1. Anderson Gait Analysis Laboratory Edinburgh
Physical Examination
Anderson Gait Analysis Laboratory
Edinburgh

2. 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.

3. 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.

4. 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.

5. Patient Specific
Tone reduction techniques
Tone inhibiting positions

6. 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

7. 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

8. 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.

9. 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

10. 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

11. Balance
Sitting
Standing

12. 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.