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Summary: This study was designed to assess the impact of close agreement with gait analysis in identifying an indication
gait analysis on the treatment of patients with cerebral palsy. for surgery. There was less agreement in the type or level of
One hundred two ambulant patients with cerebral palsy were operation recommended. Gait analysis altered the decision in
assessed clinically and with gait analysis. Separate treatment 106 of 267 operations (40%). There was good agreement for
proposals for each patient were recorded after clinical exami- bone surgery, suggesting that clinical evaluation of torsional
nation and after gait analysis. The results of the two methods of problems was fairly reliable. The poorer agreement seen for
assessment were compared. After clinical assessment, 71 of the soft tissue operations probably reflects the difficulties in as-
102 patients evaluated were recommended for a surgical pro- sessing tone-related problems in these patients clinically. This
cedure and 31 for nonoperative treatment. After gait analysis, study confirms the value of gait analysis for decision-making in
the indications for treatment were confirmed in 91 cases (89%). cerebral palsy. Key Words: Cerebral palsy—Decision mak-
Clinical assessment by the same orthopedic surgeon was in ing—Gait analysis.
There has been debate concerning the role of gait A further study by Skaggs et al. (5) demonstrated that
analysis in the overall assessment of patients with cere- despite the objective nature of information from gait
bral palsy (2,6). Proponents believe it is a valuable tool analysis, there is some subjectivity in its interpretation.
in the assessment of the dynamic and static functions of The interobserver variability reported was similar to that
the musculoskeletal system. Others argue that it is little found for established classification systems of various
more than an expensive research tool of dubious clinical orthopaedic conditions. They also found differences be-
benefit. tween institutions in the interpretation of the data. To
At least two previous studies have considered the in- obviate these interobserver differences, we compared de-
fluence of gait analysis on surgical decision-making cision-making before and after gait analysis using the
(1,4). The first, by DeLuca et al. (1), compared the sur- same orthopaedic surgeon and the same staff in the gait
gical recommendations for patients with cerebral palsy laboratory throughout.
assessed clinically and with video recordings before and
after gait analysis. Surgical recommendations were MATERIALS AND METHODS
changed in 52% of cases after gait analysis. The study
involved numerous assessors, and this may have been a All new patients with cerebral palsy who were ambu-
source of inconsistency. The second study, by Kay et al. lant and had disorders affecting their lower limbs were
(4), assessed the impact of preoperative gait analysis on seen and examined by the same orthopedic consultant. A
the orthopaedic care of 97 pediatric patients with a va- treatment plan was formulated on the basis of this con-
riety of diagnoses. Eleven different physicians referred sultation. A decision was made as to the need for surgical
patients for gait analysis. The pre-gait analysis plan was intervention or nonsurgical treatment with physiotherapy
available in only 70 of these patients. The surgical treat- or orthotics. If surgery was indicated, the level at which
ment plan was altered after gait analysis in 62 of these 70 this surgery should be performed was recorded. The out-
patients (89%), and 39% of operations from the pre-gait come and decisions made at this consultation will be
analysis plan were not performed. referred to as the “clinical assessment.”
After the clinical assessment, all patients were studied
Address correspondence and reprint requests to Mr. J. E. Robb, using three-dimensional gait analysis. Gait analysis was
F.R.C.S.Ed., Orthopaedic Department, Royal Hospital for Sick performed using a Vicon VX system (Oxford Metrics,
Children, Edinburgh EH9 1LF, Scotland (e-mail: J.E.Robb@ Oxford, UK), five infrared cameras, a Kistler force plate
btinternet.com).
From the Anderson Gait Analysis Laboratory, Princess Margaret (Kistler Instruments, AG Winthur, Switzerland), and
Rose Orthopaedic Hospital, Edinburgh, EH10 7ED, Scotland. real-time coronal and sagittal plane video recording. The
None of the authors received financial support for this study. results were analyzed by a team consisting of the same
292
GAIT ANALYSIS IN CEREBRAL PALSY 293
TABLE 1. Operation levels of groups clinical assessment results and gait recommendations
could not be found. All 102 patients had cerebral palsy
Group Operation level
and were ambulant. After clinical assessment, 71 were
1 Hamstrings thought to require some form of surgical intervention,
2 Gastrocnemius
3 Femoral derotation osteotomy (FDRO)
whereas 31 were deemed appropriate for nonoperative
4 Tibial derotation osteotomy (TDRO) treatment. After gait analysis there was agreement in 91
5 Psoas cases (89%), 61 of the 71 in whom surgery was origi-
6 Foot and ankle (see legend) nally proposed and 30 of the 31 not requiring surgery.
7 Hip adductors
8 Rectus femoris
Gait analysis, therefore, did not agree that surgical inter-
vention was required in 10 patients identified on clinical
Foot and ankle operations included tibialis anterior tendon transfer, assessment; in one patient in whom no surgery was ini-
lengthening of tibialis posterior, flexor digitorum superficialis or flexor tially proposed, gait analysis suggested that surgical in-
hallucis longus, subtalar fusion, and calcaneal osteotomy
tervention would be of some benefit.
There was far less agreement between the two meth-
orthopedic surgeon, a research fellow in gait analysis, a ods of assessment in the actual level at which the surgical
senior physiotherapist, and a bioengineer. All had exten- procedure should be performed. Because of the multi-
sive experience in gait analysis. Management recommen- level abnormalities in most of the patients studied, many
dations were recorded for each patient after gait analysis, patients had more than one operation proposed. A total of
including the need for operative or nonoperative treat- 267 operations were proposed after the clinical assess-
ment and the level and type of operation that should be ment and the gait analysis. After clinical assessment, 215
performed.
procedures were proposed in 71 patients, approximately
The recommendations from gait analysis were com-
three operations per patient. After gait analysis, 213 pro-
pared with those from the clinical assessment by an in-
cedures in 62 patients were recommended. There was
dependent observer, and the results were analyzed. The
agreement between gait analysis and the clinical assess-
frequency of operative or nonoperative recommenda-
ment for 161 of these operations. A further 54 operations
tions from each assessment method was calculated first.
were proposed by clinical assessment but not supported
Subsequently, the operative procedures recommended
by gait analysis, whereas gait analysis proposed a further
for each patient were compared. Statistical comparisons
52 operations not identified by clinical assessment.
between groups were made using the chi-square test for
Overall, there was agreement between the clinical as-
nonparametric data.
sessments and gait analysis recommendations in 60% of
To simplify the data, the operations were grouped into
procedures. The results for each group or level of surgery
eight categories (Table 1). These groups consisted of
are presented in Figure 1. The level of agreement be-
muscles with the same function or osteotomies of the
tween the two assessment techniques is shown in the left
femur or tibia. No differentiation was made as to the
column for each group; the other two columns show the
exact operation to be performed on any particular
number of times clinical assessment or gait analysis rec-
muscle; for example, no distinction was made between
ommended operations in isolation. There was greater
an intratendinous and intramuscular lengthening.
agreement between clinical assessment and gait analysis
for operations involving bone surgery (femoral or tibial
RESULTS
derotation osteotomy; agreement in 47 of 61 procedures
The study population consisted of 105 patients. Three [77%]) compared with soft tissue surgery (muscle or
were subsequently excluded because a complete set of tendon lengthening or transfer; agreement in 114 of 206
CONCLUSIONS REFERENCES
The results of this study show that gait analysis would 1. DeLuca PA, Davis RB, Õunpuu S, et al. Alterations in surgical
decision making in patients with cerebral palsy based on three-
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our patients and confirm the value of gait analysis for 2. Gage JR. The role of gait analysis in the treatment of cerebral
decision-making in cerebral palsy. The two assessment palsy. J Pediatr Orthop 1994;14:701–702.
methods agreed in identifying which patients required 3. Gage JR, Perry J, Hicks RR, et al. Rectus femoris transfer to
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treatment was necessarily changed by gait analysis, but 4. Kay RM, Dennis S, Rethlefsen S, et al. The effect of preoperative
we believe that the assimilation of extra information has gait analysis on orthopaedic decision making. Clin Orthop 2000;
been of benefit in fine-tuning the treatment of our pa- 372:217–222.
tients to ensure they receive the correct operation at the 5. Skaggs DL, Rethlefsen SA, Kay RM, et al. Variability in gait
analysis interpretation. J Pediatr Orthop 2000;20:759–764.
appropriate level. Randomized controlled studies are re- 6. Watts HG. Gait laboratory analysis for preoperative decision mak-
quired to evaluate further the benefits that gait analysis ing in spastic cerebral palsy: is it all it’s cracked up to be? J Pediatr
may have in the management of these patients. Orthop 1994;14:703–704.