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Quantitative Study of Walker-Assisted Gait

in Children With Cerebral Palsy:

Anterior Versus Posterior Walkers
R. Bachschmidt, G. F. Harris, J. Ackman,
S Hassani, M. Carter, A. Caudill
K. Reiners, W. Olson, P. Smith
Shriners Hospital f or Children
Chicago, IL 60707
J. Klein
Department of
Medical College of Wisconsin
Milwaukee, WI 53226
Many children with cerebral palsy require walkers to achieve functional ambulation, yet
little scientific study has been done to understand the mechanics of usage. The objective
of this work was to provide a quantitative pilot comparison of ambulation with anterior
and posterior walkers in children with cerebral palsy using temporal-spatial gait
parameters and an upper extremity joint kinetics. Following informed consent, data
were collected for nine children with spastic, diplegic cerebral palsy who were
community ambulators and who routinely used posterior walkers. Results of the study
showed increased double limb support time (24.3%-30.7%) with the anterior walker,
increased walking speed (16.7%-21.4%) with the posterior walker. Elbow extensor and
wrist flexor demands were greater with the anterior walker (-0.19 /kg, 0.07 /kg)
than with the posterior walker (-0.06 kg, 0.02 /kg). The methodology developed
in this study appears to provide improved insight into the effect of upper extremity
muscular demands in addition to the traditional lower extremity gait analysis, clinical
evaluation, and energy expenditure assessment.
upper extremity kinematics, upper extremity kinetics, walker dynamometer
1. Introduction
Impaired equilibrium reactions, balance, postural stability, and abnormal muscle tone are
characteristics of children with cerebral palsy. Ambulation in these patients is
sometimes limited by these factors, and their mobility may be dependent upon the use of
assistive ambulatory devices, such as canes, crutches, or walkers. These aids afford
improved balance and theoretically facilitate the forward progression of gait. Though
the literature contains information regarding the use of canes and crutches as assistive
devices and their biomechanics and determinants on gait, little quantitative data is
available on the effect of walkers on gait patterns of children with cerebral palsy.
0-7803-6469-4/00/$10.00 0 2000 IEEE
The selection of the type of walker, either anterior or posterior, is typically subjective,
based upon the observation of the child by the physician and/or therapist. This
observation is usually done in the clinic or at school or private therapist with little time
for adaptation. Objective data regarding parameters of gait, statiddynamic stability,
load borne by the upper extremities, and efficiency of gait are rarely determined.
Current studies do not address quantitative three-dimensional upper extremity kinematics
or loads borne by the upper extremities. Small population sample sizes also limit
application of the findings. The purpose of this study was to obtain insight in children
with spastic cerebral palsy who use walkers to assist in their ambulation, comparing the
traditional front or anterior walker, with the newer posterior walker.
2. Methods
2.1 Subject Selection and Testing
Nine patients aged 8 to 17 (p=l l years) with spastic cerebral palsy and a diplegic
distribution were studied using two-wheeled anterior and posterior walkers. Signed
informed consent was received from parents or guardians. They were first evaluated on
three separate occasions over a three week period while using their posterior walkers.
Evaluation consisted of computer-assisted gait analysis and clinical examination. In the
gait analysis laboratory, the subjects were asked to walk on a 10 m walkway with an
instrumented walker. A minimum of five acceptable bilateral strides were collected for
analysis. Following the initial three-test series, the subjects received training in the use
of an anterior walker by a physical therapist. After successful completion of training, the
subjects used anterior walkers daily within their community environment for a period of
one month. The subjects then underwent another three-test series using the anterior
2.2 Walker Dynamometer
To study pediatric walker-assisted gait, we modified a pediatric posterior walker (Kaye
Model W3B, Kaye Products, Inc., Hillsborough, NC) and an anterior walker (Guardian
Products Model 7749, Sunrise Medical, Simi Valley, CA) to accept two 6 axis, strain
gage-based, load cells (AMTI Model MCW-6-500), in a cooperative effort with
Advanced Mechanical Technology, Inc. (AMTI, Watertown, MA), (Figures 1,2). The
results from our finite element study and prototype walker instrumentation were used to
position the load cells so that the forces and moments generated at each hand could be
accurately detected [l ] [2] [3]. The system was lightweight, with each load cell
weighing about 100 grams and were cylindrical in shape with a diameter of 38 mmand
height of 60 mm. The load cells were tethered to two AMTI force plate amplifiers
(Model OR6-5).
The manufacturer-supplied primary sensitivities in units of mV/N(cm). Sensitivities
were maximum in the anterior-posterior Fx loading direction and minimum in the
vertical Fz loading direction. The specified non-linearity and hysteresis of the loads
cells were less than +0.20%. The lowest resonant frequency of a stand-alone cell was
700 Hz. Based on preliminary data collection, system gains of 4000 were set for the
vertical force channels and gains of 2000 were selected for the anterior-posterior and
medial-lateral force channels. Gains of 1000 were set for all moments.. Mornents
applied by the hands were uniquely determined by subtracting from the recorded
moment signals the product of applied force and distance from the transducer center to
the point of force application.
Figure 1. Posterior Walker Dynamometer
Figure 2. Anterior Walker Dynamometer
2.3 Upper Extremity Biomechanical Model
A biomechanical model to calculate sagittal, coronal, and transverse kinetics of the
shoulder, elbow, and wrist joints was developed [l]. The upper body segments are
modeled as rigid links connected by idealized joints located at stationary, estimated
centers-of-rotation. The coordinates of external passive reflective markers are used to
determine flexiodextension (sagittal), abductiodadduction (coronal), and
internal/external (transverse) rotations of the upper body using a multi-segment rigid
body model similar to that used by Kadaba, et al. [4] (Figure 3). Complete joint motion
is described with three sequence-dependent Euler angles. The loading of the upper body
joints (wrist, elbow, and shoulder) was determined using an inverse dynamics model.
Upper Body Kinematic Model
Place external reflective markers
over anatomical landmarks
Estimate internal joint centers fron
markers and anthropometric
Construct local body reference
frames using vector methods
Calculate relative joint angles
using Euler angle theory
Upper Body KiLetic Model
An Inverse Dynamics
model incorporating
measured with the
walker dynamometer
Angular and linear
Figure 3. Representation of Upper Body Kinematic and Kinetic Models
3. Results
3.1 Gait Metrics
Double stance time with anterior walker use was significantly greater than with posterior
walker use (p=0.0004) for both the left and right sides. Mean double limb support time
increased 24.3% - 30.7% with the anterior walker compared to the posterior walker.
Walking speed with posterior walker use was significantly greater than for anterior
walker use (p=O.OOOl) for both the left and right sides. Mean increases in speed were
16.7% - 21.4% with the posterior walker. This was accomplished by significant
increases in cadence (7.9% - 9.6%) and in stride length (6.1% -7.6%).
3.2 Upper Extremity Kinematics
Figure 4 illustrates the mean trunk and elbow sagittal plane joint angles when walking
with the anterior and posterior walkers. Group means were plotted at discrete
increments of the gait cycle (IO%, 30%, 50%, 70%, 90%). The right side upper
extremity kinematics were graphed with respect to the right foot stride (rfc, rfo, rfc) and
similarly the left side upper extremity kinematics were graphed with respect to the left
foot stride (lfc, Ifo, lfc).
left elbow
X gait cycle
right elbow
I ,
20 40 60 60
X gait cycle
Figure 4. Mean sagittal plane upper extremity kinematics for walking with an
anterior and posterior pediatric walker. N=9 subjects with spastic,
diplegic cerebral palsy, n=15 per subject, per walker. Flexion
(+)/extension (-).
Trunk flexiodextension did not differ significantly between the two walkers. Changes in
the trunk angle ranged from 0.0" to 2.1". The shoulder was significantly more extended
(12.9" - 19.9") with posterior walker use than with anterior walker use. Increases in
elbow flexion with the anterior walker ranged from 1.3" to 7.2" and were statistically
significant throughout the gait cycle on the non-dominant side. No significant
differences in wrist extension were determined for use of the two walkers.
22 1
3.2 Upper Extremity Kinetics
A net demand on the shoulder flexors (0.15 /kg) was noted with posterior walker use
while a net extensor demand (-0.04 kg) was seen with anterior walker use. Elbow
extensor demands were greater with anterior walker use (-0.19 /kg) than with
posterior walker use (-0.06 /kg) and the differences were statistically significant
throughout the gait cycle on the non-dominant side. Significantly greater demands on
the wrist flexors were noted when walking with the anterior walker (0.07 kg) than
with the posterior walker (0.02 /kg).
Separate trials of hand-to-walker loading for subject ER are shown in Figure 5. For this
subject as well as the others, a posteriorly directed shear force (-Fx) was observed during
late stance to swing phase when using the anterior walker. In contrast, an anteriorly
directed shear force (+Fx) was noted throughout the gait cycle when using the posterior
walker. Hand-to-walker vertical forces and moments applied in the sagittal plane were
similar in magnitude and morphology for both walkers.
Hand-to-Walker ForceFx
Posterior Walker, (+) direction of walk
Hand-to-Walker ForceFx
Anterior Walker, (+) direction of walk
30 30
-30 .30
-60 -60
gait cycle gait cycle
Figure 5. Subject ER sagittal plane hand-to-walker loads for walking with an anterior
and posterior walker.
4. Discussion
The purpose of this study was to initiate a quantitative comparison of ambulation with
anterior and posterior walkers in children with spastic, diplegic cerebral palsy.
The walker dynamometer allowed measurement of three-dimensional wrist, elbow and
shoulder loads in children and quantitative biomechanical comparison of anterior and
posterior walker usage. The system was designed for use within a standard gait analysis
laboratory and has proven to be accurate and reliable during preliminary trials. The
system is considered appropriate for further clinical application and for analysis of
therapeutic surgical and non-surgical treatment.
A limitation to this study is the small sample size of nine subjects. However, estimates
of parameter variance were used to project appropriate sample sizes for future study
design. For a sample size of thirty subjects, conservative estimates of the minimum
effect size which can be detected at the 5% significance level with 90% power are a
mean upper extremity kinematic change of 6 degrees (3 trunk - 9 shoulder) and a mean
upper extremity kinetic change of 0.07 /kg (0.04 / kg wrist - 0.10 /kg elbow).
Potential rehabilitation applications which could benefit from this technology may
include the optimization of pediatric walker-assisted gait. In order to optimize the
function with walkers, we must first understand the details of motion and force transfer.
While it is well known that upper extremity work increases energy demands, the
relationship of energy expenditure to load distribution among the wrist, elbow, and
shoulder joints is not well understood. The walker dynamometer and biomechanical
models would potentially allow design of a user-specific structure, optimized to retain
the determinants of gait, reduce internal moment demands, and improve efficiency.
[l ] R.A. Bachschmidt, G.F. Harris, G.G. Simoneau, J .J . Wertsch. Analysis of
Walker-Assisted Gait: Kinetics and Kinematics. IEEWEMBS 1s Annual
Conference, Chicago, IL pp.2851-2856, Oct 30-Nov 2, 1997.
[2] R.A. Bachschmidt, G.F. Harris, J .A. Ackman, S. Hassani , K. Reiners, W.
Olsson, F. Carignan, G. Blanchard. Development of a System for Quantitative
Study of Pediatric Walker-Assisted Gait. IEEWEMBS Conference Hong Kong
Oct. 1998.
[3] RA. Bachschmidt, G.F. Harris, J .A. Ackman, S . Hassani , K. Reiners, W. Olson.
Walker-Assisted Kinetics in Children with Spastic Cerebral Palsy: A
Preliminary Study. Proc NASGCMA, Dallas, TX, March 10-13, 1999;4.
[4] R.A. Bachschmidt, G.F. Harris, J .A. Ackman, S. Hassani, K. Reiners, W. Olson.
Walker-Assisted Gait in Children with Spastic Cerebral Palsy. Proc POSNA,
Orlando, EL May 17-19 1999.
[ 5 ] M.P. Kadaba, H.K. Ramakrishnan, M.E. Wooten. Measurement of lower
extremity kinematics during level walking. J Orthop Res, 8:383-392; 1990.