AACPDM Altiok and Krzak

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Motion Analysis in Understanding MovementPathology in Myelomeningocele

Haluk Altiok, MD. , Joseph Krzak, PT, PhD, PCS

Disclosure InformationAACPDM 69th Annual Meeting | October 21-24, 2015

Speaker Names: Haluk Altiok, MD and Joseph J. Krzak, PT, PhD

Disclosure of Relevant Financial Relationships

We have no financial relationships to disclose.

Disclosure of Off-Label and/or investigative uses:We will not discuss off label use and/or investigational use in

my presentation

Common gait deviations of individuals withmyelomeningocele

Linking gait deviations to treatment: surgical, bracingand assistive devices using motion analysis

Case studies – bracing and surgical (using gait analysis)

New Frontiers - using motion analysis to optimizewheel chair propulsion in patients withmyelomeningocele

Outline:

GCMAS Symposium at the AACPDM, October 21, 2015 Part 3: Myelomeningocele

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Neural tube defects Congenital malformation secondary to lack of closure of neural tube ,

incidence 1 -10/1000

Anencephaly

Spina bifida

Spina Bifida Myelomeningocele, meningocele, lipomeningocele

Myelomeningocele >90%

protrusion of neural tissue and its covering

through a defect in the vertebrae

-2/10000 live births

Each year, about 1,500 babies are bornwith spina bifida in US

Hispanic 4.17 per 10,000

Non-Hispanic Black or African-American: 2.64 per 1000

Non-Hispanic White: 3.22 per 10,000

CDC- CENTERS FOR DISEASE CONTROL AND PREVENTION


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The etiology is not well understood, complex, multifactorial

Maternal folate status is critical for proper neural tube closure, 1991

U.S. Public Health Service recommended 400 micrograms folic acid daily 1992FDA mandated fortification of food products, January 1998Prevalence in USA decreased 31% from pre-fortification to post-fortification

Centers For Disease Prevention and Control

Spina Bifida

1960s advances in medical care ledto the survival of majority ofindividuals

10% infant death rate

75-85% are expected to reachearly adult years

Long term disability

The mortality, disability and achievement reflected theneurological level

One-third needed daily care, while 30-40 % lived independently There is lack of comprehensive and lifelong care available to the adult

The death rate from age 5 to 40 years is 10 times the national average Late deterioration is common


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Social support and parental hope are more strongly associated withself –worth and health related quality of life than gender, age,diagnosis, or physical impairment

Mobility is an important determinant of quality of life for thosewith Spina Bifida (SB)

Perceived HRQOL of young adults with SB is lower, especiallywithin the physical functioning domain

The ultimate walking ability of the patientswith Spina Bifida

depends on many factors of which the mostimportant is the extent of the neurological deficit

Children with similar level of motorparesis do not always develop similarambulatory levels:

Negative factors Balance disturbances Multiple shunt revisions Spasticity Knee and hip joints contractures

Hip dislocation was not


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Gait analysis has radically changed thetreatment of cerebral palsy

Assessment of patient`s pathology before and aftertreatment

Could the same principles of gait analysis( treatment based on the objective assessment)

be applied to the patients with Spina Bifida ?

Gait Analysis and Spina Bifida

Objective analysis of gait plays afundamental role in the assessment ofboth the functional limitation and theoutcome of the treatment


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Gait Analysis and Spina Bifida

Gait patterns

Assessment and treatment

Effectiveness of orthoses& assistive devices

JB1.mpg

JB2.mpg

Gait Patterns

Gait PatternsKinematics

Persistent dorsiflexiondue to plantar flexorweakness led to moreflexed position at kneesand hips and anterior tiltof the pelvis


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Gait PatternsKinematics

Hip abductor weakness

Produces the largestchange in gait strategy Trunk and pelvic rotation

Large lateral trunk sway

Hip abduction during stance

Pelvic hike

- In this gait pattern, energytransferred from hips down into thelower extremities

Gutierrez et al, Gait and Posture 2003

Pelvis tilt and hip flexion is increasedWeak hip extensorsHip flexors are used to initiate gait in theabsence of plantar flexors

Pelvic obliquity is increasedLateral sway of the body over the stance phasehip “Trendelenburg gait” helps to elevate thepelvis on swing side and hike the swing limbforward

Pelvic rotationInternal rotation is increased at initial contact asa result of “hiking”the swing limb phaseforward

HipAbducted at initial contact and remainsabducted over the stance phase

KineticsValgus Knee Stress

25% 50% 75%

Knee Valgus Moment1.0

-1.0

Val

Var

Nm/kg

25% 50% 75%

Knee Rotation Moment

-1.0

Nm/kg


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Assessment and TreatmentHIP

Management of hip disorders hadundergone a radical change over the years

“It was not possible to determine whether or notthe patients would have been able to walk withoutiliopsoas transplantation, or a similar operationas there were no controls”


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16 transplants in 13 patients

EMG activity is recorded for active hip flexion, abduction,extension and passive flexion All transplants :Active in active flexion but not in passive, some

activity during abduction, very minimal activity with extension

“ it is doubtful if it acts as a true gluteal replacement or thatindependent abduction and extension are readily achieved “

28 patients 10 patients with L4 level, all had reduced hips

No difference in the range of pelvic obliquitybetween those who had posterolateral transfer ofthe iliopsoas to greater trochanter and who hadnot

Range of hip adduction /abduction and rotationwas significantly worse

“Abductor limp is not eliminated, but lessened,self reported substantial increase in sense of security”


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• 28 hips, L3-4 to S1• 85.5% active in swing phase

• 69.2% during toe-off

• 46% during stance phase

• 93% of a time the musclefunctioning during the gaitcycle as a hip abductor, it isphasic

Gait symmetry corresponded to theabsence of hip contractures and hadno relation to the presence of hipdislocation

CASE PRESENTATION


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“A level pelvis and a good range of motion were foundto be more important for function than reduction of thehip “

“A pelvic obliquity and hip dislocation did not affect theambulatory status when analyzed together with scoliosis, age andneurological level”

Assessment and TreatmentKNEE

72 patients-lumbo-sacral- communityambulators,24 % did have knee symptoms of

pain, instability with activity

Selber and Dias ,23%, JPO, 18, 1998

Valgus Knee Stress

Coronal plane valgus knee stress ismultifactorial and trunk motion andexternal tibial torsion are majorcontributors


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Valgus Knee Stress

25% 50% 75%

Knee Valgus Moment1.0

-1.0

Val

Var

Nm/kg

25% 50% 75%

Knee Rotation Moment

-1.0

Nm/kg

CASE VIDEO

Crouch Gait

STATIC CLINICALEXAM MAY NOTALWAYS REFLECTTHE ACTUALFUNCTIONALSTATUS OF THESEPATIENTS


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Crouch Gait

Crouch Gait

Pelvic Ti lt50

-10

Ant

Post

deg

25% 50% 75%

Hip Flexion/Extension90

-20

Flex

Ext

deg

25% 50% 75%

Knee Flexion/Extension75

-15

Flex

Ext

deg

25% 50% 75%

Foot Dorsi/Plantar40

-80

Dors

Plan

deg

25% 50% 75%

Down

deg

Add

Abd

deg

deg

deg

Tibial Torsion

EXCESSIVE INTERNAL /EXTERNAL TIBIAL ROTATION Tripping , poor balance and difficulty with gait Poor fitting with the brace, pressure sore Valgus knee stress Diminished effectiveness of the solid ankle foot orthosis


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Tibial Torsion

Patients with external tibial rotation deformity on the order ofmagnitude around 20° or greater who fail to demonstrateimproved knee extension moments may benefit from correctionof their increased tibial torsion

Tibial Torsion

Significant improvement in the abnormal internal kneevarus moment as well as significant increase in thestance phase knee extension


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CASE VIDEO

Assessment and TreatmentCalcaneal Foot Deformity


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25% 50% 75%

Tibial is Anterior5.0

0.0

V

25% 50% 75%

Pre – Post Peabody Transfer: Pedobarography

71%

10%

18%

39%

44%

17%


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Effectiveness of Orthosesand Assistive Devices

With respect to barefootconditions, the use of AFOsleads to an improvement ingait and reduced energyconsumption

L4 –L5 patient group Improved ankle and knee sagittal plane

function Reductions in excessive ankle dorsiflexion,

increases in peak plantar flexor moment,reductions in crouch and knee extensor moment

Sacral patient group Diminished power generation pre-swing

All groups Increase in transverse plane knee rotation

( was normal with sacral group barefoot)

Improvements in brace construction anddesign with stronger and lighter energy-storing materials can result in improvedambulation

Carbon fiber spring orthosis Improves ankle plantar flexion moment Ankle positive work Stride length Increases energy return during the 3rd

rocker, simulating the natural push-offaction


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Crutches alleviate weight bearing on the lowerextremities, decrease exaggerated pelvic and hipcompensatory kinematic movements and helpfacilitate forward progression

The maximum stressesduring swing throughgait were found to besignificantly greater thanthose during reciprocalgait

New Frontiers - using motionanalysis to optimize wheelchair propulsion in patientswith myelomeningocele


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Shoulder Pain for Individuals withSpina Bifida (Roehrig and Like, 2008)

30%-41% of individuals diagnosed with spinabifida reported shoulder pain related tomanual wheelchair propulsion

Individuals older than 18 years-old hadgreater pain than those between ten andeighteen year of age.

Optimal 2-D Pushrim Kinematics

Optimal Motion:Semicircular Pattern

Users hit the pushrim lessfrequently and used more ofthe pushrim to go the samespeed.

Bonniger et al., 2005

Hurdles to Motor Learning

Learning novel tasks can be difficult for individuals with SpinaBifida due to high prevalence of impaired:

Sustained attention (Castersen and Habekost, 2013)

Executive function (Tuminello, 2012)

Intrinsic motivation (Tuminello, 2012)

Upper limb functional deficits (Dennis,2009) Arm posture and rebound

Finger–nose–finger

Rapidly alternating hand movements


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Propulsive Training withAugmentative Visual Feedback

During skill acquisition,children who receivedconstant augmentative visualfeedback during trainingperformed a novel task withgreater accuracy andconsistency than childrenwho received reducedfeedback during practice

WheelchairDynamometer

Visual Display

PassiveMarkers

Motion Capture Cameras

Sullivan et al., 2008

Training with AugmentativeFeedback


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Post-Training

Smartwheel(Out-Front, Mesa AZ)

X

Z

Y

SMART Wheel Report


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Pre-Training

Negative Contact Forces

Negative Contact Forces

Post-Training


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Pre – Post Comparison

Value Pre Post

Average Speed (m/s) 1.2 1.4

Push Frequency (contacts/second) 0.9 0.8

Push Length (degrees) 67.2 78.0

Weight-Normalized Force (% bodyweight)

5.2 7.5

Acknowledgements

Shriners Hospitals forChildren:

Adam Graf, MS

Gerald F. Harris,Ph.D., PE

Thank you!


AACPDM Altiok and Krzak

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