ankle level. So this is the natural course of CP. If you don't do any treatment interventions, they may start with equinus, then they eventually come down neutral on the ground, and then finally with all the joint changes, deformities and deviations of gait, they end up with a calcaneus walk at the ankle level. So the likelihood of having equinus and in-toeing decreases while crouch and out-toeing or external rotation increases with age. And the higher gross motor functional levels, meaning the more severely involved kids, the more triplegic or quadriplegic kids that are ambulatory, and the more surgery they have, the more crouched and out-toeing they end up with increasing age. So with the CP gait, we have both qualitative and quantitative analysis. We talked about the gait analysis, how that's been crucial in informing decision-making in the surgical or spasticity world. We also have qualitative descriptive terms, which I will mention shortly. Now what is the cornerstone, what is the foundation of treatment, surgical treatment in these kids with all this abnormal, very complex gait patterns? The single event multilevel surgery is the orthopedic surgery recommended for our CP patients. And the reason this surgery works is because as the surgeon addresses the multiple planes of motion abnormality and the multiple levels or segments of deformity in one session, the number of surgeries the kids need as they achieve their adult age or skeletal maturity and also the prolonged recovery or downtime is much less when they need less surgery with our kids. So going back to the gait patterns in CP, before I talk about the descriptive patterns we see or the abnormalities, we need to remember there are primary, secondary, and tertiary deviations in cerebral palsy. The primary being the original, the initial CNS insult or injury that leads to spasticity weakness and compromised or impaired sensory, proprioceptive, visual, or vestibular pathways. The secondary deviations are due to growth. So our kids, different than adults, they keep growing until they hit that adult age or skeletal maturity and with growth we see abnormal loading that leads to shortening of muscle tendon units which we call contractures. It may also result in persistent bony deformities like the rotational deformity of the femur, femoral anteversion. It may result in subluxations, the hip subluxation, or the equino-planovalgus deformity of the feet which at some point may become permanent and would require, again, a surgery to correct. And then of course, in addition to all this, there is the compensation of the individual child that results in very abnormal or maladaptive patterns of walking. So they find ways to be more functional, but while they're trying to do that, they're recruiting wrong muscles and they're not using their biomechanical advantages. So this is just a picture of one of my patients to show a very common finding. I know this is not a video, we do have some videos at the end, but I just want to point out when we see this kid, the first thing that strikes us is the way he is on his toes. But just looking at the ankle, one level, one segment is not going to help us come up with the correct analysis because this kid, yes, has equinus or has toe walk, but he also has some intoeing. And when we talk about intoeing, remember we talked about different segments. So when I look at, well, you may be able to see it some here under his pants, the patella, we need to look at the knee level and see if this is coming from tibia. So he does have some left internal torsion of the tibia. And of course, this picture also emphasizes how important it is to undress our kids and look at the whole body, the whole kinetic chain again, ankles, knees, hips, pelvis, spine, head and neck and everything. Now let's talk about the descriptive or qualitative classification of gait and CP. So this is during the gait cycle, during the stance phase. This is based on the ankle or foot and ankle, knee and hip joints. How do we describe the gait of kids that have cerebral palsy? So equinus gait is one. Jump knee gait or jump gait is the other one. Crouch is a very well-known complication or long-term outcome of CP gait. And then there's also a stiff knee gait, which is a little different because stiff knee gait refers to a swing phase abnormality. So just so I can explain this a little bit better, this is a visual, a diagram that tells you exactly what's going on with our ambulatory kids with CP that have deviations and this is how we classify their gait when we see them in our clinics. So looking at the true equinus, this is where we have plantar flexion at the ankle level and then we have a hip and knee that's extended. And sometimes there's hyperextension of that knee and pretty much it's a straight leg walk, but they're on their toes. Now, when we talk about the jump knee gait, it's a little bit tricky because this time we do see the equinus again. They're hitting with their toes, post-strike or toe walk, but their hips and knees are a little different. They're bent. They're flexed. And most commonly, this hip and knee flexion is accompanied by an anterior pelvic tilt. And we will see a video of this shortly too. And this anterior pelvic tilt usually results in an increased lumbar lordosis. So it's really important to look at all three or four different segments or levels and come up with descriptive terms for the deviations. Now in a different equinus gait, what we call the apparent equinus gait, the kid may be walking on their toes, but when we measure the actual range of motion, when you look at the angle between the tibia and the foot, it's not actually plantar flexion. It is dorsiflexed. So the hips and knees are flexed and then there is some dorsiflexion there. So that's why we call it apparent equinus. Now if they have excessive dorsiflexion at the ankle and they have excessive hip and knee flexion, this is what we would call a crotch gait. And most of these kids actually also have scissoring. And we will talk about crotch gait in a little bit, how we see this or when we see this in our CP patient cohorts. Scissoring is a very common finding and this is at the hip level when we see excessive induction with internal rotation and this may be coexisting with crotch gait or jump gait. So we may have to use multiple descriptive terms when we examine or communicate a gait evaluation. This is another patient of mine and one of my colleagues. This is just a picture again. I just wanted to emphasize with this picture we need to look at the whole kinetic chain. Well obviously you can't see the spine, the rest of the spine here, but it gives you some idea and obviously she's not undressed. But this is again for me to point out how tricky or how complex it is when we talk about gait when the kids have their shoes, their braces on, when they're dressed, they may be messed, the deviations, the patterns of abnormality may be messed. So as clinicians we need to do a little bit better in terms of teasing out or differentiating different reasons or underlying pathologies. So with this kid what you see here is the typical plantar flexion or toe wall, the equinus. Then when you go up you see the knees flexed, you see the hips flexed and this kid actually has the anterior pelvic tilt which means there is a little bit increase of the lordosis too. So when you put it all together this appears as a jump knee gait or maybe an apparent equinus. So to differentiate the jump knee gait from apparent equinus you need to do an exam where you have the kid relaxed supine on the bed or maybe sitting on your exam table and you need to check the range of motion to see if there is dorsiflexion and then you need to get them up barefoot, no socks, no shoes, no braces to watch and see how much dorsiflexion they have while they're walking. We talked about or I mentioned stiff knee gait briefly. The most important thing with the stiff knee gait is that's a swing phase finding in the gait cycle. So going back to the gait cycle unit we look at the stance phase and then we look at the swing phase and different deviations may occur at different phases and that's important to differentiate so we can again come up with a list of multiple problems leading to this one gross gait pattern and based on the problem list we will be addressing each one of them. Now if there's a swing phase abnormality with a knee that's stiff that means on a gait analysis if you have an EMG emission you can put that on your quads muscles, your electrodes on your quads muscles and you'll be catching the rectus femoris or quads getting recruited or firing out of phase and it doesn't calm down during the swing phase. Of course an instrumentational gait analysis will confirm this. The important thing is sometimes the stiff knee gait can be a compensation, can be a tertiary deviation, not a primary deviation like the quadriceps spasticity, but a tertiary deviation as a compensation due to a hip pathology. So if you don't know how to differentiate these two, your surgical management may actually cause harm for this patient so it's very important to again identify each problem at each segment or joint level in each plane. So one last pearl before I go or move on to the couple videos to talk about gait is despite the age-related differences the fundamental components of gait develop at a very early age. So as a result if you have a kid, a young kid or a school-aged kid who is going to be different than an adult with their gait pattern and you watch their gait you need to make sure there's no variation, variability from step to step. So you look at their step cycles, you look at their stride cycles, the full gait cycle unit and you watch them walk and ask them to walk a couple of times for a certain distance so you're looking for the variability from step to step to say if there's anything wrong, anything that would be a pointing and underlying problem and also any change, any deviation from normal is an indication for gait pathology both in children and adults. So they don't have to be adults so they don't have to have a mature gait pattern for us to say there's something wrong with their gait. Now before I go to this slide let me make sure I can play this. I'm hoping everybody can see this. Let me play it one more time. The reason I included this patient of ours and by the way this is a good place for me to mention gait work just like any other pediatric rehab work is a teamwork and it takes a village to treat cerebral palsy and gait problems. So in this picture you see our physical therapy faculty who has been a huge component of our gait work here at Children's. So anyway with this kid what I wanted to show you, oops sorry let me go back and play this one more time. So this is the initial gait study we had on her. Now this kid had some surgeries. I'm not going to go into details and this kid has received a lot of therapy, has braces and in the end she ended up with a gait like this. This is a couple years later. She's a little older. This is in the clinic now, not in the gait lab. This is after a round of surgery mostly at the knee and ankle level. So now going back to remembering what I mentioned earlier with all the gait cycle, with all the metrics, with all the parameters, with all the different levels or segments, it's very hard to look at her and say what is going on exactly. Is there weakness? Yes, there's weakness. Correct? Hip extensors, hip abductors obviously are weak and you can tell that by looking at her and looking at that trunk control abnormality or posture control abnormality and then let's look at the knee level. You can tell there's weaknesses there too. Let me play it one more time and then look at the ankles, the feet. Now I asked her to walk and I asked her to turn and I watched her from front and back and I actually also did the side view too. So when you look at the side view, what you get is all different than what you get when you look at from the coronal view. In this kid, I would classify this as an anterior tilt at the pelvic level, a lot of hip extensor weakness, so there's that forward trunk lean, and she also has, and I know this because I examined her, you couldn't tell this from looking at her, but she also has a hip flexion contracture, she has quadriceps spasticity, so she has a hard time flexing the knees to clear at times. So she started with a stiff knee gait way back, a couple years back, and with all the surgeries and treatment, now she's able to bend the knees a little bit better, but it's not smooth or well controlled. And also she has gastric spasticity, and the way I can tell that is she's not hitting with the toes, but look at that knee going back, so she has knee hyperextension, and when you have knee hyperextension, there could be quadriceps weakness or muscle weakness trying to lock the knee to stabilize the weight acceptance, but also it could be the gastric tightness, the gastric muscle pushing the tibia back or pulling the tibia back and causing this type of gait. So without doing a gait analysis, motion lab analysis, it's very hard to come up with the list of individual problems that lead to this very complex abnormal gait pattern. Now let me see if I can move on to the next video. So this time, again, we're in the gait lab, we're asking him to do his walks, we usually ask him to do five, six walks unless they're tired, sometimes more. So now this kid has a different gait pattern, and his CP is a different type of CP too. Look at that upper extremity. So when we talked about gait, I did say it has to be systematic evaluation, you start at the head and go down, or you can start at the bottom and go up. Look at the way he holds his head. So he's trying to compensate with some visual sensory input, right, and look at that lean towards one side. So spine, trunk has a little bit of that curvature, and that upper guard position with the right arm is dystonia, so that's when the high tone or hypertonia is present with distal movement, this tone kicks in and makes him keep that arm up. And then lastly, when you look at his hip, knee, and ankle, the most prominent feature is equinus, right? So knee flexed, hip flexed, ankle implantar flexion. Okay, let's see if I can move it on to a year later. He had some muscle release surgery. Now of course, the orthopedic surgery addressed one extremity, right, so it doesn't do anything for the arm, but there's some indirect results with surgery and post-op recovery or rehab work with all the physical therapies, strengthening, and all that that goes into it. He's a little bit better, and with aging and maturation, he's a little bit better with his trunk control. But look at what he does with his ankle, which is very different. He still has the dystonic reflex, so he's not on his toes anymore, he's not equinus. He still has a very uncontrolled flat foot gait, almost like slapping, but he's not on his toes. So one more case before I will open it to questions, sorry, not this one. Okay, the last case will be this little guy, and we talked about the kinetic chain, the upper segments, but in this case, I want you to pay attention to both feet and watch and see what he's doing. So remember we talked about secondary deviations, the deformities, subluxations. So subluxations don't always happen at the hip joint level, it may happen with the feet too. The subtalar joint, so that the navicular bone is collapsed, and he is still hitting with his toes, so equinus there. So he has an anterior lean, but his pelvis is not really tilted. There's some hip flexion tightness, knee flexion, equinus, so altogether I would call it jump knee. Again, a very complex abnormal gait pattern. Okay, that's it. Well, if you have any questions, I think we have a few minutes, maybe five minutes, Craig? Yes, thank you so much. That was really fantastic, and I always think the cases at the end of these are perhaps most instructive because you walk through the definitions and protocol and then to apply that is really helpful, I think. I'm not seeing any questions as of yet. They can sometimes trickle in, but I see your email address there on the screen. People can contact you directly if they have any questions that come up with this? Of course. Definitely. That's why I put it here. Anytime. Just email me. If you include pictures, videos, that always helps in terms of coming up with some answers, and if not, I may always ask for more information, but happy to answer or help out with any gait problem. Perfect. Thank you so much. Thank you. I appreciate you inviting me. Yes. Thank you. We appreciate you joining us. Again, here's her email address if anybody has any questions, they can reach out to her directly. Any questions about the lecture series, please feel free to contact me or AAP. You can reach out to us on Twitter, and again, all of the links to these videos are available there on the website physiatry.org slash webinars. Thank you again for joining us, and we appreciate your lecture today.

gait abnormalities

pediatric patients

cerebral palsy

equinus gait

jump knee gait

crouch gait

stiff knee gait

muscle weakness

spasticity