Utilizing three dimensional clinical gait analysis to optimize mobility outcomes in incomplete spinal cord damage

Improvement of the gait deviation index for spinal cord injury to broaden its applicability: the reduced gait deviation index for spinal cord injury (rSCI-GDI)

Background

The SCI-GDI is an accurate and effective metric to summarize gait kinematics in adults with SCI. It is usually computed with the information registered with a photogrammetry system because it requires accurate information of pelvic and hip movement in the three anatomic planes, which is hard to record with simpler systems. Additionally, due to being developed from the GDI, the SCI-GDI is built upon nine joint movements selected for a pediatric population with cerebral palsy, for which the GDI was originally developed, but those nine movements are not necessarily as meaningful for adults with SCI. Nevertheless, pelvic movement and hip rotation have been proven to have low reliability even when acquired with gold-standard photogrammetry systems. Additionally, the use of photogrammetry is limited in real-life scenarios and when used with rehabilitation technologies, which limits the use of the SCI-GDI to evaluate gait in alternative scenarios to gait laboratories and to evaluate technologies for gait assistance. This research aimed to improve the SCI-GDI to broaden its applicability beyond the use of photogrammetry.

Methods

An exploration of the mathematical relevance of each joint movement included in the original GDI for the performance of the metric is performed. Considering the results obtained and the clinical relevance of each of the 9 joints used to compute the SCI-GDI in the gait pattern of the SCI population, a more adaptable SCI-GDI is proposed using four joint movements that can be precisely captured with simpler systems than photogrammetry: sagittal planes of hip, knee and ankle and hip abduction/adduction.

Results

The reduced SCI-GDI (rSCI-GDI) effectively represents gait variability of adults with SCI as does the SCI-GDI, while providing more generalizable results and equivalent or stronger correlations with clinical tests validated in the population. During the derivation of the improved index, it was demonstrated that pelvic movements, hip rotation, and foot progression angle introduce high variability to the dataset of gait patterns of the adult population with SCI, but they have low relevance to characterize gait kinematics of this population. The rSCI-GDI can be calculated using the 14-feature vectorial basis included in the electronic addendum provided.

Factors influencing the clinical adoption of quantitative gait analysis technology with a focus on clinical efficacy and clinician perspectives: A scoping review

INTRODUCTION

Quantitative gait analysis (QGA) has the potential to support clinician decision-making. However, it is not yet widely accepted in practice. Evidence for clinical efficacy (i.e., efficacy and effectiveness), as well as a users' perspective on using the technology in clinical practice (e.g., ease of use and usefulness) can help impact their widespread adoption.

OBJECTIVE

To synthesize the literature on the clinical efficacy and clinician perspectives on the use of gait analysis technologies in the clinical care of adult populations.

METHODS

This scoping review followed the Joanna Briggs Institute (JBI) methodology for scoping reviews. We included peer-reviewed and gray literature (i.e., conference abstracts). A search was conducted in MEDLINE (Ovid), CENTRAL (Ovid), EMBASE (Ovid), CINAHL (EBSCO) and SPORTDiscus (EBSCO). Included full-text studies were critically appraised using the JBI critical appraisal tools.

RESULTS

A total of 15 full-text studies and two conference abstracts were included in this review. Results suggest that QGA technologies can influence decision-making with some evidence to suggest their role in improving patient outcomes. The main barrier to ease of use was a clinician's lack of data expertise, and main facilitator was receiving support from staff. Barriers to usefulness included challenges finding suitable reference data and data accuracy, while facilitators were enhancing patient care and supporting clinical decision-making.

SIGNIFICANCE

This review is the first step to understanding how QGA technologies can optimize clinical practice. Many gaps in the literature exist and reveal opportunities to improve the clinical adoption of gait analysis technologies. Further research is needed in two main areas: 1) examining the clinical efficacy of gait analysis technologies and 2) gathering clinician perspectives using a theoretical model like the Technology Acceptance Model to guide study design. Results will inform research aimed at evaluating, developing, or implementing these technologies.

FUNDING

This work was supported by the Walter and Maria Schroeder Institute for Brain Innovation and Recovery and AGE-WELL Graduate Student Award in Technology and Aging [2021,2022].

Construct Validity of the Gait Deviation Index for People With Incomplete Spinal Cord Injury (GDI-SCI)

BACKGROUND

The Gait Deviation Index for Spinal Cord Injury (SCI-GDI) was recently proposed as a dimensionless multivariate kinematic measure based on 21 gait features derived from 3-dimensional kinematic data which quantifies gait impairment of adult population with incomplete spinal cord injury (iSCI) relative to the normative gait of a healthy group. Nevertheless, no validity studies of the SCI-GDI have been published to date.

OBJECTIVE

To assess the construct validity of the SCI-GDI in adult population following iSCI. Methods. SCI-GDI data were obtained from a sample of 50 healthy volunteers and 35 adults with iSCI. iSCI group was also assessed with the following measures: 10-Meter Walk Test (10MWT) at both self-selected (SS) and maximum speeds, Timed Up and Go Test (TUGT), SS and maximum levels of the Walking Index for Spinal Cord Injury (WISCI) II, mobility items of the Spinal Cord Independence Measure III (SCIM IIIIOMob), Lower Extremity Motor Score (LEMS), and Modified Ashworth Scale (MAS). Spearman's correlation coefficient was used to investigate the relationship with the SCI-GDI.

RESULTS

SCI-GDI shows strong correlation with the 10MWT (r ≥ -.716) and good correlation with LEMS (r = .638), TUGT (r = -.582), SS WISCI II levels (r = .521), and SCIM IIIIOMob (r = .501). No significant correlations were found with maximum WISCI II levels and MAS (P > .006).

CONCLUSIONS

Construct validity of the SCI-GDI was demonstrated with the 10MWT, TUGT, LEMS, SCIM IIIIOMob, and SS WISCI II levels for independently walking adults with iSCI. Future work will include assessing the psychometric characteristics with a more heterogeneous sample, also considering the pediatric population.

[Movement analysis in spinal cord injuries : Assistance in clinical decision making]

For motor incomplete spinal cord injured patients, improvement of walking function is an important aim in the rehabilitation program. In specialized treatment centers, the 6‑minute walking test, the 10-meter walking test or the timed-up-and-go test are used as an assessment tool to determine walking ability, but these tests are not able to assess the quality of gait. Marker-based movement analysis can be used as a reliable method to evaluate the gait pattern. This allows an objective assessment of gait quality over time or can be used to support therapy planning. The benefit of such an analysis is presented by means of two case studies.

Factors Influencing the Clinical Adoption of Quantitative Gait Analysis Technologies for Adult Patient Populations With a Focus on Clinical Efficacy and Clinician Perspectives: Protocol for a Scoping Review

BACKGROUND

Quantitative gait analysis can support clinical decision-making. These analyses can be performed using wearable sensors, nonwearable sensors, or a combination of both. However, to date, they have not been widely adopted in clinical practice. Technology adoption literature has highlighted the clinical efficacy of technology and the users' perspective on the technology (eg, ease of use and usefulness) as some factors that influence their widespread adoption.

OBJECTIVE

To assist with the clinical adoption of quantitative gait technologies, this scoping review will synthesize the literature on their clinical efficacy and clinician perspectives on their use in the clinical care of adult patient populations.

METHODS

This scoping review protocol follows the Joanna Briggs Institute methodology for scoping reviews. The review will include both peer-reviewed and gray literature (ie, conference abstracts) regarding the clinical efficacy of quantitative gait technologies and clinician perspectives on their use in the clinical care of adult patient populations. A comprehensive search strategy was created in MEDLINE (Ovid), which was then translated to 4 other databases: CENTRAL (Ovid), Embase (Ovid), CINAHL (EBSCO), and SPORTDiscus (EBSCO). The title and abstract screening, full-text review, and data extraction of relevant articles will be performed independently by 2 reviewers, with a third reviewer involved to support the resolution of conflicts. Data will be analyzed using content analysis and summarized in tabular and diagram formats.

RESULTS

A search of relevant articles will be conducted in all 5 databases, and through hand-searching in Google Scholar and PEDro, including articles published up until December 2022. The research team plans to submit the final scoping review for publication in a peer-reviewed journal in 2023.

CONCLUSIONS

The findings of this review will be presented at clinical science conferences and published in a peer-reviewed journal. This review will inform future studies designed to develop, evaluate, or implement quantitative gait analysis technologies in clinical practice.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/39767.

Kinematics and paraspinal muscle activation patterns during walking differ between patients with lumbar spinal stenosis and controls

BACKGROUND

The narrowing of the spinal canal due to degenerative processes may lead to symptomatic lumbar spinal stenosis (sLSS) and impairments in the patients' gait. Changes in lower extremity joint kinematics and trunk flexion angles have been reported, yet less is known about muscle activation patterns of paraspinal and gluteal muscles in patients with sLSS compared to healthy participants.

RESEARCH QUESTION

Do muscle activation patterns together with sagittal joint kinematics differ between patients with sLSS and healthy controls and do these differences-quantified using gait scores-correlate with clinical scores?

METHODS

In 20 patients with sLSS scheduled for surgery and 19 healthy participants, gait was assessed using seven inertial sensors and muscle activation of gluteus medius, erector spinae and multifidus using wireless surface electromyography (EMG). Differences in joint kinematics and EMG patterns were assessed using statistical parametric mapping with non-parametric independent sample t tests (P < 0.05). Gait scores that describe the overall deviation in joint angles (mGPS) and muscle activation patterns (EMG-Profile Score) were calculated as root mean square distances between patients and healthy participants and their associations with clinical scores (pain, Oswestry Disability Score (ODI)) were analyzed using Spearman's correlation coefficients rho (P < 0.05).

RESULTS

Patients had larger mGPS (+1.9°) and EMG-Profile Scores (+50%) and walked on average slower (-0.26 m/s) than controls. EMG patterns revealed higher activation of multifidus, erector spinae and gluteus medius during midstance in patients compared to controls. Clinical scores (pain, ODI) did not correlate with mGPS or EMG-Profile Scores within patients.

SIGNIFICANCE

Observed differences in gait and muscle activation patterns and in the summary scores of gait and EMG deviations between patients with sLSS and healthy controls may represent additional functional outcomes reflecting the functional status of patients that can be measured using wearable sensors and hence is suitable for application in clinical practice.

Characterizing The State Of Heart Rate Autonomic Regulation And EEG In Elderly Women With Falls Syndrome

Objective — The goal of our study was to evaluate the contribution of the central and autonomic nervous systems to the maintenance of postural balance in the elderly. Material and Methods ― This study included 120 healthy women 60-74 YO living in the community. They were distributed among two subgroups: (1) fallers (n=60) and (2) non-fallers (n=60). Fallers had falls in the past 12 months, while non-fallers had none. Walk tests were performed using Balance Master® posturography machine (NeuroCom, Natus, USA). The state of the central nervous system was assessed by Geodesic 300 EEG system (GSN; Electrical Geodesics, Inc.; Eugene, OR, USA). The state of the autonomic nervous system was assessed by the VNS-Spectrum (Neurosoft, Russia) via cardiointervalography. Results ― In Sit to Stand test, the postural sway velocity was higher (p=0.047) and the walking speed (p=0.008) in Tandem Walk test was lower in fallers, compared with non-fallers. The results of the Step Quick Turn test showed that the movement times of the left and right legs were longer for the fallers vs. non-fallers (p=0.044 and p=0.036, respectively), and postural sway values during turning left or right were higher in fallers as well (p=0.001 and p=0.003, correspondingly). At the same time, Step Up and Over test revealed that lift-up index values were higher in fallers vs. non-fallers (p=0.016). There were no statistically significant differences between the groups in the state of the autonomic nervous system. The absolute spectral power of the EEG was lower in the frontal region of the right hemisphere in the alpha and beta EEG bands in the study group, compared with the control. Conclusion ― A deterioration in the quality of performing complex motor actions and a decrease in postural control in elderly women with falls syndrome were which may have caused their postural instability. Our results confirmed the need for early assessment of the dynamic components of postural control to prevent the development of falls as a geriatric syndrome.

Three dimensional analysis of hip joint reaction force using Q Hip Force (AQHF) software: Implication as a diagnostic tool

Assessment of hip joint reaction force (JRF) is one of the analytical methods that can enable an understanding of the healthy walking index and the propensity towards disease. In this study, we have designed software, Analysis Q Hip Force (AQHF), to analyze the data retrieved from the mathematical equations for calculating the JRF and ground reaction force (GRF) that act on the hip joint during the early part of the stance phase. The stance phase is considered the least stable sub-phase during walking on level ground, and the gait stability is sequentially minimized during walking on elevated ramps. We have calculated the JRF and GRF values of walking stances on varied inclinations. The data obtained from these calculations during walking on elevated ramps were exported from mathematical equations to Q Hip Force software as two separate values, namely the JRF data and GRF data of the hip joint. The Q Hip Force software stores the two reaction force data in a text file, which allows the import and easy readability of the analyzed data with the AQHF application. The input and output data from the AQHF software were used to investigate the effect of different walking ramps on the magnitude of the hip JRF and GRF. The result of this study demonstrates a significant correlation between the JRF/GRF values and healthy walking indices till a ramp elevation of 70°. The software is designed to calculate and extrapolate data to analyze the possibility of stress in the hip joint. The framework developed in this study shows promise for preclinical and clinical applications. Studies are underway to use the results of JRF and GRF values as a diagnostic and prognostic tools in different diseases.

Derivation of the Gait Deviation Index for Spinal Cord Injury

The Gait Deviation Index (GDI) is a dimensionless multivariate measure of overall gait pathology represented as a single score that indicates the gait deviation from a normal gait average. It is calculated using kinematic data recorded during a three-dimensional gait analysis and an orthonormal vectorial basis with 15 gait features that was originally obtained using singular value decomposition and feature analysis on a dataset of children with cerebral palsy. Ever since, it has been used as an outcome measure to study gait in several conditions, including spinal cord injury (SCI). Nevertheless, the validity of implementing the GDI in a population with SCI has not been studied yet. We investigate the application of these mathematical methods to derive a similar metric but with a dataset of adults with SCI (SCI-GDI). The new SCI-GDI is compared with the original GDI to evaluate their differences and assess the need for a specific GDI for SCI and with the WISCI II to evaluate its sensibility. Our findings show that a 21-feature basis is necessary to account for most of the variance in gait patterns in the SCI population and to provide high-quality reconstructions of the gait curves included in the dataset and in foreign data. Furthermore, using only the first 15 features of our SCI basis, the fidelity of the reconstructions obtained in our population is higher than that when using the basis of the original GDI. The results showed that the SCI-GDI discriminates most levels of the WISCI II scale, except for levels 12 and 18. Statistically significant differences were found between both indexes within each WISCI II level except for 12, 20, and the control group (p < 0.05). In all levels, the average GDI value was greater than the average SCI-GDI value, but the difference between both indexes is larger in data with greater impairment and it reduces progressively toward a normal gait pattern. In conclusion, the implementation of the original GDI in SCI may lead to overestimation of gait function, and our new SCI-GDI is more sensitive to larger gait impairment than the GDI. Further validation of the SCI-GDI with other scales validated in SCI is needed.

Gait and dynamic balance in adults with spina bifida

BACKGROUND

Spina bifida (SB) is a complex congenital malformation, often causing impaired gait performance depending on the level and extent of malformation. Research regarding gait and balance performance in adults with SB, has not been sufficiently described yet.

RESEARCH QUESTION

What are the characteristics of spatiotemporal gait parameters and balance performance in adults with SB? Further, do persons with muscle function (MF) level 3 differ regarding gait and balance performance from those with MF level 1-2?

METHODS

Cross-sectional observational study at an outpatient clinic. 41 adults with SB (18-65 years), who walked regularly. Spatiotemporal parameters of gait was assessed with the APDM system and balance performance with the Mini Balance Evaluation Systems Test (Mini-BESTest). Muscle strength in the legs was assessed with 0-5 manual muscle test, and participants were classified according to level of MF into groups MF1, MF2, and MF3. Two-sided t-test was used for parametric independent variables, and Cohen's d was used for effect sizes. The Mann-Whitney U test was used for non-parametric independent data and effect size was calculated by the z value (r = z/√n).

RESULTS

Mean gait speed was 0.96 (SD 0.20) m/s and mean stride length 1.08 m (SD 0.17), individuals with MF3 showed significantly slower gaitspeed and shorter stride length (p < 0.05). Lumbar rotation was 21° (SD 11), and thoracic lateral sway 15° (IQR 15) with significantley difference (p < 0.001 and p < 0.05) for individuals in MF3. Mini-BESTest showed a mean score of 11.3 (SD 6.9), and individuals with MF3 showed significantly lower scores (p ≤ 0.001).

SIGNIFICANCE

Gait and balance performance was reduced compared to normative data in almost all parameters, especially in persons with less muscle function. Increased knowledge from advanced gait analysis may help healthcare professionals to design rehabilitation programmes, in order to achieve and maintain a sustainable gait and balance performance.

Application of the Gait Deviation Index to Study Gait Impairment in Adult Population With Spinal Cord Injury: Comparison With the Walking Index for Spinal Cord Injury Levels

The Gait Deviation Index (GDI) is a multivariate measure of overall gait pathology based on 15 gait features derived from three-dimensional (3D) kinematic data. GDI aims at providing a comprehensive, easy to interpret, and clinically meaningful metric of overall gait function. It has been used as an outcome measure to study gait in several conditions: cerebral palsy (CP), post-stroke hemiparetic gait, Duchenne muscular dystrophy, and Parkinson’s disease, among others. Nevertheless, its use in population with Spinal Cord Injury (SCI) has not been studied yet. The aim of the present study was to investigate the applicability of the GDI to SCI through the assessment of the relationship of the GDI with the Walking Index for Spinal Cord Injury (WISCI) II. 3D gait kinematics of 34 patients with incomplete SCI (iSCI) was obtained. Besides, 3D gait kinematics of a sample of 50 healthy volunteers (HV) was also gathered with Codamotion motion capture system. A total of 302 (iSCI) and 446 (HV) strides were collected. GDI was calculated for each stride and grouped for each WISCI II level. HV data were analyzed as an additional set. Normal distribution for each group was assessed with Kolmogorov-Smirnov tests. Afterward, ANOVA tests were performed between each pair of WISCI II levels to identify differences among groups (p < 0.05). The results showed that the GDI was normally distributed across all WISCI II levels in both iSCI and HV groups. Furthermore, our results showed an increasing relationship between the GDI values and WISCI II levels in subjects with iSCI, but only discriminative in WISCI II levels 13, 19, and 20. The index successfully distinguished HV group from all the individuals with iSCI. Findings of this study indicated that the GDI is not an appropriate multivariate walking metric to represent the deviation of gait pattern in adult population with iSCI from a normal gait profile when it is compared with the levels of walking impairment described by the WISCI II. Future work should aim at defining and validating an overall gait index derived from 3D kinematic gait variables appropriate for SCI, additionally taking into account other walking ability outcome measures.

Walking Ability Outcome Measures in Individuals with Spinal Cord Injury: A Systematic Review

Walking function recovery in spinal cord injury (SCI) is tackled through several therapeutic approaches in which precise evaluation is essential. A systematic review was performed to provide an updated qualitative review of walking ability outcome measures in SCI and to analyze their psychometric properties. PubMed, Cochrane, and PEDro databases were consulted until 1 April 2020. Seventeen articles written in English were included. Five of them studied the walking index for SCI, four studied the 10 meter walk test, and two studied the six-minute walk test, the timed Up and go test, and the Berg balance scale. The rest of the articles studied the following metrics: gait profile score, spinal cord injury functional ambulation profile, five times sit-to-stand test, spinal cord injury functional ambulation inventory, spinal cord independence measure (indoors and outdoors mobility items), locomotor stages in spinal cord injury, community balance and mobility scale, and activity-based balance level evaluation scale. The choice of a single or a set of metrics should be determined by the clinician. Based on the results obtained in this review, a combination of outcome measures is proposed to assess walking ability. Future work is required to integrate a more realistic environment for walking assessment.

Gait Characteristics in Youth With Transverse Myelitis

Background

Transverse myelitis (TM) in childhood is a rare disorder characterized by the presence of spinal cord inflammation. Gait difficulty in children with TM is common; however, there is a paucity of literature regarding quantitative assessment of gait in children and adolescents with TM.

Objectives

To characterize gait patterns in a cohort of ambulatory children with TM and age-matched, typically developing peers in order to better understand the functional mobility of patients diagnosed with childhood TM.

Methods

This was a retrospective study of 26 ambulatory pediatric patients with a confirmed diagnosis of TM who had undergone three-dimensional, instrumented gait analysis (3D-IGA) at 3 years of age or older. A group of 38 typically developing children served as a control group.

Results

Gait in children with TM was characterized by moderate kinematic deviations as measured by the Gait Deviation Index (GDI) and a crouched gait pattern (p < .001), increased anterior pelvic tilt (p < .001), decreased motion at the knees (p < .001), and a wider base of support (foot progression angle, p < .001). The TM group had a slower walking speed (p < .001), shorter strides (p < .001), and an increased stance phase compared to controls.

Conclusion

Our study results showed moderate kinematic deviations quantified by the GDI. Overall, the gait pattern in the TM population tested had greater hip and knee flexion with wider foot progression angle. Identification of gait characteristics in children with TM is the first step in predicting changes in gait pattern as they mature over time, which may ultimately allow for targeted intervention to maintain their ambulatory function.

Technological advancements in the analysis of human motion and posture management through digital devices

Technological development of motion and posture analyses is rapidly progressing, especially in rehabilitation settings and sport biomechanics. Consequently, clear discrimination among different measurement systems is required to diversify their use as needed. This review aims to resume the currently used motion and posture analysis systems, clarify and suggest the appropriate approaches suitable for specific cases or contexts. The currently gold standard systems of motion analysis, widely used in clinical settings, present several limitations related to marker placement or long procedure time. Fully automated and markerless systems are overcoming these drawbacks for conducting biomechanical studies, especially outside laboratories. Similarly, new posture analysis techniques are emerging, often driven by the need for fast and non-invasive methods to obtain high-precision results. These new technologies have also become effective for children or adolescents with non-specific back pain and postural insufficiencies. The evolutions of these methods aim to standardize measurements and provide manageable tools in clinical practice for the early diagnosis of musculoskeletal pathologies and to monitor daily improvements of each patient. Herein, these devices and their uses are described, providing researchers, clinicians, orthopedics, physical therapists, and sports coaches an effective guide to use new technologies in their practice as instruments of diagnosis, therapy, and prevention.

Mobility in association with anxiety and quality of life in middle-aged and older female fallers and non-fallers

Objective ― The goal of our study was to compare mobility vs. cognitive function and quality of life in middle-aged and older women, both fallers and non-fallers. Material and Methods ― A total of 246 healthy community-dwelling women 55-74 YO participated in this study. They were distributed among two subgroups: (1) fallers (n=95) and (2) non-fallers (n=151). Fallers had falls in the past 12 months, while non-fallers did not. Walking tests were performed using Balance Master® posturography system. Trait anxiety and state anxiety were assessed by Spielberger-Hanin test; health state and quality of life (QoL) were evaluated from SF-36 health survey questionnaire; subjectively experienced age (SEA) and the rate of aging were also estimated. Results ― In Walk Across test, the average speed was lower in fallers (p=0.020), as compared with non-fallers. In Tandem Walking test, step width (p=0.016) and endpoint sway velocity (p=0.029) were higher, while speed (p=0.030) was lower in fallers vs. non-fallers. Step-Quick-Turn test time (p=0.016) was longer and sway (p=0.011) was higher in fallers in the course of turning both to the left and to the right. SEA in female non-fallers was less (p=0.033) than in female fallers of the same age. Trait anxiety was higher in female fallers (p=0.012) with a lower QoL level (p<0.001). Conclusion ― Our results validated the need for early assessment of the postural control dynamic components in order to prevent the development of falls as a geriatric syndrome.