Anderson Gait Analysis Laboratory Edinburgh Physical Examination Anderson Gait Analysis Laboratory Edinburgh

Who’s involved? Physiotherapist Bioengineer Patient handling Muscle strength, tone and bulk assessment Balance testing Postural examination Bioengineer Joint range measurement We currently have no technician working with us in the lab but in his place we have 2 half time trainee bioengineers. Although we have interchangeable skills within the lab we routinely have physiotherapists doing the patient manual handling and the engineer running the technical aspects of the gait analysis session.

What’s included? Passive ROM Active ROM and muscle strength Muscle tone Muscle bulk Balance Posture/bony torsion In addition, we take height, weight, leg length and joint widths for anthropomorphic scaling in our motion analysis software.

Passive ROM Debrunner scoring One handler, one measurer Joint range and muscle length Numerical values for all ranges Manual goniometer / visual estimation This method is followed for all patients seen in the gait lab, although additional procedures are adopted for specific patients, which I will come on to. Debrunner measurement method used for scoring; so no minus values. As mentioned, the physiotherapist moves the patients’ joints through their available range and the start and end points are measured by the engineer with a manual goniometer. Measures are taken of both joint ranges, (e.g. hip flexion, extension) and muscle length, (such as popliteal angle). Although all measures are give a numerical value, some are estimated visually by the physiotherapist. The measures which are visually estimated are: hip adduction, midfoot inversion/eversion and forefoot abduction/adduction. This practice came about after reviewing the inter and intra-rater repeatabilities for measures of physical examination. We found that we could reliably repeat measures within a given tolerance for most joint measures using a goniometer but not all. The purpose of giving an estimated numerical value was to indicate the normality or degree of abnormality that existed. Estimated values are highlighted.

Patient Specific Tone reduction techniques Tone inhibiting positions

Passive hip measures Hip flexion knee flexed Popliteal angle Hip flexion knee extended Abduction knee flexed / knee extended Adduction Hip extension Staheli (S) Thomas (T) Internal rotation prone External rotation prone Duncan-Ely +ve/-ve prone Knee flexion hip extended prone

Passive knee/foot measures Knee extension Knee flexion Dorsiflexion knee flexed / knee extended Forefoot equinus/midfoot break Plantarflexion Subtalar inversion prone Subtalar eversion prone Midfoot inversion Midfoot eversion Forefoot adduction Forefoot abduction

Active ROM and muscle strength Range +Resistance Hip flexors - supine I 5 Quadriceps - supine, hip extended, knee flexed 4 Quadriceps lag ?º Extensors - prone knee flexed M Extensors - prone knee extended O Plantarflexors - prone/ SLS tiptoe Abductors - side lying Dorsiflexors - sitting, voluntary Dorsiflexors -sitting, triple flexion Nil Active range (against gravity) and muscle strength In Range column score I= inner, to shortened position; M=mid, O=outer, in lengthened position; nil = no movement. In Resistance column put range maintained against resistance (i.e., I, M, O, nil). Add MRC 4 or 5 if inner range (i.e., I4). We use this method in kids who have increased muscle tone in preference to the MRC scale. Muscle strength is tested, for the main part in muscle groups rather than individual muscles and always against gravity. This is a good pragmatic measure given that we are interested in their function during gait. It also gives us added information about those muscles which would fall between two stones at MRC grade 2-3 and 3-4, i.e., a good proportion of our diplegics. For patients without altered tone, we use the MRC scale.

Muscle Tone Ashworth’s Score: Clonus Type of spasticity Hip flexors Adductors Internal rotators Rectus femoris Hamstrings (medial/lateral) Tibialis anterior Extensor digitorum/hallucis Triceps surae Tibialis posterior Flexor digitorum/ Flexor hallucis Peronei Clonus Type of spasticity Point of Catch in Rectus Use the Modified Ashworth’s score, 0 = no increase, 1 = slight catch, 2 = slight catch + slight resistance, 3 = more marked increase but easily moved, 4 = considerable increase, passive movement difficult, 5 = affected part rigid in flexion or extension

Muscle Bulk Balance Thigh Calf Sitting Standing Bulk: Visual estimation only Sitting balance tested by a/p and lateral displacement Single leg standing times noted up to a max of 20 seconds

Balance Sitting Standing

Posture and Bony Torsion Spine in sitting Spine in standing Hallux Valgus Patella Alta Hindfoot/thigh Hindfoot/Forefoot Transmalleolar axis Noting Kyphosis/scoliosis/”c” curves, and hallux valgus by observation Patella alta is judged as positive if the patellar tendon is more than 1.5 times the length of the patella. We judge this by eye. Hindfoot/thigh and hindfoot/forefoot measures are taken by goniometer Transmalleolar axis measured in sitting and marked on lined paper. We prefer this method following our study comparing 3 different clinical methods of TMA measurement : prone method, footprint method & jig method. The investigation checked repeatability and agreement between methods. The conclusions stated that there was poor agreement between the methods suggesting that they should not be used interchangeably. The footprint method proved easy to use and was the most repeatable between users of the three methods tested.