6 general measures of walking (nov 2014)
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General measures of walking, Measuring Walking, University of Salford, 2014
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6 general measures of walking (nov 2014)
- 1. General measures of walking Richard Baker Professor of Clinical Gait Analysis Blog: wwRichard.net 1
- 2. 2
- 3. WHO International Classification of Functioning, Disabilities and Handicaps 3
- 4. 4 Environmental Factors (e) Personal factors World Health Organization. How to use the ICF: A practical manual for using the International Classification of Functioning, Disability and Health (ICF). Exposure draft for comment. October 2013. Geneva: WHO Body functions (b) Activity & participation (d) Body stuctures (s) ICF Part 1: Functioning & disabiltiy Part 2: Contextual factors Part Component
- 5. 5 Environmental Factors (e) Personal factors b710 Muscle power b750 Motor reflexes b750 Involuntary movement http://www.icfillustration.com/icfil_eng/b/b75.html Body functions (b) Activity & participation (d) Body stuctures (s) b7 Neuromusculoskeletal and movement related functions b710 Joint mobility b715 Joint stability b720 Bone mobility!? b715 Muscle tone b720 Muscle endurance b71 & b72 Bone and joint functions b73 & b74 Muscle functions b75 – b78 Movement functions b755 Involuntary movement reactions b760 Control of voluntary movement b770 Gait pattern b780 Sensations related to muscles and movement
- 6. 6 Environmental Factors (e) Personal factors http://www.icfillustration.com/icfil_eng/b/b75.html Body functions (b) Activity & participation (d) Body stuctures (s) s7 Structures related to movement s710 Head and neck s720 Shoulder region s730 Upper extremity s740 Pelvic region s750 Lower extermity s760 Trunk s7500 Thigh s7501 Lower leg s7502 Ankle and foot s75000 Bones s75001 Joints (proximal) s75002 Muscles s75003 Ligaments
- 7. 7 Environmental Factors (e) Personal factors d450 Walking d470 Using transportation http://www.icfillustration.com/icfil_eng/b/b75.html Body functions (b) Activity & participation (d) Body stuctures (s) d4 Mobility d410 Changing position d415 Maintaining position b420 Transfers d430 Lifting and carrying d435 Moving with lower extremity b440 Fine hand use d445 Hand and arm use d455 Moving around b460 Moving around in different locations d465 Moving around using equipment d475 Driving b480 Riding animals for transportation d41 & d42 Changing basic body position d43 & d44 Carrying, moving & handling objects d45 & d46 Walking & moving d47 & d48 Moving around using transportation
- 8. 8 Environmental Factors (e) Personal factors d4600 Within home http://www.icfillustration.com/icfil_eng/b/b75.html Body functions (b) Activity & participation (d) Body stuctures (s) D45 & d46 Walking and moving d455 Moving around b460 Moving around in different locations d450 Walking d465 Moving around using equipment d4500 Walking short distances d4501 Walking long distances d4502 Walking on different surfaces d4502 Walking around obstacless d4550 Crawling d4551 Climbing d4552 Running d4553 Jumping d4554 Swimming d4601 Within buildings Other than home d4602 Outside
- 9. 9 Health Condition Disorder or disease Body functions & structure Activity Participation Gait pattern Walking Environmental factors Personal factors Contextual Factors
- 10. Performance and Capacity 10 Performance is what a person does in their actual environment. Capacity is what the person can do in an idealised environment Gait analysis clearly measures Capacity
- 11. Summary • Gait analysis only measures a very small spectrum of the health condition. • Need a much more holistic approach to evaluate clinical outcomes… • … but this is a course on measuring walking! 11
- 12. Temporal spatial parameters 12
- 13. Walking speed • Best measured independently of gait analysis. • Walk tests as far as possible in a given time – 6 minute walk test (6MWT) – 2 minute walk test (2MWT) – 1 minute walk test (1MWT) 13 ATS statement: guidelines for the six-minute walk test. Am J Respir Crit Care Med, 2002. 166(1): p. 111-7.
- 14. 6 minute walk test 14 ATS statement: guidelines for the six-minute walk test. Am J Respir Crit Care Med, 2002. 166(1): p. 111-7.
- 15. 1 minute walk test 15 McDowell, B.C., et al., Validity of a 1 minute walk test for children with cerebral palsy. Developmental Medicine and Child Neurology, 2005. 47(11): p. 744-8.
- 16. 1 minute walk test 16 (After practice walk) No equivalent data for self-selected walking speed? McDowell, B.C., et al., Test-retest reliability of a 1-min walk test in children with bilateral spastic cerebral palsy (BSCP). Gait and Posture, 2009. 29(2): p. 267-9.
- 17. Walking speed is a consequence of stride length and cadence 17
- 18. Normalisation • Required to remove variations in size and weight of patient from the measures we make. • Most important for work with children where there is greatest variablity in size. • May not always be relevant. 18
- 19. Non-dimensional normalisation 19 Hof A. Scaling gait data to body size. Gait Posture. 1996;4:222-3.
- 20. Should really be tested 20 “Raw” “By mass” “Non-dimensional” Schwartz MH, Koop SE, Bourke JL, Baker R. A nondimensional normalization scheme for oxygen utilization data. Gait Posture. 2006; 4(1):14-22.
- 21. Non-dimensional normalisation • Removes most of the systematic variability amongst gait parameters after children are old enough to cooperate reliably enough for gait analysis to be practical (age 5?) 21
- 22. Non-dimensional normalisation Results do not have units. Not familiar (particularly to referring clinicians). Report as % of normative reference values. 22
- 23. Gait indices 23
- 24. Gait indices Single number to reflect the quality of gait. • Gillette Gait Index (GGI, normalcy index) • Gait deviation index (GDI) • Gait profile score (GPS) 24
- 25. Gillette Gait Index • Originally called “Normalcy” index • Doesn’t feel right! – Small number of parameters – Mixes temporal-spatial and kinematics – Black box – No significance to values – Forgot to take the square root! 25
- 26. GPS and GDI Extremely similar measures 26
- 27. 27 GPS and GDI Baker, R., et al., The gait profile score and movement analysis profile. Gait Posture 2009;30(3):265-9. Both measure how different the gait pattern is from the average normal trace
- 28. GPS and GDI • GPS simple score (how many degrees different from normal) – About 6º is normal – Girl scores 16º • GDI – – 100 = normal – 10 points = one standard deviation – Girl scores 74/100 28
- 29. GPS an GDI The same measure scaled in two different ways. 29 퐆퐃퐈 ≈ ퟏퟎퟎ − ퟏퟎ × 퐥퐧 푮푷푺 − 푨 푩 퐆퐏퐒 ≈ 퐞퐱퐩 퐁(ퟏퟎퟎ − 퐆퐃퐈) ퟏퟎ + 푨 A = mean ln RMS , and B = sd ln RMS Absolutely no point calculating both – they tell you the same thing! An New Method for Computing the Gait Deviation Index and Motion Analysis Profile Schwartz, Rozumalski and Baker, GCMAS 2013
- 30. 30 GPS and MAP Baker, R., et al., The gait profile score and movement analysis profile. Gait Posture 2009;30(3):265-9.
- 31. GPS and MAP GPS = 16.2° (normal = 6 °) GPS = 9.1° (normal = 6 °)
- 32. Gait profile score vs GMFCS Baker R, McGinley JL, Schwartz MH, Beynon S, Rozumalski A, Graham HK, et al. The gait profile score and movement analysis profile. Gait Posture. 2009; 30(3):265-9.
- 33. Gait profile score vs FAQ Baker R, McGinley JL, Schwartz MH, Beynon S, Rozumalski A, Graham HK, et al. The gait profile score and movement analysis profile. Gait Posture. 2009; 30(3):265-9.
- 34. Gait profile score vs speed Baker et al. Gait and Posture 2009
- 35. Gait profile score vs clinical opinion Beynon S, McGinley JL, Dobson F, Baker R. Correlations of the Gait Profile Score and the Movement Analysis Profile relative to clinical judgments. Gait Posture. 201;32(1):129-32.
- 36. MAP vs clinical opinion Beynon S, McGinley JL, Dobson F, Baker R. Correlations of the Gait Profile Score and the Movement Analysis Profile relative to clinical judgments. Gait Posture. 201;32(1):129-32.
- 37. Minimal clinically important difference 37 MCID = 1.6° Baker R, McGinley JL, Schwartz M, Thomason P, Rodda J, Graham HK. The minimal clinically important difference for the Gait Profile Score. Gait Posture. 2012;35(4):612-5.
- 38. Assessing efficacy of interventions 38
- 39. Change in GPS following SEMLS 39 y = 0.16x + 8.10 R² = 0.07 y = 0.12x + 10.77 R² = 0.04 30° 25° 20° 15° 10° 5° 0° GMFCS II GMFCS III 95% normal range 90% 80% 50% 0° 5° 10° 15° 20° 25° 30° Postoperative GPS Preoperative GPS
- 40. Change in GPS following SEMLS 40 y = 0.84x - 8.10 R² = 0.68 y = 0.88x - 10.77 R² = 0.68 20° 15° 10° 5° 0° -5° -10° GMFCS II GMFCS III 95% normal range 90% 80% 50% 0° 5° 10° 15° 20° 25° 30° Improvement (decrease) in GPS Pre-operative GPS +MCID -MCID
- 41. Change in GPS following SEMLS 41 If we analyse all these children as a group then we might conclude that surgery improves gait quality for all children. If we look at the underlying data we realise that it only really benefits the more severely affected children.
- 42. MCID 42 y = 0.84x - 8.10 R² = 0.68 y = 0.88x - 10.77 R² = 0.68 20° 15° 10° 5° 0° -5° -10° GMFCS II GMFCS III 95% normal range 90% 80% 50% 0° 5° 10° 15° 20° 25° 30° Improvement (decrease) in GPS Pre-operative GPS +MCID -MCID 66% of children had a change of greater than MCID. Improved
- 43. MCID 43 y = 0.84x - 8.10 R² = 0.68 y = 0.88x - 10.77 R² = 0.68 20° 15° 10° 5° 0° -5° -10° GMFCS II GMFCS III 95% normal range 90% 80% 50% 0° 5° 10° 15° 20° 25° 30° Improvement (decrease) in GPS Pre-operative GPS +MCID -MCID 66% of children had a change of greater than MCID. Improved 32% of children had a change a change of less than MCID either way. No change
- 44. MCID 44 y = 0.84x - 8.10 R² = 0.68 y = 0.88x - 10.77 R² = 0.68 20° 15° 10° 5° 0° -5° -10° GMFCS II GMFCS III 95% normal range 90% 80% 50% 0° 5° 10° 15° 20° 25° 30° Improvement (decrease) in GPS Pre-operative GPS +MCID -MCID 66% of children had a change of greater than MCID. Improved 32% of children had a change a change of less than MCID either way. No change 2% of children deteriorated by more than MCID Deteriorated
- 46. Detecting change Statistically importance To have 95% confidence that 2 measures are different the change needs to be 3 times the standard error of measurement (SEM) • Need to know the SEM. • Can be quite large for many clinical measures. 46
- 47. Detecting change Statistically importance 47 x3! McGinley JL, Baker R, Wolfe R, Morris ME. The reliability of three-dimensional kinematic gait measurements: a systematic review. Gait Posture. 2009 Apr;29(3):360-9.
- 48. Detecting change Statistically important change 48 x3! McDowell BC, Hewitt V, Nurse A, Weston T, Baker R. The variability of goniometric measurements in ambulatory children with spastic cerebral palsy. Gait Posture. 2000 Oct;12(2):114-21.
- 49. Need more reliable measures for clinical use than we do for research 49
- 50. Thanks for listening Richard Baker Professor of Clinical Gait Analysis Blog: wwRichard.net 50
Notas del editor
- The International Classification of Functioning, Disability and Health (known affectionately as the ICF) is a way of thinking about health conditons. It was the result of considerable debate within the World Health Organisation leading up to its endorsement by all 191 WHO Member States in the Fifty-fourth World Health Assembly in 2001 (resolution WHA 54.21) as the international standard to describe and measure health and disability. It stresses health and functioning rather than disability and assumes that we can all have some decrement in health and thus some experience some disability. People with disabilities are thus seen on a continuum with the rest of us and not as in a specific category. It also tries to provide an alternative to either a medical or social model of disability. In a medical model, disability is seen as a fearure of the individual. It needs to be addressed through individual treatment by health professionals. Thus a limitation in walking ability requires treatment of the individual to give them greater function. In a social model, disability is seen as a socially created problem rather than as an attirbute of any individual. It needs to be addressed by challenging society’s attitudes and structures. A limitation in walking might thus require the modification of the environment or the provision of a wheelchair. The ICF aims to incorporate elements of both models. (If you want to get technical it is an example of a biopsychosocial model).
- Although the model is not percieved as hierarchical (the different aspects of the model are simply seen as interacting with each other) the [1] classification does have a hiearachical structure. It is divided into two parts. Within Functioning and Disability, Body Functions and structures are separated out so that codes describing function are prefixed by a b and those describing structures by an s. Activity and participation, on the other hand are grouped together with codes prefixed by the letter d. [3] Following the underlying model Contextual factors are divided into Environmental (prefixed by an e) and Personal (which as I’ve already commented are not yet specified. [4] The five boxes at this level are termed components.
- Within body functions the most relevant chapter is 7 Neuromsuculoskeletal and movement related functions. This is subdivided using the second digit into three. Bone and joint functions are subdivided into joint mobility and stability and bone mobility. I’m not particularly convinced by this last category and suspect this is a consequence of two many generalists on the WHO committee that drew upthe classification. Mobility isn’t really a characteristic of bones. Even for the scapula, pelvis, carpal and tarsal bones that are listed within this group it is essentially the joints that are immobile rather than the bones. It may sound paradoxical but the main contribution that bones make to movement is their rigidity and geometic alingment. I can’t see anywhere in the ICF that this can actually be captured. There is a further level of coding depending on the extent of the problem (single joint, several joints or a genearl joint condition). Muscle function does seem to be reasonably sensibly divided into power (we’d pribably tend to refer to “strength” in clinical biomechanics), Tone and endurance. As with the jointe the next level down refers to the extent of the problem. The final group here are Movement Functions. Where orthopaedists appear to have been missed out on defining the roles of bones and joints the neurologists would appear to have had a field day here. Not only are there 6 categories here but for many of these there is a further level of refinement. Involuntary movements for example is further sub-divided into Involuntary contractions, Tremor, Tics, Sterotypies (whatever they are), other and unspecified. What is perhaps most significant here is that the gait pattern is listed as a movement pattern. We’ll come back to this a little later in the talk.
- The classification of body structures is quite different in that it is by anatomical region first and then by the structures. Thus the second digit defines the broad region (the lower extremity for example), the [1] third a more specific segment (the thigh) and the [2] fourth the type of structure (bone, joint, muscle or ligament). Note that joints between segments are included with the more distal segment.
- Within activity and participation Chapter 4 refers to mobility and is subdivided into four. [1] The first group [2] includes changing and maintaining body position and trasferring oneself. The second group [3] is divided into lifting and carrying, moveing with the lower extremity, fine hand use and hand and arm use. The most relevant group for us [4] is the third which is subdivided into walking, moving around, moving around in different locations and moving around using equipment. The final group [5] is includes moving around using transportation, driving and riding animals for transportation. All of these are further sub-divided. We’ll only look a the subdivisions of the most relevant category walking and moving.
- Walking [1] is divided into short and long distances, different surfaces and around obstacles. Moving around [2] specifies types of movement other than walking. Moving around in different locations specifies within the home, within building s other than home and outside.
- The structure also allows us to think about what we are doing in gait analysis. Walking as we’ve just been considering it is seen as an activity [1]. The gait pattern, however, is considered to be a function of the neuromusculoskeletal system. Presumably we are talking about the production of a stereotypical cyclic pattern of movement that can move us from one place to another. This makes it very clear that although the aim of our patient management may be to improve their ability to walk (an activity) the tests we are performing are a documentation of function. Gait analysis is thus an analysis of function.
- The classification also rerminds us of the importance of performance and capacity in relation to activity and participation. What we are measuring in the gait analysis laboratory is capacity. It is the ability to perform in an idealised environment on a flat uncluttered surface whilst able to focus fully on the task. What is generally important to the individual is performance, what they do in the real world. Patients, families and health professionals may need to be reminded that what we are measuring is capacity if the results conflict with their lived experience of performance.