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O
RIGINAL
A
RTICLE
Gait in Children With Cerebral Palsy
Observer Reliability of Physician Rating Scale and EdinburghVisual Gait Analysis Interval Testing Scale 
 Karel G. B. Maathuis, MD, PhD,*† Cees P. van der Schans, PhD,‡ Andries van Iperen, MD,* Hans S. Rietman, MD,*† and Jan H. B. Geertzen, MD, PhD*† 
Abstract:
The aim of this study was to test the inter- and intra-observer reliability of the Physician Rating Scale (PRS) and theEdinburgh Visual Gait Analysis Interval Testing (GAIT) scale for usein children with cerebral palsy (CP). Both assessment scales arequantitative observational scales, evaluating gait. The study involved 24 patients ages 3 to 10 years (mean age 6.7 years) with an abnormalgait caused by CP. They were all able to walk independently with or without walking aids. Of the children 15 had spastic diplegia and 9had spastic hemiplegia. With a minimum time interval of 6 weeks,video recordings of the gait of these 24 patients were scored twice bythree independent observers using the PRS and the GAIT scale. Thestudy showed that both the GAIT scale and the PRS had excellent intraobserver reliability but poor interobserver reliability for childrenwith CP. In the total scores of the GAIT scale and the PRS, the threeobservers showed systematic differences. Consequently, the authorsrecommend that longitudinal assessments of a patient should be done by one observer only.
Key Words:
cerebralpalsy,videogait assessment,gait analysis,visualgait assessment (
 J Pediatr Orthop
2005;25:268–272)
 A
 bnormal gait is a common problem in children with cere- bral palsy (CP). These children are at great risk of dete-rioration in their walking ability as they grow up. Manytreatment modalities have been developed in the past decade,dependingon the ageof the child and thenature and severityof the restricted walking ability. Because of the importance of  planning in the timing of interventions and the difficulty in predicting the outcome of different interventions, monitoringthe patient, including gait analysis, before and after anintervention is essential.
1–6
Instrumented gait analysis, in-cluding computerized kinematics and kinetics, electromyog-raphy, and videotaping, is increasingly used in the evaluationof gait pattern of CP patients and is considered the gold standard for gait assessment.
7–9
However, because thisassessment is complex, expensive, and time-consuming and is not generally available, it is impractical for routine use. Inthe past decade simplified methods have been developed toquantify walking in children with a spastic gait by usinga standardized observation scoring system with videotapingonly,
10–14
 but existing measures are either not easily accessed or untested.One of these instruments is the Physician Rating Scale(PRS), an observational clinical evaluation of gait originallyreported by Koman et al in 1993
15
and modified by others.
16–18
This simple scale records gait in thesagittal plane only.A moresystematic and extended gait-evaluating instrument is theEdinburgh Visual Gait Analysis Interval Testing (GAIT) scale,developed by Read et al in 1998.
19,20
In 2002 the GAIT scalewas refined and renamed the Edinburgh Visual Gait Score.
21
It was developed to give a quantitative assessment of gait whereinstrumented gait analysis is not available. The PRS and theGAIT scalewere used for this study because, to our knowledgein 2002, a good validation study for observer reliability in CPfor these instruments had not been carried out before. The aimof this study was to test the inter- and intraobserver reliabilityof the PRS and the GAIT scale for use in children with CP.
MATERIALS AND METHODS
The study population consisted of 24 children with CPwith a mean age of 6.7 years (range 3.3–9.9 years); 18 (75%)of them were boys. Of the children, 15 had spastic diplegia and 9 had spastic hemiplegia (right, n = 8; left, n = 1). All childrenhad an abnormal gait caused by CP but were able to walk independently with or without walking aids. All patients wereassessed in the University Hospital of Groningen, the Netherlands, between 1999 and 2001. Frontal and sagittalvideo recordings were used, taped on a split-screen video. Theobservers were three physicians in rehabilitation medicine(A.van I., C.M., J.R.); two of them were experienced in thefield (C.M., J.R.). They all scored the video recordingsindependently. Guidelines for the PRS and the GAIT scalewere provided to the observers, and they received a short training (1 hour) in scoring using the PRS and GAIT scale.PRS variables are given in Table 1. The last subscale (change)was not used for the purpose of this cross-sectional study.
From the *Centre for Rehabilitation University Hospital, Groningen, The Netherlands;
†
 Northern Centre for Health Care Research, UniversityGroningen, The Netherlands; and 
‡
University for Professional Education,Hanzehogeschool, Groningen, The Netherlands.Study conducted at the Department of Rehabilitation, University HospitalGroningen, Groningen, The Netherlands. None of the authors received financial support for this study.Reprints: Karel G. B. Maathuis, MD, PhD, Department of Rehabilitation,University Hospital Groningen, Hanzeplein 1, P. O. Box 30.001, 9700 RB,Groningen, the Netherlands (e-mail: c.g.b.maathuis@rev.umcg.nl).Copyright 
Ó
2005 by Lippincott Williams & Wilkins
268
J Pediatr Orthop
 Volume 25, Number 3, May/June 2005
 
GAIT scale variables are given in Table 2. It contains 17variables of observation during gait at six anatomic levels(foot, ankle, knee, hip, pelvis, and trunk), including sagittal
22
and frontal
23
observations. Recordings are made using a three- point ordinal scale: 0 (normal), 1 (moderate deviation), and 2(marked deviation). Both sides of the patients were scored separately.Observers were recommended to use slow-motion facil-ities, to stop or repeat the video if necessary, and to take their time. They were instructed not to measure degrees directlyfrom the video screen but to give their best visual estimate. For all patients, either with hemiplegia or diplegia, both sides werescored. All video recordings were scored twice using both thePRS and GAIT scale with a minimal time interval of 6 weeksto avoid any effects of memory; this also corresponds withclinical practice.
Statistical Analysis
All statistical analyses were performed using SPSS 11.0.Reliability analysis was done using analysis of variance(ANOVA). As we were interested in the inter- and intra-observer reliability of the total scores and in the sources of 
TABLE 2.
Edinburgh Visual Gait Analysis Interval Testing Scale
25
MovementSagittal 2 1 0 1 2MovementFrontal 2 1 0 1 2
FOOT
FOOT
1 foot clearance
none reduced full n.a n.a 5 stance positionhind foot in load
.
15valgus6–15valgus5–0–5neutral6–15varus
.
15varus
2 initial contact 
toe flat foot heel n.a n.a 6 foot progressionangle
.
15 ir 6–15 ir 5–0–5neutral6–15 er
.
15 er
3 heel lift 
none early normal delayed n.a
4 max dorsiflexionhind foot in stance
.
10plan10–0–9plan/dor10–20dor21–30 dor
.
30dor
KNEE
KNEE
7 terminal swing
.
30flex15–30flex0–15flex
.
0hyperextn.a 10 kneeprogressionangle mid-stancepartcap irall cap ir neutral allcap erpartcap er
8 peak stance kneeextension
.
30flex16–30flex0–15flex1–10hyperext
.
10hyperext
9 peak knee flexionin swing
.
80flex65–80flex60–64flex30–59flex
.
30flex
HIP
HIP
11 peak hipextension in stance
.
30flex16–30flex15–0–15flex/extn.a n.a 13 positionin swing
.
15add5–15add4–0–9add/abd10–20abd
.
20abd
12 peak hip flexionin swing
.
75flex51–75flex30–50flex15–29flex
,
15flex
PELVIS
PELVIS
14 pelvic rotationmidstance
.
15fwd6–15fwd5–0–5neutral6–15bwd
.
15bwd15 contralateral dropin stance marked mod normal n.a n.a
TRUNK 
TRUNK
16 peak sagittal position in stance
.
15fwd6–15fwd5–0–5neutral6–15bwd
.
15bwd17 max lateralshift in stance marked mod neutral n.a n.a
TOTAL
TOTAL
Score 2 means marked deviation, score 1 is moderate deviation, score 0 is normal range.n.a, not available; plan, plantarflexion; dor, dorsiflexion; flex, flexion; hyperext, hyperextension; fwd, forward rotation; bwd, backward rotation; ir, internal rotation; er, externalrotation; part cap, only a part of the knee cap is visible; all cap, whole knee cap is visible; add, adduction; abd, abduction; lat, lateral; mod, moderate.
TABLE 1.
Physician Rating Scale
15
Definition Right Left
CrouchSevere (
.
20
°
hip, knee, ankle)
0 0
Moderate (5–20
°
hip, knee, ankle)
1 1
Mild (
,
5
°
hip, knee, ankle)
2 2
 None
3 3
KneeRecurvatum
.
5
°
0 0
Recurvatum 0–5
°
1 1
 Neutral (no recurvatum)
2 2
Foot contact Toe
0 0
Toe-heel
1 1
Flat 
2 2
Occasional heel-toe
3 3
Heel-toe
4 4
ChangeWorse
2
1
2
1
 None
0 0
Better 
1 1
q
2005 Lippincott Williams & Wilkins
269
 J Pediatr Orthop
 Volume 25, Number 3, May/June 2005
Observer Reliability of Two Gait Scales 
 
variance (child, observer, and repetition), for each total scorewe chose this method, not kappa statistics of the separateitems. Total GAIT scale and PRS and subscores of both scalesfor the right and left side were taken as independent factors.For each independent factor the estimated variances werecalculated. Post hoc comparison of differences between thethree observers was done using the Friedman test.
P 
,
0.05was considered statistically significant.
RESULTS
Two subjectswere excluded from analysis: in one patient the frontal video imaging failed; in the other the sagittal onefailed. The 22 patients who remained for the reliabilityanalysis were assessed at random by the observers. On theright as well as the left side, both observer and child proved to be significant sources of variance in the GAIT scale and in thePRS. Repetition was not a significant source of variance (Table3); in most cases it even approached 
P 
= 1. In fact, both theGAIT scale and the PRS showed excellent intraobserver reliability. The interobserver reliability of both assessment scales, the GAIT scale and the PRS, was considered poor.Post hoc analysis showed considerable differences between the three observers. The mean (SD) scores for eachobserver are given in Table 4; box plots are shown in Figure 1.In Table 5, the GAIT scale is subdivided into sevensubscales: the first five subscales correspond to the different anatomic levels, and the last two correspond to the different directions of observing gait (frontal and sagittal views). Onlywith the ankle subscale on the left side did the observer appear not to be a significant factor in the source of variation. In allother GAIT subscales the observer appeared to be a significant source of variance.
DISCUSSION
The differences in mean total scores of the threeobservers were considerable and were considered clinicallyrelevant because the differences in the outcome of 1.1 in thePRS and 4.4 in the GAIT scale (Table 4) for the same personshould be clearly visible when observing gait. Besides, if thesame difference in the PRS and GAIT scale could be measured as a result of an intervention in CP patients, it would beconsidered a clinically relevant difference.The total scores of the GAIT scale and the PRS, betweenthe three observers, also showed systematic differences. Thereason is not clear. Probably, angle estimation of the different anatomic levels from a video screen was done systematicallydifferent between the observers.Although the PRS is used often in research, we onlyfound one study in the literature
23
that reported interobserver reliability; we found no study that reported intraobserver reliability data. Corry et al
23
studied the interobserver reliabilityof the PRS in a group of 20 CP children with a dynamiccomponent in spastic equinus, treated by serial casting or 
FIGURE 1.
Box plots of GAIT scale and PRS. The ends of therectangle reflect the interquartile range; the horizontal line inthe rectangle reflects the median value; the whiskers indicatethe minimum and maximum values.
TABLE 3.
Sources of Variation in the GAIT Scale and PRS
SS MS
P 
Value Variance Estimates
GAIT scale right Observer 
240 120
,
0.001 2.6
Repetition
0.2 0.2 0.846 0
Child 
3904 186
,
0.001 30.1
GAIT scale left Observer 
162 81
,
0.001 1.7
Repetition
0.1 0.1 0.941 0
Child 
7571 361
,
0.001 59.2
PRS right Observer 
21 10.5
,
0.001 0.2
Repetition
0.4 0.4 0.395 0
Child 
509 24
,
0.001 4.0
PRS left Observer 
14.6 7.3
,
0.001 0.1
Repetition
0 0 1 0
Child 
872 42
,
0.001 6.8
SS, sum of squares; MS, mean square.
TABLE 4.
Total Scores of GAIT Scale and PRS of All ThreeObservers
Observer 1(AvI)Mean (sd)Observer 2(CM)Mean (sd)Observer 3(JR)Mean (sd)
P 
Values*
GAIT scale right 
9.1 (5) 10.3 (5.2) 13.5 (6.7)
,
0.001
GAIT scale left 
7.8 (6.8) 8.5 (6.9) 11.1 (9.4) 0.003
PRS right 
5.5 (1.9) 4.4 (2.1) 4.4 (2.2)
,
0.001
PRS left 
6.1 (2.4) 5.4 (2.7) 5.5 (3.0) 0.004
*Friedman test.
270
q
2005 Lippincott Williams & Wilkins Maathuis et al 
J Pediatr Orthop
 Volume 25, Number 3, May/June 2005
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