Objective gait analysis.

University Degree Mathematical and Computer Sciences

Objective gait analysis made (and continues to make) a significant contribution in improving the outcome of interventions of children with cerebral palsy (CP). The use of objective gait analysis and the change in surgical approach is a prime example of how technology and open, inquiring minds came to interact for the benefit of our patients.
The University Hospital of Leuven (Pellenberg) has seen rapid developments in the area of clinical gait analysis since 1992, using a multidisciplinary approach. For the past decade, the gait laboratory has been a centre for the evaluation of children and adults with gait problems. In today's competitive health care market, we cannot rely on traditional treatment theories without rigid research to prove them. Therefore, apart from the individual clinical gait evaluations, the gait laboratory has always been the heart of numerous research projects.
The team of the gait analysis laboratory was honoured to receive the invitation of the ESMAC committee to organize the eleventh annual meeting in Leuven. We have the privilege of welcoming you to Leuven for the ESMAC gait courses and conference, for the week beginning September 16.

History
The first steps towards a clinical gait analysis laboratory at the University Hospital of Leuven were taken in 1992.
At that time, gait evaluations were performed using a set of normal video cameras and a four camera automatic video system synchronised with a forceplate. From these first evaluations, the use of objective gait analysis became more and more obvious and crucial in defining an optimal treatment plan for children and adults with spasticity.
After a training session with the group under the direction of Prof. Gage at the Gillette Specialty Child Care Center in Minnesota, U.S.A in 1993, Dr. Guy Molenaers, Paediatric orthopaedic surgeon of the University Hospital of Leuven, was convinced of the need for an up-to-date three dimensional gait lab, integrated within the multidisciplinary framework of the hospital. However, lack of both budget and space prevented an immediate update of the available gait lab facilities.
Finally, in July 1996, the gait lab was upgraded with a Vicon 370 system, founded as a multidisciplinary service. This was the result of a joint effort of three departments within the University of Leuven: the department of paediatric orthopaedics under Prof. Fabry, rehabilitation, headed by Prof. Lysens, and the child neurology department led by Prof. Casaer.
The Vicon 370 system with five cameras was synchronised with two AMTI forceplates, four normal video-cameras and a 16 channel surface EMG system. A typical data collection at that time involved kinematic and kinetic data collection, sagittal, coronal and transverse plane split screen video, and bilateral surface EMG of the rectus femoris, vastus lateralis, medial and lateral hamstrings, tibialis anterior, gastrocnemius, soleus, and for some patients gluteus medius, or other surface muscles of the lower limb. The Vicon clinical manager was used to process the data.

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The current gait analysis laboratory
Since September 2001, the three-dimensional lab has been advanced further by means of a Vicon 612 system with eight M-cameras, supported by three AMTI force plates and a 16 channel surface EMG system (K-Lab). For most routine gait analyses, the M-cameras are used at 120 Hz. Gait data are now processed using Polygon, making use of the PluginGait marker set. Bodybuilder software is available for special model development. Clinical gait analysis is always combined with a thorough clinical examination, assessing ROM, spasticity and muscle force and selectivity.
In young children (<4 years) gait analysis is limited to standardized video recording, because of a lack of sustained concentration. The 2D video laboratory runs in parallel with the Vicon 3D lab. The 2D laboratory uses a standardized video protocol in order to characterize motor function, including walking, in young children and adults that do not meet the inclusion criteria for a 3D gait assessment. A video recording is taken in different planes, including a close-up of the foot. Apart from five normal video cameras, the 2D lab also includes a foot pressure system (RS-scan platform and in-shoe pressure measurement system) in order to study pressure distribution in patients with foot deformities. The 2D lab is also used for upper limb evaluation. A standardized protocol for the evaluation of upper limb function has recently been developed and is used with an adopted clinical examination. A special trajectory in the 2D lab is used for energy measurements (Cosmed b4).
Since the Vicon lab began in 1996, over 2500 full 3D gait assessments have been performed according to the established protocol. At present 15 full gait evaluations and between eight and ten video analyses are planned each week.

Clinical applications
From the start of the activities, the major field of interest was the evaluation of gait deviation associated with neuromuscular disorders (mainly children with CP, but also patients with spina bifida, Charcot-Marie Tooth, arthrogryposis). Other evaluated patient categories are tip-toe walkers, children with clubfeet and other lower limb deficiencies. Since 2000, adults are more often evaluated in the gait lab (adults with CP, stroke, craniocerebral trauma, incomplete paraplegia, post-polio gait difficulties, foot problems with total gait involvement and other lower limb deficiencies). The areas of application are continuously extending.
The use of gait analyses in our department serves several purposes:
- First gait evaluation (preferably at a young age)
- Follow-up gait evaluation (frequently throughout growing spurt)
- Evaluation and tuning of ankle foot orthoses
- Evaluation of assistive devices
- Pre-intervention screening (orthopaedic surgery, selective dorsal rhizotomy, Botulinum toxin A treatment, intrathecal baclofen).
- Post-intervention gait analysis to evaluate the individual treatment result and to evaluate the present treatment hypothesis.

The multidisciplinary team
Gait analysis results are discussed during multidisciplinary review meetings. As a result of this, recommendations for therapeutic interventions are formulated and communicated to referring doctors or physiotherapists. These can be a broad selection of either physiotherapy settings, orthoses, surgical procedures directed to elongation or transfer of soft-tissue or restoration of bone alignment, Botulinum toxin injections, selective dorsal rhizotomy, baclofen treatment (oral or intrathecal administration). For each of these interventions, a history exists within the University Hospital of Leuven.

Initially the lab was equipped with a small team. The gait analysis data was collected and processed by one kinesiologist, and discussed within a team comprising a kinesiologist, a paediatric orthopaedic surgeon, a neuro-paediatrician and a paediatric rehabilitation doctor. The laboratory multidisciplinary team gradually expanded, co-ordinated by Dr. Guy Molenaers (paediatric orthopaedic surgeon, clinical director of the gait laboratory), by kinesiologist Kaat Desloovere (PhD in biomechanics, manager of the gait laboratory) and by Professor Roeland Lysens (department director of the rehabilitation division and of C.E.R.M.). The gait laboratory is now a major part of C.E.R.M. (Centre of Evaluation en Rehabilitation of Motor functions) of the University Hospital of Leuven. The gait analysis laboratory team now includes:

Movement sciences:
- Three kinesiologists (with a PhD in biomechanics)
Kaat Desloovere (100 %)
Ilse Jonkers (50 %)
Louis Peeraer (20 %)
- One paediatric therapist (lab assistant)
Catherine Huenaerts (50 %)
- One podologist/therapist (lab assistant)
Barbara Callewaert (100 %)

Secretarial management
Ann Fort (50 %)

Medical staff :
- Two Paediatric orthopaedic surgeons
Dr. Guy Molenaers
Dr. Ludo De Borre
- One paediatric rehabilitation doctor
Dr. Petra Pauwels
- One neuro-paediatrician
Dr. Marijke Eyssen

Physiotherapist:
Jos De Cat (Lic. Physiotherapy - Bobath Instructor)

Students:
A group of students working on research projects

Apart from these core people of the multidisciplinary team, there is a strong interaction with other hospital departments. Multidisciplinary spasticity consultations are ongoing with colleagues of the child neurology department (Prof. De Cock), as well as the neurosurgery department (Prof. Nuttin). Furthermore, similar collaboration with the adult foot clinic (Prof. Dereymaeker) and the adult rehabilitation unit (Dr. Kiekens) has been established. A close cooperation with the orthotic workplace, located at the hospital site, exists to allow optimal orthotic management. There are also close links to the University (Faculty of Physiotherapy and Physical Education) through clinical and fundamental research projects.

Research in the gait laboratory
Clinical gait analysis at the University Hospital of Leuven (Pellenberg) has
seen rapid development in the six years since the opening of the Vicon laboratory. Each patient needs to be evaluated individually, assessing strengths and weaknesses. This is best done in a multi-disciplinary team of health professionals with substantial input from the parents of the patient. With the professional instrumentation and the expertise of the team, we feel confident that we can help our patients to reach their full potential. However, it is also extremely important for us, as health professionals, to always examine the premises that we base our treatment interventions upon. We are determined in the quest for quality improvement by the ethics of our professional associations. We should always be evaluating to ensure that our treatment is effective and constantly be looking for ways to improve it.
Following this philosophy, the gait lab is also the heart of numerous research projects including:
- Evaluation of the influence of integrated multilevel Botulinum toxin A treatment on the gait pattern for children with CP
- Evaluation of the gait patterns of specific patient groups (CP with hemiplegia, adults, clubfeet, etc)
- Evaluation of the influence of different types of orthoses on gait (for different patient groups)
- Study of typical gait patterns (stiff knee, rotational problems)
- Longitudinal evaluations of gait pattern and study of the natural history of children with CP
- Musculo-skeletal modeling (SIMM)

Objective gait analysis.

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