Sign. Pair 1 Cli 1–cli 2 0.17568 1.08991 0.12670 0.170 0.501 0.000 Pair 2 Cli 1 dominant–cli 2 dominant 0.10811 1.02154 0.16794 0.524 0.550 0.000 Pair 3 Cli 1 non-dominant–cli 2 non-dominant 0.24324 1.16441 0.19143 0.212 0.451 0.002 Pair 4 Dominant–non-dominant −0.35135 0.88870 0.14610 0.021 higher (more lax) than cli 2, though not significantly. Finally, the dominant and non-dominant hand (pair 4, scores of cli 1 and 2 added) were compared and a significant difference was found. The non-dominant hand scored more lax than the dominant hand. Significant correlations are found between the scores of cli 1 and 2 (pairs 1–3). The dominant hands from both clinicians were added, this score was compared with the other tests and no significant (Cli versus Mayo) or very low correlations (Cli versus Beighton (0.37), Cli versus GE (0.43)) were found. Between the other tests only low correlations were found: Beighton versus Mayo (0.49), GE versus Mayo (0.57), GE versus Beighton (0.63). 6. Discussion Both clinicians scored the same level of wrist laxity while using their own techniques. Because cli 1 scored (not significantly) higher than cli 2 in all the tests, it may be assumed cli 1 has a higher reference point at this specific population. The difference found between the dominant and non-dominant hand was in contrast with earlier results [6]. A possible reason can be because the muscles strength and tension is likely higher in the dominant hand, the wrist becomes stiffer. The clinical judgment had no or very low correlation with any of the other methods. Correlations, though low, were found between the other methods. Assuming the clinicians estimation of wrist joint laxity is correct, the other methods are not capable of quantifying what they define as wrist joint laxity. Creating a standardized and more detailed scale for clinicians to score the level of wrist joint laxity seems to be the best option for reaching an objective measurement tool. Also, the clinicians test the wrist by translating the hand dorsal and palmar, a measurement device that simulates this movement may be more successful in determining the level of laxity.

Historically, clinical applications of measurements of force and energy followed electromyography and kinematics in temporal sequence. This sequence is mirrored by the order of topics included in this trilogy on the Evolution of Clinical Gait Analysis, with part I [Sutherland DH. The evolution of clinical gait analysis part I: kinesiological EMG. Gait Posture 2001;14:61-70.] devoted to Kinesiological EMG and part II [Sutherland DH. The evolution of clinical gait analysis part II - kinematics. Gait Posture 2002;16(2):159-179,] to Kinematics. This final review in the series will focus on kinetics as it relates to gait applications. Kinematic measurements give the movements of the body segments, which can be compared with,normal controls to identify pathological gait patterns, but they do not deal with the forces controlling the movements. As a major goal of scientifically minded clinicians is to understand the biomechanical forces producing movements, the objective measurement of ground reaction forces is essential. The force,plate (platform) is now an indispensable tool in a state-of-the-art motion analysis laboratory. Nonetheless, it is not a stand-alone instrument as both kinematic and EMG measurements are needed for maximum clinical implementation and interpretation of force plate measurements. The subject of energy assessment is also given mention, as there is a compelling interest in whether walking has,been made easier with intervention. The goals, of this manuscript are to provide a historical background, recognize some of the important contributors, and describe, the current multiple uses of the force plate in gait analysis. The widespread use of force plates for postural analyses is an important and more recent application of this technology, but this review will be restricted to measurements of gait rather than balance activities.Finally, this manuscript presents my personal perspective and discusses the developments and contributors that have shaped my thoughts and actions, and which I have found to be particularly noteworthy or intriguing. Just as in parts I and II, emphasis has been placed on the early development. All subtopics and important contributors, in this third and certainly most challenging of the review papers, have not been included. Some may find that my perceptions are incomplete. I accept responsibility for all deficiencies, as none were intended. Letters to selected contributors and their responses reveal how each contributor built on the work of others. The level of cooperation and sharing by these early investigators is extraordinary. Had they wished to withhold information about their own work, clinical gait analysis would have been severely delayed. (c) 2004 Published by Elsevier B:V.

Orthopedic surgery for patients with cerebral palsy addresses motion impairments, assuming that this will improve motor function. This study evaluates the relationships among clinical impairment measures with standardized assessments of function and disability as an initial step in testing this assumption. A total of 129 ambulatory children and adolescents across six institutions participated in a prospective evaluation that consisted of passive motion and spasticity examination of the lower extremities, three-dimensional gait temporal-spatial and kinematic analysis, and administration of the Gross Motor Function Measure (GMFM) and the Pediatric Outcomes Data Collection Instrument (PODCI). The analysis found that isolated impairment measures of motion and spasticity were only weakly related to motor function in cerebral palsy and even when averaged across multiple joints yielded no more than a fair correlation with functional scores, nor did a combination of impairments emerge that could predict substantial variance in motor function. These findings suggest that caution should be exercised when anticipating functional change through the treatment of isolated impairment and that addressing multiple impairments may be needed to produce appreciable effects.

The Ely Test (or Duncan-Ely test) has been accepted as a clinical tool to assess rectus femoris spasticity by passively flexing the knee rapidly while the patient lies prone in a relaxed state. In this retrospective review, patients' dynamic knee range of motion (ROM) during gait and an electromyogram (EMG) were compared with the results of the Ely test. Data for 70 patients (44 males, 26 females; 104 limbs) were included. Mean age of patients was 13 years, SD 9 years, range 4 years 5 months to 54 years. All patients were diagnosed with cerebral palsy (spastic diplegia, n = 42; spastic quadriplegia, n = 15, and hemiplegia, n = 13). All patients were ambulatory (50 independent, 20 with assistive devices). A standard matrix was used to calculate sensitivity and specificity of the Ely test as well as its positive and negative predictive value. For the gait variables examined (decreased dynamic knee ROM, timing of peak knee flexion, and abnormal EMG in swing) the sensitivity of the Ely test ranged from 56 to 59% and the specificity ranged from 64 to 85%. For the same variables the positive predictive value ranged from 91 to 98% and the negative predictive value ranged from 4 to 19%. The Ely test was shown to have a good positive predictive value (i.e. the certainty about the presence of rectus spasticity in patients with a positive Ely test result) for rectus femoris dysfunction during gait.

The act of walking involves the complex interaction of muscle forces on bones, rotations through multiple joints, and physical forces that act on the body. Walking also requires motor control and motor coordination. Many orthopaedic surgical procedures are designed to improve ambulation by optimizing joint forces, thereby alleviating or preventing pain and improving energy conservation. Gait analysis, accomplished by either simple observation or three-dimensional analysis with measurement of joint angles (kinematics), joint forces (kinetics), muscular activity, foot pressure, and energetics (measurement of energy utilized during an activity), allows the physician to design procedures tailored to the individual needs of patients. Motion analysis, in particular gait analysis, provides objective preoperative and postoperative data for outcome assessment. Including gait analysis data in treatment plans has resulted in changes in surgical recommendations and in postoperative treatment. Use of these data also has contributed to the development of orthotics and new surgical techniques.

Kinematics is treated as a single topic in this manuscript and the emphasis is on early history, just as it was in Part I, Electromyography. Needless to say, neither kinematics nor electromyography, nor kinetics and energy (the latter to be included in Part III) are stand-alone components of clinical gait analysis. The only reason for this selective format is that it lessens my task to be able to write about one subject at a time. One of the consequences of this arbitrary separation is that some contributors, who have enriched more than one portion of clinical gait analysis, are highlighted only in the area in which they have contributed the most. I began with Kinesiological Electromyography in Part I because the earliest stirrings of the dream of clinical gait analysis were expressed in the development of KEMG (kinesiological electromyography). The early investigators realized that very little could be said about the dynamic action of muscles without KEMG. Next, in chronological order, came kinematics. I have been an active participant and eyewitness, and take full responsibility for attempting to write an early history at a time when most of the contributors are still alive. Ordinarily, history is written much later, in order to fully grasp the significance of individual contributions in the tapestry of the whole. As stated in Part I, Electromyography, the emphasis has been placed on the early history. The application of motion analysis to sports medicine, and sports medicine functional analysis, is covered only lightly here, and this should not be interpreted as minimizing its importance. The literature on this subject is now quite voluminous and it would not be possible to cover it adequately in this manuscript. Later historical writings may differ significantly and will hopefully give more recognition to pioneers in later generations: those physicians, engineers, physical therapists and kinesiologists who are lifting the level of clinical gait analysis and directing their energies in expanding clinical directions. It is hoped that this manuscript will prompt additional manuscripts, as well as letters to the editor of Gait and Posture on the content of this review paper.

In 1996, I was asked by Roy Davis, President of the Gait and Clinical Movement Analysis Society, to be the presidential guest speaker at the Birmingham, AL, annual society meeting and present a talk on the development of clinical gait analysis. Following my presentation, James Gage, Editor-in-Chief for Gait and Posture, and David Winter, Associate Editor for review articles requested a manuscript for publication. To address this task I have the advantage of being a participant throughout this exciting era and of personally knowing most of the people mentioned in this manuscript. To prepare for this assignment, I wrote letters and/or made phone calls to them. Their replies to my inquiries, plus their publications, provide documentation for this review paper. The opinions expressed, for better or worse, are my own. Due to space limitations, only a partial list of the many that have contributed is presented and I regret that not all of the important contributors have been included. In some instances they will be found in Part II and Part III. Hopefully, later publications on this subject will correct the omissions. Emphasis has been given to the earliest years and to walking gait. The subject of upper extremity analysis has not been included, though studies of subjects with upper extremity motion problems are carried out in many motion laboratories including our own. A further disclaimer is that the flood of more recent publications does not receive equal coverage. History is being written daily as clinical gait analysis gains momentum. We have barely scratched the surface of the development and potential contributions of clinical gait analysis.

A dynamic knee-brace system (DKBS) has been designed which provides stance phase stability and swing phase freedom. A wrap-spring clutch controls knee flexion. Clutch optimization was performed minimizing clutch length. Kinematic tests on a normal subject using the DKBS document nearly normal dynamic knee flexion during swing (38 degrees versus 53 degrees for normal).

The purpose of this study was to quantify the gait of subjects receiving two injections of either botulinum A toxin or saline vehicle into the gastrocnemius muscle(s). The study group consisted of cerebral palsy patients who walked with an equinus gait pattern. This study was a randomized, double-blinded, parallel clinical trial of 20 subjects. All were studied by gait analysis before and after the injections. There were no adverse effects. Peak ankle dorsiflexion in stance and swing significantly improved in subjects who received the drug and not in controls. Results of this double blind study give support to the short term efficacy of botulinum toxin A to improve gait in selected patients with cerebral palsy.

The purpose of this study was to quantify the gait of subjects receiving two injections of either botulinum A toxin or saline vehicle into the gastrocnemius muscle(s). The study group consisted of cerebral palsy patients who walked with an equinus gait pattern. This study was a randomized, double-blinded, parallel clinical trial of 20 subjects. All were studied by gait analysis before and after the injections. There were no adverse effects. Peak ankle dorsiflexion in stance and swing significantly improved in subjects who received the drug and not in controls. Results of this double blind study give support to the short term efficacy of botulinum toxin A to improve gait in selected patients with cerebral palsy. (C) 1999 Elsevier Science B.V. All rights reserved.

A database of femoral anteversion and neck-shaft angle was compiled of measurements made by the trigonometric fluoroscopic method of 147 patients (267 hips) with cerebral palsy. The angles of femoral anteversion were similar at early ages between healthy children and children with cerebral palsy. However, as the age of the children increased, those with cerebral palsy showed little change in anteversion angle, whereas the healthy children had progressively decreasing angles of femoral anteversion as they approached adulthood. The neck-shaft angle was increased significantly in children with cerebral palsy compared with the angles of healthy children. Patients who were ambulatory were shown to have an increased angle of femoral anteversion and a decreased neck-shaft angle compared with nonambulatory patients. There was no significant difference in angles among the various distributions of involvement, including patients with diplegia, hemiplegia, and quadriplegia.

A self-contained electronically controlled dynamic knee-brace system (DKBS) has been designed and tested which allows knee flexion during swing phase, but restricts flexion during the stance phase of gait. Cardiovascular energy measurements indicate that DKBS use allowed a more energy efficient gait.

Patients with cerebral palsy often develop rotational deformities of the lower extremities. These deformities may be caused by abnormal muscle tone, soft-tissue contractures, or bony malalignment. When rotational deformity persists after correction of the soft-tissue components, bony-realignment procedures are warranted to improve gait in ambulatory patients. We performed a retrospective review of 10 ambulatory children with cerebral palsy and tibial torsion who underwent 13 distal tibial and fibular derotation osteotomies. Preoperative and postoperative three-dimensional gait analysis were used to determine the effect of distal tibial and fibular derotation osteotomy on tibial rotation, foot-progression angle, gait velocity, and moments about the ankle. Mean tibial rotation and foot-progression angle were significantly improved by the procedure. Gait velocity improved but not significantly. Moment data demonstrated a trend toward normal. This study demonstrates that the derotational distal tibial and fibular osteotomy stabilized with percutaneous crossed Kirschner wires is a safe, reliable, and effective procedure for correcting rotational deformities of the leg in patients with cerebral palsy.

Seventeen patients with cerebral palsy (29 hips) underwent psoas recession at the pelvic brim. The operative technique was a direct anterior approach, lateral to the femoral sheath. There were no infections or nerve or arterial injuries. After surgery, clinical examination revealed that fixed hip-flexion contractures decreased significantly in all patients. All of the subjects retained the ability to flex the hip against gravity and against manual resistance. All of the subjects underwent pre- and postoperative gait analysis. Stance-phase dynamic minimum hip flexion decreased significantly. Dynamic pelvic tilt improved to a statistically significant level for the younger children but did not for the group as a whole. There was less improvement with increasing age. Step length was significantly increased and cadence significantly decreased in all patients. We conclude that psoas recession at the pelvic brim, by using the anterior approach, lateral to the femoral sheath, is a safe, reliable, and effective procedure for children with cerebral palsy who have excessive anterior pelvic tilt and excessive dynamic hip flexion or hip-flexion contracture.

Modern movement analysis has significantly altered the surgical treatment of cerebral palsy. By providing an objective measurement of pre- and postoperative kinematics, kinetics, and electromyography, treatments can be devised and outcomes can be assessed. This article reviews the rationale for gait analysis, its component parts, and its utility in the development of modern surgical concepts, such as single stage surgery of the lower extremities, rectus to hamstring transfers, treatment of ankle equinus, and upper extremity tendon transfers. It's use as a clinical tool is also emphasized. MRDD Research Reviews 3:212-219, 1997. © 1997 Wiley-Liss, Inc.

Recognizing that outcome assessments are necessary to justify new and costly prosthetic components, the authors have compared the gait characteristics of a single transfemoral amputee using two prosthetic knee units: the Total Knee and the DAW 4Bar pneumatic knee. All other components of the prosthetic systems were identical, and the patient was given sufficient time to adapt to each system. The authors conducted the research and collected kinematic and kinetic data at the Motion Analysis Laboratory of Children's Hospital in San Diego. Movement measurements varied slightly between the two prosthetic knee units and differed markedly from normal. The gait using the Total Knee unit demonstrated slight movement of the knee into flexion during stance while the gait using the 4Bar pneumatic unit demonstrated full extension throughout stance. During the loading response of the prosthetic limb, a relatively large initial external extension moment occurred with the 4Bar pneumatic knee unit; the Total Knee demonstrated an initial external flexion moment at this same phase. The vertical force and fore/aft shear curves were closer to normal with the Total Knee. Walking velocity and stride length were improved with the Total Knee, but cadence was unchanged. Overall, the gait parameters were more favorable with the Total Knee unit. A single trial such as this does not provide statistically significant data but can serve as a model for multiple studies to obtain objective information about prosthetic systems.

A cartilage-viewing technique was developed to overcome the shortcoming of not seeing the cartilaginous components, believed to play more important role than the osseous components in children's hips, with computed tomography. This technique was applied to 25 dysplastic hips in children younger than 10 years to evaluate their global and local deficiencies. The findings helped us to understand more about their individual problems. To quantify the three-dimensional (3-D) parameters of acetabular anatomy and femoral head coverage, a measuring technique was developed based on digitization of the 3-D coordinates and fitting of every component of the hip. The improved images and the quantified parameters were expected to aid the planning, formulation, and even simulation of individualized surgical treatment for children with developmental dysplasia of the hip.