Gait and Posture 16 (2002) 159 – 179 www.elsevier.

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The evolution of clinical gait analysis Part II Kinematics
D.H. Sutherland *
Children’s Hospital San Diego, 3020 Children’s Way MC 5054, San Diego, CA, USA 92123 -4282 Accepted 18 December 2001

Abstract Kinematics is treated as a single topic in this manuscript and the emphasis is on early history, just as it was in Part I, Electromyography. Needless to say, neither kinematics nor electromyography, nor kinetics and energy (the latter to be included in Part III) are stand-alone components of clinical gait analysis. The only reason for this selective format is that it lessens my task to be able to write about one subject at a time. One of the consequences of this arbitrary separation is that some contributors, who have enriched more than one portion of clinical gait analysis, are highlighted only in the area in which they have contributed the most. I began with Kinesiological Electromyography in Part I because the earliest stirrings of the dream of clinical gait analysis were expressed in the development of KEMG (kinesiological electromyography). The early investigators realized that very little could be said about the dynamic action of muscles without KEMG. Next, in chronological order, came kinematics. I have been an active participant and eyewitness, and take full responsibility for attempting to write an early history at a time when most of the contributors are still alive. Ordinarily, history is written much later, in order to fully grasp the significance of individual contributions in the tapestry of the whole. As stated in Part I, Electromyography, the emphasis has been placed on the early history. The application of motion analysis to sports medicine, and sports medicine functional analysis, is covered only lightly here, and this should not be interpreted as minimizing its importance. The literature on this subject is now quite voluminous and it would not be possible to cover it adequately in this manuscript. Later historical writings may differ significantly and will hopefully give more recognition to pioneers in later generations: those physicians, engineers, physical therapists and kinesiologists who are lifting the level of clinical gait analysis and directing their energies in expanding clinical directions. It is hoped that this manuscript will prompt additional manuscripts, as well as letters to the editor of Gait and Posture on the content of this review paper. © 2002 Published by Elsevier Science B.V.
Keywords: History; Kinematics; Clinical gait analysis

1. Introduction Accurate measurement of motion is central in any scientific method of gait analysis. Measurements of individual joint angular rotations, as well as translations of segments and of whole body mass, allow the comparisons with normal that are necessary to distinguish pathological from normal gait. Complex hardware and software are necessary to accomplish this task with accuracy and reliability. This component of clinical gait analysis has proven to be very challenging and the evolutionary process continues to this day. The individual joint angles and the displacements of segments and of the whole body mass were recognized to be essential measurement requirements in the late 1800s by Braun and Fischer [1–5]. Their clever ap-

Note from re6iew editor: This article is the second in a series of three historical narratives that Dr Sutherland has very kindly agreed to author for Gait and Posture. As Dr Sutherland indicated in his abstract for Part I, these are very personal accounts that focus primarily, although not exclusively, on the early history of clinical motion analysis. He further acknowledged that not all important contributors or events may be chronicled or weighted in the same manner as others might have done. Still, these accounts are extremely valuable because they provide a very alive ‘behind the scenes’ view of how our field has progressed over the years as told by one of its true pioneers, with a richness that could never be captured by a mere listing of names or documented events. * Tel.: +1-858-966-5807; fax: + 1-858-966-7494 E-mail address: dsutherland@chsd.org (D.H. Sutherland). 

0966-6362/02/$ - see front matter © 2002 Published by Elsevier Science B.V. PII: S 0 9 6 6 - 6 3 6 2 ( 0 2 ) 0 0 0 0 4 - 8

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proach to kinematic analysis was to apply Geissler tubes to the limb segments, interrupt the illumination at regular intervals by a large tuning fork, and photograph the subject walking in total darkness with four cameras while the lenses were open. One camera was positioned in front of the subject, one behind, and one on each side, making their measurements tri-dimensional. The subjects were protected from electrical shock by wearing rubber suits resembling wet suits. The process of collecting data required 8 or 10 hours per subject and then it involved months of work to reduce the data and calculate kinematic measurements. This was a fantastic scientific achievement, however, because it was so time consuming, Braun and Fischer’s method could only be applied in gait research. One of the methods used by Eberhardt and Inman [6] in the 1940s also included the use of interrupted light. A photograph was obtained with the subject walking in front of the open lens of a camera while carrying small light bulbs located at the hip, knee, ankle and foot. A slotted disk was rotated in front of the camera, producing a series of white dots at equal time intervals. These dots could be laboriously connected to provide joint angles that could be manually measured. Again, this was a slow and labor-intensive process, not suitable for clinical application. In order to examine transverse plane rotations, Vern Inman, MD, PhD, drilled pins into the pelvis, femur, and tibia, and recorded pin rotation with the aid of a movie camera located above the subject [7]. One of his subjects, David Chadwick, MD, then a student at the University of California, Berkeley, later became the Medical Director of Children’s Hospital of San Diego. He described his experience as ‘very painful’, something he would not have agreed to had he understood ‘what it would be like’. Needless to say, this technique gained very few followers, although there has been some recent use of pins inserted into bones in normal subjects for a different purpose, i.e. to determine the difference between movement of markers taped to the skin surface and those placed into the skeleton. 2. Early pioneers and techniques (post Inman)

of the individual segments. Her method did include upper extremity and trunk markers, as well as pelvis and lower extremity. She successfully used this method to produce landmark articles in the 1960s, 70s and 80s outlining the walking patterns, first of normal men [8], then of normal women [9], and then patients with pathological conditions [10– 12]. Although, viewed by today’s standards, this appeared to be a crude method, the sagittal plane joint angle measurements of normal subjects in her publications are very similar to those obtained with current technology, (see Fig. 1) [9]. The primary problems with Dr Murray’s method were the need for manual measurements of all the joint angles and the inherent difficulty with the method in providing hip, knee, and ankle joint rotations in the transverse plane.

2.2. Electrogoniometry
There was a flurry of enthusiasm for recording joint angles with electrogoniometers. The Karpovich brothers were early contributors who used goniometers to record joint angles. Their reason for using electrogo-

2.1. Strobe light, reflecti6e strips and manual goniometer
Mary Pat Murray, PhD, working at the Veteran’s Administration Hospital in Milwaukee, Wisconsin, devised a simple, effective, and low cost way to record and measure movements. She and her team attached reflective targets (including reflective strips in the lower extremity) to specific anatomic landmarks and the subjects walked in the illumination of a strobe light. The resultant photograph was used to make measurements

Fig. 1. Sagittal measurements of pelvis, hip, knee and ankle in normal women. Reprinted from the Archives of Physical Medicine and Rehabilitation, with permission from W.B. Saunders Company [9].

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Fig. 2. Triaxial Goniometer as applied to a subject for bilateral hip and ankle joint motion analysis. Reprinted from the Journal of Biomechanics, vol. 13, 1980, pp. 989 –1006, Chao: ‘Justification of triaxial goniometer for the measurement of joint rotation’; with permission from Elsevier Science [22].

niometers was that many gait cycles could be collected quickly, and analog graphs of motion could be displayed, without the need for data reduction by hand [13]. In 1976, Bajd et al. [14] published an article describing online electrogoniometric gait analysis using six precision potentiometers, giving time-dependent angles in hip, knee, and ankle of both legs in the sagittal plane. Their reasons for choosing this method of instrumentation were that it was suitable for online processing of measured data, and was simple, reliable and inexpensive. Other important contributors to electrogoniometry are McLeod [15], Tata [16], Johnston and Smidt [17], Lamoreux [18], Kinzel et al. [19] and Townsend et al. [20]. Foort presented the electronic recording of joint function with analog recordings of three-dimensional hip, knee, and ankle joint motion [21] at a workshop on Human Locomotion and Clinical Analysis of Gait in Philadelphia, in 1976. Edmund Y.S. Chao, PhD published a report in 1980 on the design of a triaxial goniometer, based on the gyroscope concept utilizing Eulerian angles in the computation of the measurements (see Fig. 2) [22]. Again, this did not gain wide acceptance, arguably because of the difficulty in preventing cross talk from the three motion axes. An anecdotal description by Jacquelin Perry (unpublished) of significant motion recorded in the hip joint of a patient with a solid hip fusion did not help promote adoption of this method. At first glance, the goniometric method holds great appeal. However, with the tremendous range of height and weight of subjects, and the difficulty for small subjects to walk comfortably with this amount of hardware, widespread adoption of this technique never occurred. The difficulties encountered with the use of goniometers, then and now, are

the necessity for matching the size of the individual with the appropriate goniometers, the offset of the recording device to the side of the limb segments, and the inability to obtain simultaneous measurements of all of the moving segments. Quoting from Dr Chao’s article entitled, Justification of Triaxial Goniometer for the Measurement of Joint Rotation, ‘‘This paper attempts to provide the theoretical and experimental justifications of the existing triaxial goniometer design so that these potential problems can be resolved’’ [22]. The experimental device used for the justification was a mechanical model, thus any problems with skin motion were not considered. Quoting further, in the ‘Discussions’ section of the article, Dr Chao states, ‘‘Although the triaxial goniometer is the only instrument that can provide instantaneous angular motion of a joint in three dimensions, its user must realize the potential drawbacks of the method in order to avoid unnecessary complications. First of all, the external attachment of the device could introduce error in the data due to relative movement of the underlying soft tissues’’. Chao goes on to mention other critical points to consider in the use of the triaxial goniometers relating to alignment, lateral projection, and the weight of the measuring device. Although these difficulties have prevented widespread adoption of electrogoniometers for routine clinical gait analysis, goniometers are effective when multiple recordings are required, when studies are being carried out outside of a motion analysis laboratory, and when sagittal movements are sufficient for data acquisition. A final objection yet remains: moment studies cannot be made without the measurements of the position of joint centers in space, something that goniometers do not provide.

2.3. Cine film and passi6e marker systems with manual entry of marker positions 2.3.1. Vanguard Motion Analyzer Other investigators concentrated on developing photographic techniques for gait analysis. Photographic methods have a key advantage over other techniques in that the whole body can be included and the relationship of each extremity and the trunk can be simultaneously viewed. The opportunities for measurement are thus greatly expanded over prior techniques. A further advantage is that individuals of all sizes are suitable for clinical analysis. Initially, however, there were formidable obstacles, including the need for excessive time spent in reducing the data and the absence of computer availability for storing data and performing voluminous mathematical computations. While casually scanning a technical journal, my eyes focused on an advertisement for a Vanguard Motion Analyzer. The very name was intriguing and its capability for projection of movie film on a backlit screen for

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easy frame-by-frame viewing, and measurement of selected points with x and y coordinates, was most appealing. Dick Freeborg, later President of Instrumentation Marketing Corporation and now a Vice-President in the Kodak Corporation, suggested that I contact Ray Linder at Lockheed Aircraft Corporation Missiles and Space Company, Sunnyvale, California. Ray Linder was the leader of a section charged with making measurements of machines, rocket trajectories, etc. In 1965, he published a description of the methods that he and his team had developed to measure pitch, yaw, and roll, using mathematical formulae, two or more cameras, and a two-dimensional coordinate system of measurements [23]. After a telephone call and a letter from me, Ray Linder invited me to come to his section during their lunch hour and explain the need for human gait measurements. Roger Mann, MD, accompanied me. Ray Linder made a prescient comment after our presentation to the group, ‘‘You mean you would like to measure the movements of the skeleton from surface markers with skin movements confounding the interpretation. Is not that like trying to measure the movements of a broomstick within a gunny sack?’’ Nothing daunted, we were fascinated to see about 17 Vanguard Motion Analyzers in one room. We were introduced to an interested and bright group of people employed at the task of making measurements of pitch, yaw and roll. Their level of interest in our project was very exciting. Out of this contact, John Hagy and Richard Oyama came forward as volunteers to the Shriners Hospital in San Francisco, bringing with them high-speed movie cameras, generously loaned by Lockheed Missiles and Space Company. In a relatively short time, Hagy, Oyama, and Keller helped us establish a system to add kinematics to the electromyography already in clinical use in our laboratory. Hagy assisted during evenings and weekends until we were able to persuade him to come full-time in April of 1971. John Hagy and Cecil Keller, also a Lockheed employee, assisted in the development of our movement measurement system, first reported in 1967 in the article, ‘Measurement of Movements and Timing of Muscle Contraction from Movie Film’ [24]. Initially, our methods of computation were very time consuming. After recording x and y coordinate measurements from the cine film displayed on the Vanguard Motion Analyzer, we used a slide rule to perform the trigonometric computations. Later, an optical encoder was added to replace the necessity of manually recording the x and y coordinates. This task was further simplified by utilizing a sonic digitizer to input the data (see Fig. 3) [25]. Significant progress in time reduction came when a computer was added to store and perform the mathematical calculations, (see description of our first use of a dedicated computer by Electronic Processors, Inc. in Appendix C). We used this method for many years, but

hand digitizing continued to be an obstacle. Individuals were trained and employed to do the digitizing. They were enthusiastic, but in time became bored with the repetitious nature of their task. The average length of time for a technician to be employed in our laboratory was 2–4 years; many used this opportunity as a stepping stone in their career. We made use of these gait analysis data to provide treatment recommendations and to study the outcome of treatment intervention. Some of the papers from our laboratory were on the subjects of crouch gait [26], gait analysis in cerebral palsy [27], the role of the ankle plantar flexors [28], and the pathomechanics of gait in Duchenne muscular dystrophy [29]. When our methods and results were given, many were enthusiastic about the possibilities for further development of this emerging application of science, but very few were willing to undertake such a labor-intensive effort. The real breakthrough, needed to bring about widespread adoption of three-dimensional movement measurements for clinical gait analysis, was yet to come when the measurements could be automated. In fact, had there been no further improvements in technology, clinical motion analysis might have continued in only a few locations. The time and energy required to digitize film prevented many centers from using gait analysis as a clinical tool. In spite of the difficulties, the stage was set for automation.

2.4. A turning point! Fully automated mo6ement measurements 2.4.1. European contributors and techniques Engineers and physicists deserve full credit for developing methods to automate human movement measure-

Fig. 3. Vanguard motion analyzer and Graf-Pen sonic digitizer used to determine the X and Y coordinates of the markers shown on the viewing screen. Reprinted with permission from the Journal of Bone and Joint Surgery [25].

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Measurement Systems: Aspects of Data Acquisition, Signal Processing and Performance’ [36]. J. Paul, PhD, who started his kinematic measurements with two orthogonal Bolex cine film cameras driven by synchronous electric motors at 50 Hz and a homemade ground-to-foot force platform, wrote this personal letter to me in response to some questions I had posed: ‘‘As you may imagine, the processing of the cine film and hand digitizing was an onerous procedure, and I was therefore very excited when, in 1967, I saw the presentation of Furnee, hybrid instrumentation in ´ Prosthetics Research Proceedings in the 7th International Conference on Medical and Biomedical Engineering in Stockholm. Furnee presented his invention ´ of a single camera television system for 2-D movement analysis. As soon as possible thereafter, I got two of our research students to develop a 2-camera system for 3-D video/computer movement analysis. In 1972, M.O. Jarrett, and B.J. Andrews started their PhD studies with the remit of developing the system. Between them, they got our system up and running based on a PDP-12 computer, which allowed us a total of 36 analog inputs. Brian Andrews did not complete his PhD at that time, but came back to us in 1980 as a member of the staff. At that time, he did further development on the system to allow it to work with a PDP-11 computer and took the opportunity to try the use of shutters on the camera to improve definition, but then implemented what I believe was the first application of strobe infrared lighting.’’ ‘‘When Jarrett finished his studentship, he was employed jointly by ourselves and George Murdoch at Dundee to develop a system for implementation at Dundee. He did this, but to my great astonishment, implemented a two-dimensional system there, and Julian Morris became aware of this, and went on to develop the Oxford Metrics System, which was developed to be three-dimensional. Julian was very surprised, at a later date, to find that our first and only computer television movement analysis system had been three-dimensional. Apparently Jarrett, with whom he was interacting had not told him!’’ ‘‘At that time, we were not very assiduous at publication of our work, and the only one which I can cite is, Jarrett, Andrews and Paul, 1976, which is the text of a conference presentation as you will see on my publication list [37–39]’’. From the letters of Hans Furnee and J. Paul, and ´ their publications, there is an unmistakable sequence of interweaving paths and shared enthusiasm for automating gait analysis. Hans Furnee led the effort; J. Paul ´

Fig. 4. Cat on a treadmill with reflective markers. Reprinted with permission from Dr Hans Furnee [30]. ´

ments. E.H. Furnee, PhD, Faculty of Applied Physics, ´ Technical University, Delft, The Netherlands, began around 1967 to develop TV/motion analysis systems with automated recording of reflective marker positions. His experiment, capturing multiple joint angles of a cat running on a treadmill, was a strong portent of the future widespread adoption of the photo-electronic method to measure the kinematics of human walking. The markers used by Furnee were passive paper disks that were ´ brightly visible in ultraviolet light, and the ultraviolet light was pulsed to prevent ‘smearing’, (see Figs. 4 and 5) [30]. Prior to the first publication directly authored by Furnee [31,32], a student of Furnee, P.C. Steilberg, ´ ´ reported the method more completely as BS and MS thesis work in 1967 and 1968 [33,34]. Furnee is the ´ originator of the Primas System, from the Motion Studies Lab, Delft University of Technology. The current Primas system emphasizes real-time marker identification and real-time marker centers by circle fitting (pilot), developed, respectively at Delft University in 1990 and 1992. Additional publications authored by Dr Furnee ´ include: ‘TV/Computer Motion Analysis Systems: The First Two Decades’ [35] and ‘Opto-Electronic Movement

Fig. 5. Variation of angles at shoulder, elbow, hip and knee of limbs of same side during stepping on treadmill at 2.0 m s − 1. Upward excursion indicates extension, downward flexion. Reprinted with permission from Dr Hans Furnee [30]. ´

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was excited by his work and set graduate students, Andrews and Jarrett, to work, with the resultant production of a 3-D automated video camera system for movement measurement. Prior to his entry into automated movement measurements, J. Paul had already become an expert in gait analysis, using a digitized cine-film system for movement measurements. His publications cover a wide range of clinical subjects, with a special emphasis on the gait of amputees. A large number of students of Dr Paul are spread worldwide and it is fair to say that he has been a central figure in the development and expansion of clinical motion analysis. In response to questions posed to Julian Morris, DPhil, I received a personal correspondence dated April 13, 1996. The following correspondence is printed in its entirety. The history of the development of Oxford Metrics and VICON is as follows: 1973 ‘‘I first met Mick Jarrett at an ISPO conference in Montreux, Switzerland, while he and I were both graduate students. He was working (together with Brian Andrews, now in Edmonton, Alberta) on a 2-D TV computer system and I was using accelerometers for measuring gait. Mick and I both presented our doctoral theses later the same year, his to Strathclyde University and mine to Oxford. Mick was by now working with David Condie in University of Dundee, and I was working at the Nuffield Orthopaedic Centre in University of Oxford. We both wanted to set up automated, non-cine gait analysis facilities in our respective hospitals. I arranged for an Oxford engineering friend of mine, Malcolm Herring, who was a far more experienced electronics designer than either of us, to redesign Mick’s prototype from Strathclyde. Three of these (multi-camera but still 2-D) systems were built—one for Strathclyde, one for Dundee, and one for Oxford. Having left the Nuffield Orthopaedic in 1977 (Mike Whittle took over my job), I was now Technical Director

1983–84

1974–75

1979

of Oxford Medical Systems, part of the Oxford instruments group. Although our main product range was for cardiology (Holter monitors), I believed that there was a commercial market for an automatic 3-D gait analysis system. I hired Malcolm Herring (see above), Graham Klyne, and Annabel MacLeod as the development team, and made a licensing deal with Universities of Strathclyde, Dundee, and Mick Jarrett personally, for the existing technology. Over the next 2 years, the VICON (the name derives from video-converter) development team redesigned the hardware and wrote the first 3-D photogrammetry software applied to this field. The first system was shipped to Eric Radin, MD, in West Virginia in 1980, and the second to Sheldon Simon, MD, Boston Children’s Hospital, a few months later. The Oxford Instruments Group decided to float on the London Stock Market and focus on their core businesses, primarily building cryogenic magnets for MRI. They ‘spun-off’ the biomechanics business, by then called Oxford Dynamics, which was sold to myself and other members of the VICON development team. We renamed the company, Oxford Metrics Ltd. (Graham Klyne won a bottle of wine for the name). During the 70s I was aware, through publications, of the work of Hans Furnee and David Winter. However, ´ I do not think I first met either of them until after VICON was launched. To my knowledge, Hans did not ever spend time working in Oxford. The connection between Hans and VICON is largely technical, rather than historical. The hardware technology used by VICON is basically the same as that developed by Hans. Whether either one derived from the other is hard to say. Certainly, I believe that Hans published his early work and may have been visited in Holland by Mick Jarrett while the latter was a graduate student.’’

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Author’s comment: In a letter to me, Hans Furnee ´ confirmed the visit of M.O. Jarrett to his laboratory and stated that he had freely shared information with Jarrett. Again, back to Julian Morris’ letter: ‘‘Although they both use video, there is minimal technical connection between what David Winter published and VICON. I certainly believe that Hans and David developed video-based systems a year or two ahead of Mick, but as you imply, this is, for some, a sensitive area! Mick Jarrett and Brian Andrews, I believe, wrote most of the software for the 1973 Strathclyde TV system jointly. However, the VICON development team never saw or used any of it. The first true VICON 3-D software was designed by Graham Klyne and myself, and written entirely by Graham. We drew on the published ideas of many others, including Herman Woltring.’’ Eric Radin, MD, used the technology supplied by VICON to study the running and walking gait of sheep on a treadmill. In 1983, along with gait colleagues from San Diego, Ed Biden, and Marilynn Wyatt, I visited Eric Radin’s Laboratory in Morgantown, West Virginia. The Laboratory provided an extraordinary scene of stacked bales of straw, sheep in a pen at the side of the room, and the odor of sheep lying like a pall over all. I asked Dr Radin, ‘Eric, do you do any studies of human patients?’ Eric, in his inimitable style, said, ‘‘Well, yes, of course, but we only let people in on Fridays’’. I silently wondered how well human subjects responded to being studied in this environment! Following this visit, we purchased VICON hardware and Ed Biden, DPhil, wrote custom software in 1984 for clinical application in our San Diego Gait Laboratory. After a period of comparison of studies on normal individuals with cine-film digitization, and data collected on the same individuals with the VICON hardware and Ed Biden’s software, we made the transition from film digitization to automated data capture. The initial problems were associated with the difficulty of identifying and tracking markers; this was initially done in two dimensions. A tremendous move forward occurred with the contribution of Andrew Dainis, who wrote three-dimensional tracking software (details to follow later). Michael Whittle, MD, PhD, spent 2 years doing surgical research after internship, which led to a master’s degree in biomechanics. As a research medical officer in the Royal Air Force, he was loaned for 3 years to NASA in Houston to supervise the musculoskeletal experiments on the Skylab Space Station. One of these experiments was on the 3-D measurements of the astronaut’s body form [40], and this

became the subject of his PhD dissertation, which he obtained after he returned to Great Britain. He took over the directorship of the Motion Laboratory at Oxford after Julian Morris left to found Oxford Metrics. The only software available for the new Oxford Metrics system was for data capture, so Dr Whittle wrote full 3-D motion capture software, ‘‘So, in effect, we had the first 3-D TV computer system in the world’’. (Author’s comment: Communication from J. Paul indicates earlier 3-D development in Strathclyde.) Michael Whittle now holds the Cline Chair of Rehabilitation Technology at the University of Tennessee at Chattanooga. He is author of a book entitled, ‘Gait Analysis: An Introduction’, which is now in its 2nd edition [41]. Another important player in the exciting world of motion capture is the Bioengineering Technology Systems, or BTS, which is home-based in Milan, Italy. BTS traces its origins to the contribution of the bioengineering center of the Pro Juventute Foundation and the Politecnico di Milano. The company was formed in 1986. The engineering contributions of Ferrigno, Pedotti, and Cappozzo were key in the development of the ELITE System [42 –44]. BTS rapidly expanded into the complete world of clinical gait analysis, combining kinematics, kinetics, and electromyography in a robust, all-inclusive approach to clinical gait analysis and research in motor skeletal function. In point of time, BTS entered the field of clinical motion analysis after Oxford Metrics, Inc. and Motion Analysis Corporation. The story does not stop here. The entry of many new companies and new systems of motion capture attests to the enduring fascination with movement analysis. The competition between the companies now marketing motion capture systems has resulted in more rapid processing of information, new methods of displaying the data, and a surging interest in clinical gait analysis. Laboratories are now available in all of the developed countries and in many of the developing countries.

2.5. Automated mo6ement measurements 2.5.1. North American early contributors and techniques While the early advances in gait analysis and automated movement measurements were occurring in the Netherlands, England, and Scotland, exciting activities were also taking place in Canada. Robert K. Greenlaw, MD, then the Chief Surgeon of the Shriners Hospital, Winnipeg, Canada, and a former resident in the Shriners Hospital in San Francisco, was aware of Dr Inman’s work and of my work in the San Francisco Shriners Hospital Gait Laboratory. It was not obvious

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Fig. 6. Gait studies data acquisition system. ‘Locomotion studies as an aid in clinical assessment of childhood gait’—reprinted from, by permission of the publisher, CMAJ, 1975; 112 (9), pp. 1091–www.cma.ca [46].

to me then that orthopedic resident Greenlaw had an interest in motion analysis, but the events that followed proved otherwise. He had the good judgment to ask David Winter, PhD, to design the first gait analysis laboratory in the Shriners system in Canada. David Winter, PhD, then with the Department of Electrical Engineering and the Department of Surgery, University of Manitoba, Winnipeg, designed a Gait Laboratory for the Winnipeg Shriners Hospital. Dinn et al. submitted a manuscript in 1969 entitled, ‘Computer Interface for Television’, which was ultimately published in IEEE Transaction of Computers in 1970 [45]. In a letter to me, Dr Winter states, ‘‘Our first routine use of the interface began early in 1970 at the Shriners Hospital in Winnipeg. For the 5 years I was there it was the backbone of all our kinematic data collection. Actually, it goes back to the time of Furnee. ´ Our first operational TV interface was reported at biomedical engineering conferences on this side of the Atlantic at the same time (unknown to us) as he was reporting in The Netherlands’’, (see Fig. 6), [46]. Winter et al. subsequently published an article entitled: ‘Television–Computer Analysis of Kinematics of Human Gait’ in Computer and Biomedical Research in 1972 [47]. Winter et al. published an important study of the kinematics of normal locomotion in the Journal of Biomechanics in 1974 [48]. Doctor Winter’s publications since that time are legendary [49]. He has profoundly influenced the course of clinical gait analysis through his scientific studies, teaching, mentoring of many graduate students and his many publications. His book entitled, ‘Biomechanics and Motor Control of Human Movement’, now in its 2nd edition, is a ‘must read’ for all who are interested in gait analysis [50].

Sheldon Simon, MD, obtained his medical degree from Harvard and his residency training was completed in the Harvard Training Program. During his residency training, he worked in the laboratory of Robert Mann, PhD, at the Massachusetts Institute of Technology. He received a Cave Traveling Fellowship and, in January through June 1974, divided his time between the San Francisco Shriners Gait Analysis Laboratory, then directed by Roger Mann, MD, and the Pathokinesiology Laboratory at Rancho Los Amigos, directed by Jacquelin Perry, MD. He says that he was very impressed by the electromyographic studies at Rancho and the force and kinematic studies in San Francisco. By the time of his return, the Kistler force plate was available as a commercial product, but the price was steep for his budget in Boston. He persuaded Walt Synutis, President and CEO of AMTI, to design a new strain-gauge force plate at a price within his budget. The space available for him in Boston was small and he realized that a three-dimensional coordinate software system for kinematic measurements should be developed. The laboratory opened in Boston Children’s Hospital in September 1974, with two AMTI strain gauge force plates, a three-camera 16 mm high speed camera system, a Vanguard Motion Analyzer and a computer which stored the measurements from force plates and electromyograph simultaneously. The software for kinematic measurements utilizing a three-dimensional coordinate system from film was conceived by Dr Simon and written by Roy Nuzzo, MD, an orthopaedic resident at the time [51]. Mick Jarrett, PhD spent a good deal of time at Boston Children’s Hospital in 1982 perfecting software for clinical application of the VICON system. According to Dr Simon, initially it took

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just as long to process 3-D VICON measurements as 3-D film measurements. Nonetheless, it was clear that further developments would establish automated video measurements and there would be no turning back. In 1986, Dr Simon moved to Ohio State University, where he held the positions of Chairman of the Department of Orthopedic Surgery and Medical Director of the new Motion Analysis Laboratory. Numerous clinical and research publications have followed [52]. One of Dr Simon’s many interests has been the application of artificial intelligence to gait data. He says that he realized that interpretation would continue to offer the greatest challenge and, in 1984, began work on an artificial intelligence application. This work has continued to this time and a system, which can be separately used as a decision helper and as a trainer, is currently being tested. Dr Simon is the editor of a book entitled, ‘Orthopaedic Basic Science’, published by the American Academy of Orthopaedic Surgeons [53]. He now resides in New York City and continues his career-long interest in clinical gait analysis. In 1978, James R. Gage, MD, visited Eugene Bleck’s Gait Laboratory at Stanford Children’s Hospital, Jacquelin Perry’s laboratory at Rancho Los Amigos Hospital, and my laboratory at San Diego Children’s Hospital, in preparation for beginning his first laboratory at Newington Children’s Hospital. United Technology Research Corporation, located in Newington, Connecticut, had offered extraordinary engineering and financial support for the establishment of a Gait Laboratory. In early 1980, Gage returned to the San Diego Laboratory for an in-depth look, bringing with him Ken Taylor, United Technology Project Engineer, and Jim Clark, Manager of the Newington Gait Laboratory project. The three men asked many questions, including what we would do if we were starting another laboratory with optimal funding and full technical assistance. We answered openly, even with ideas that were not yet fully realized in our own laboratory. This cooperation and sharing of information continued during the development of the Newington Laboratory. The Newington Gait Laboratory opened in July 1981. Special features of this laboratory included synchronization of all gait data, full custom clinical software and rapid processing of data. Scott Tashman, MS (now PhD), validated and continued the United Technologies software package. Follow-up gait studies were regularly performed on patients who had undergone preoperative gait studies, thus opening the way for a great many clinical papers [54 –59] and a book entitled ‘Gait Analysis in Cerebral Palsy’ [60]. Following Dr Gage’s move to Gillette Children’s Hospital in 1990, the Newington laboratory continued under Peter DeLuca, MD, as Medical Director, with Roy B. Davis, PhD, as Director until 1998. Sylvia . Ounpuu, M Sc., a prior student of David Winter, is the

current Director. The Newington Gait Laboratory moved to Hartford Connecticut, with the opening of Children’s Hospital of Connecticut as an integral part of the University of Connecticut Medical Center. Many papers have been published both by Gillette Children’s Hospital and Newington/Children’s Hospital of Connecticut covering a variety of subjects, including: running patterns of normal children [61] [62], outcome of multilevel surgery in cerebral palsy [63], stiff-knee gait [64,65], the utility of basing treatment decisions in cerebral palsy on preoperative gait analysis, [66], and a gait analysis data collection and reduction technique, which includes Davis’ much referenced joint center determination method [67]. Gage has pushed the envelope in advocating gait analysis routinely in patients with cerebral palsy [60]. Some surgeons, none of whom have gait laboratories, have criticized this. An anecdote illustrating this point follows: At a course jointly sponsored by the American Academy of Orthopaedic Surgeons (AAOS) and the Pediatric Orthopaedic Society of North America (POSNA) in San Francisco, May 6, 1990, entitled Controversies in the Treatment of Cerebral Palsy, the course chairpersons were Dr Michael Sussman and Dr Walter Greene, myself, Dr Simon, and Dr Gage, in that order. We had just finished giving views on the importance of clinical gait analysis when, from near the back row, Hugh Watts, MD, a pediatric orthopaedist and friend, but never one to avoid controversy, rose to challenge the clinical usefulness of gait analysis. He claimed that the gait laboratory setting is not a suitable environment for arriving at the true walking patterns of children with cerebral palsy. He implied that observational analysis of children in the playground, or in other familiar surroundings, is better. The entire back section of the auditorium, filled mostly with orthopaedists, burst into spontaneous applause. The heated discussion that followed resulted in back-to-back editorials by Gage and Watts in the Journal of Pediatric Orthopaedics [59,68]. Be that as it may, acceptance of clinical gait analysis has steadily increased and new laboratories are being established throughout the world. The new generation of orthopaedic surgeons, introduced to gait analysis in their training, increasingly demands functional analysis, before and after treatment, in order to better understand the magnitude of the disability and to ascertain the impact of their intervention. As my ‘parting shot over the bow’ on this subject, I would like to quote Max Planck, the famous German physicist, who pioneered modern physics by proposing the quantum theory and won the 1918 Nobel Prize. He said, ‘‘An important scientific innovation rarely makes its way by gradually winning over and converting its opponents. What does happen is that the opponents gradually die out’’ [69].

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Murali Kadaba, PhD, became interested in gait analysis when he joined Helen Hayes Hospital as a research scientist in 1979. Dr George Van Cochran was influential in his decision to work in the area of clinical gait analysis. Dr Kadaba states that his interest was intensified after a visit with Dr Perry at Rancho Los Amigos Pathokinesiology Laboratory in Downey, California, and with me at the Motion Analysis Laboratory at San Diego Children’s Hospital. He received a NIH grant in 1984 to study the reproducibility and reliability of gait data [70]. Following completion of this study, he became interested in the numerical representation of kinematic and kinetic data for pattern recognition in spastic diplegia [71]. The Helen Hayes clinical software was completed in 1985. ‘‘This was a cooperative effort; the other team members were H.K. Ramakrishnan, Mary Wootten, Janet Burn (Gainey) and Dr Van B. Cochran’’ [72]. This clinical software served a critical need for software to be used in a clinical setting. It was implemented at the following centers: Richmond Children’s; Shriners Hospital, Houston Unit; Methodist Hospital, Houston, Texas; Children’s Memorial Hospital, Chicago; Children’s Milwaukee; and Shriners Hospital, Portland Unit. The Helen Hayes Team, under the leadership of Dr Kadaba, deserve great credit for developing and supporting clinical software (no small task), in the precarious early years. At that time, the writers of commercial software were attuned to the diverse needs of researchers, but they lacked confidence in the ability of clinical laboratories to agree on nomenclature and formats for data presentation. As a consequence, new laboratories were forced to adapt commercial software to their own tastes. The Helen Hayes Software helped fill this temporary void. Happily, the common needs of most of us are now met with commercially available software. The original Helen Hayes software could now be named the Helen Hayes marker set as software is available that can handle both the Helen Hayes marker set and the Cleveland Clinic marker set. The competing marker set is the Cleveland Clinic, credited to Kevin Campbell of the Cleveland Clinic Foundation. The differences in the two marker sets are briefly outlined as follows: Both marker sets are used to define joint centers and segmental coordinate systems (SCS) needed to calculate angular kinematics. The main difference between both sets is in the way the joint centers and coordinate systems are defined. Helen Hayes (HH) is a ‘wandbased’ marker set, in which joint centers and segmental coordinate systems are defined using a wand marker on each segment (i.e. thigh and shank). As joint markers are shared between segments and, therefore, each seg-

ment has at least three markers for its definition, the Helen Hayes is considered a simplified marker set, which along with a static trial of markers on the medial and lateral sides of each joint (ankle and knee), gives everything that is needed to calculate joint angles (i.e. location and orientation of each joint axis) [73]. The Cleveland Clinic Foundation (CCF) marker set is a ‘cluster-based’ marker set, in which clusters or arrays of three (or sometimes four) markers are used to define joint centers and segmental coordinate systems. With this marker set, the clusters are placed on each segment along with the medial and lateral markers, which define the flexion-extension axis of each joint, during the static trial. As the clusters define a coordinate system to reference the positions of the medial and lateral markers, all medial and lateral joint markers can be removed after the static trial, and a dynamic trial can be collected, while still maintaining the location and orientation of each joint axis [74]. The advantage of the Helen Hayes marker set is that it is relatively simple to use and more applicable to gait analysis of children. The arrays used in the Cleveland Clinic marker set have been known to hit each other in smaller children. In a recent comparison study, conducted in our Motion Analysis Laboratory by Arnel Aguinaldo, MA, ATC, and the laboratory team, we observed less variability in the transverse plane kinematics with the Cleveland Clinic marker set. This was probably because there was less marker movement, due to the fact that there are at least three markers fixed to a rigid frame, although skin motion over the segment defined by the array is still a factor.

2.6. Methods of joint angle calculation
Although, there are two methods of joint angle calculation most frequently used: Euler/Cardan and Helical screw axis, there are at least three additional methods, with definitions and pros and cons noted in Table 1. Further use and description of joint movement and rotational three-dimensional motion by Kenton Kaufman, PhD, includes the transformation matrix method for complete representation [78]. The Euler/Cardan method lends itself well to clinical interpretation. Therefore, we utilize it for most of our clinical studies that do not involve translational movement, such as that found in patients with anterior cruciate insufficiency. For persons with knee instability, which may add more than normal translation to angular rotation, the use of the helical screw axis method of joint angle calculation is more appropriate. John Greaves, PhD, a graduate in electrical engineering from the University of California, Santa Barbara, while he was a student with Glen Culler, worked on a project they dubbed ‘the bug watcher’. The researchers in the biological sciences department were interested in

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monitoring the motion of the microscopic marine plankton known as dynoflagellates. Greaves tackled the problem for them by designing and building a system using a video camera to look into a microscope coupled with a computer to process the video signals and provide position and velocity information about the dynoflagellates. The system worked. After some intervening post-doctoral activities, John Greaves founded Motion Analysis Corporation; a company that provides 3-D motion capture systems for many clinical gait laboratories, sports analysis research facilities, and equipment for use in the movie industry. This company utilizes ORTHOTRAK software for processing of movement, developed jointly by the Cleveland Clinic Foundation and Motion Analysis Corporation, in conjunction with Chet Tylkowski, MD, then at the Human Motion Laboratory, Department of Orthopaedics, University of Florida, Gainesville. The current version is a joint development effort with James Richards, PhD, Freeman Miller, MD, and Patrick Castagno, MS, from the University of Delaware and the Alfred I. duPont Hospital for Children. Chester Tylkowski, MD, became interested in gait analysis while working as a fellow with Dr Sheldon Simon at Boston Children’s Hospital, 1978– 79. He set up a clinical gait laboratory at the University of Florida, Gainesville, in 1980. Subsequently, in 1989, Dr Tylkowski and the laboratory moved to the Miami Children’s Hospital. His third move was to the Shriners Hospital, Lexington, Kentucky, in 1995, where he holds the position of Chief of Staff. He holds the unofficial record for the physician responsible for forming the largest number of clinical gait laboratories. This is an indication of his commitment to the importance of clinical gait analysis throughout his orthopaedic career [79– 81]. A kinesiologist, Susan Sienko Thomas, MA, a former student of David Winter, holds a similar record for involvement in three gait laboratories. In 1985, Susan was hired to oversee the operation of the Southern Illinois University Motion Analysis Laboratory in Springfield, Illinois, after the tragic death of Maxine Covert. The laboratory had been established with a VICON system in 1983. In 1989, she assisted in the set up and operation of the Motion Analysis Laboratory at Children’s Memorial Hospital, Chicago, where the He-

len Hayes clinical software package was used. She currently holds the position of Clinical Research Coordinator at the Shriners Hospital in Portland, Oregon [82,83]. Steven J. Stanhope, PhD, from the Biomechanics Laboratory, National Institutes of Health, has strongly advocated inter-laboratory reliability and the need for demonstrating proven means of testing kinematic movement measurements. His efforts have lifted the standards for all gait laboratories in the U.S. Similar efforts are occurring in Europe under initial funding by the European Union. The testing of laboratories should be a requirement for certification. Although many efforts have been exerted to move this important task forward, it still remains in the discussion stage. There should be no objection to the concept that patients, referring physicians, and payers have a right to know that a laboratory is capable of providing accurate and reliable data. There is little doubt that testing and certification will be instituted, hopefully in the near future. The majority of clinical patients seen at the Biomechanics Laboratory, National Institutes of Health, are adults referred by physiatrists or internists. Thus, the clinical applications have been primarily for subjects with rheumatoid arthritis, osteoarthritis, limb deficiency, diabetes, stroke, and neuromuscular disorders [84 –86]. The establishment of a three-dimensional musculoskeletal database is a research effort that will contribute greatly to clinical applications [87]. Software for clinical applications, as well as for research, were developed in this laboratory, and provided to laboratories throughout the world. The program is called Move 3D. This software is very robust and, according to Dr Stanhope, is the first software to provide six degrees of freedom gait measurements. 3. Shriners network of gait laboratories There are 19 orthopedic Shriners Hospitals in the U.S., Canada and Mexico. Of these, 12 currently have gait laboratories, with a 13th laboratory being established in Tampa, all of them carrying out clinical analysis before and after treatment. In addition, they

Table 1 Methods of joint angle calculation (A. Aguinaldo, MA, ATC, Motion Analysis Laboratory, Children’s Hospital, San Diego) Method Plane projections Direction cosines Euler/Cardan Grood and Suntay Helical References: [75,76,73,77]. Definition Angles projected onto plane Transformation matrix Sequence of rotations Euler with floating axis Screw axis Pros Simple Complete representation Clinical interpretation Sequence independent Rotation and translation Cons Parallax Not clinically relevant Gimbal locks Not suitable for kinetics Sensitive to noise

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are involved in collaborative research. This confirmation of the usefulness of clinical gait laboratories has not gone unnoticed by physicians in the children’s hospitals of North America. This powerful statement by a major block of children’s hospitals may well have helped spur the establishment of centers for analysis in the other Children’s Hospitals, both private and University affiliated.

neers and physicists will be well served by reading Furnee’s very complete, and highly technical, descrip´ tions of passive and active motion capture systems [35,36].

3.2. Three-dimensional marker identification and tracking
Andrew Dainas deserves much credit, along with Doug McGuire, for more efficient processing of raw TV data to 3-D coordinates. In a personal communication Dainas writes, ‘‘By 1988 we had finished the first version of the AMASS software. The software development was carried independently of NIH, and was not supported by NIH. At that time, we installed it on the NIH VICON system and offered it as a replacement to Oxford Metrics for their aged system. As it turned out, in 1988, Oxford Metrics had completed their new VAX – VX hardware system but lacked appropriate software, and they agreed to market AMASS with their systems. Between 1988 and 1993, Oxford Metrics sold some 70 VICON systems bundled with the AMASS hardware. In 1993, Oxford Metrics announced the VICON 370 system, with their own software (which replicates many functions of AMASS). We (at ADTECH) in turn ported AMASS to the PC computer, and adapted it to work with raw data from both Motion Analysis Corporation systems and ELITE systems. Currently, we offer AMASS as alternative software for these systems. AMASS can claim to be the first software used in clinical and gait applications to provide: 1. Intelligent marker reduction to 2-D centers in the camera image data by fitting circles to the pixels outlining the markers. 2. Provide the user with the ability to linearize each camera for distortions, etc. 3. Do automatic identification of reference markers in the 3-D camera calibration process. 4. Do completely hands-off 3-D reconstruction and tracking of unidentified camera image data. In 1994, I wrote and incorporated into AMASS the first program to carry out the 3-D camera system calibrations using a large number of markers whose locations in 3-D space need not be measured beforehand. This technique does away with the need for rigid calibration objects, or hanging strings or rods, and is capable of eliminating a chief source of inaccuracies in most currently used 3-D measurement systems. The method has since been also implemented by Oxford Metrics.’’

3.1. Acti6e marker systems
The Selcom Company of Sweden developed the Selspot System, which used active markers taped to the limb segments, prior to the advent of VICON and Motion Analysis Corporation. The first Selspot movement capture systems in the U.S. were installed in the laboratory of Thomas Andriacchi, PhD, at Rush Presbyterian Medical Center in Chicago, and in the laboratory of Robert Mann, PhD, at Massachusetts Institute of Technology, Cambridge, MA. Herman Woltring, PhD, did some of the early work with the Selspot System as did Andrew Dainas. Robert Mann, PhD, and Eric Antonsson, PhD, established a clinical laboratory at Massachusetts General Hospital in 1984, along with several orthopedists, William Harris, MD, Henry Mankin, MD, Donald Madeiras, MD, and Michael Erlich, MD, PhD. Their system was designed for cerebral palsy gait analysis. David Krebs, PhD, PT, continues this work, collecting data on human subjects with a variety of problems, including cerebral palsy and disorders of posture and balance. This laboratory utilizes Selspot active markers, arranged in clusters on a fixed base, applied to each of the body segments being studied. A large database of children and adults with neuromuscular disorders, including many with problems of balance, has been established. One area of investigation is sitting-to-stand movements. Although the Selspot system eliminates the need for marker identification and tracking, it contains other less positive features including its propensity to pick up reflections, the necessity for the subjects to carry cumbersome apparatus, and the trade-off between sampling rate and the number of markers. These inherent drawbacks in this active marker system served to energize the proponents of passive marker systems and to keep them working to solve the difficulties with marker identification and tracking. In spite of the current preponderance of passive marker systems, some active marker systems are emerging to compete with the passive models. Examples of active marker systems are those by CODA and Skill Technologies, (see Appendix A). The brief discussion contained in this manuscript will be useful to clinicians, but engi-

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3.3. Present reality
Commercial hardware and software now available have nearly eliminated problems with marker identification and tracking, thus removing the chief objection to passive marker systems. As a consequence, the development and utilization of active marker systems was on hold for a time. In today’s state-of-the-art laboratory, a subject can be fitted with appropriate reflective markers and walk down a calibrated walkway, while the markers are automatically tracked and thousands of computations are performed by a dedicated high-end PC computer or a computer work station. The resultant joint angles can be viewed within minutes from the end of collection of the data. An increase in the number of cameras, plus 3-D identification and tracking of markers, now enable laboratory personnel to examine the data for reliability and potential errors while the subject is still present in the laboratory. This represents an enormous evolution in automated movement measurements in the 34 plus years since the technology was first developed. There are still some problems to be worked out. For example, accurate timing of toe-off is problematic with kinematic methods. The incorporation of force platform input establishes the events of foot-strike and toe-off accurately for those patients able to contact two or more force platforms. However, it is the slow walkers, using crutches or a walker, who often exhibit variable or even inaccurate foot-contact times, as calculated from the trajectory velocities of markers on the foot. Yet another problem is that of marker movement due to skin movements over the underlying skeleton. A number of research studies address this problem, but none have discovered a way to totally eliminate inaccuracies due to skin movement [88–95]. If these reasons are not enough to convince the reader of the need for additional research, or even investigation of other methods of measuring movement, there is yet another problem, that of placing markers accurately and reliably. Mistakes can alter the calculations of joint centers. The models for establishing hip center, used in all of the commercial software systems, have come from cadaver studies and are not patient specific. This inherent flaw in patients with pathology of the hip makes moment and power calculation of the hip suspect. Discussion of this topic will be included in The Evolution of Clinical Gait Analysis Part III, Kinetics and Energy.

systems dominating the field, is this occurring? The passive marker systems are expensive, considerable training is still required for optimal use of the hardware and software, and flexibility in programming for special studies requires the talents of engineers. Our laboratory currently uses an 8-camera, passive marker system, and even larger camera arrays are in use in some laboratories. Possible developments in the next decade are: (1) The elimination of the need for either passive or active targets and a reduction in the number of cameras now in use. With increasing computer memory and disc capacity, markerless measurements of 3-D motion loom on the horizon as a possibility. (2) The development of an active marker system with radio-frequency active emitters is a promising approach for the economics of gait analysis hardware. This would bring about economies in the number of cameras required. The technology for 3-D identification of radiofrequency signals is already well established in military applications. The active emitters are lightweight and relatively inexpensive and there is little to prevent the use of a large number of markers. If such a system is to be implemented, there must be initial research and development investment, following which the costs for purchase of software and hardware would be well below the present costs for passive marker systems. (Tera Research has a patent pending for this technology. For further information, contact Dr Walter Heine at wheine@tera-research.com.) (3) Better methods of defining joint centers, especially with regard to hip joint center, will be required, possibly with the aid of CT and MRI scanning. Moment measurements are sensitive to the accuracy of joint center calculations; consequently, errors in joint centers degrade the accuracy of moment calculations. (4) The use of neural network statistical analysis is still in its infancy in clinical gait analysis [96] and computer assisted diagnostic and problem identification [97] will surely expand in the next decade. (5) In addition to whole body gait analysis, foot models are emerging. Analyzing joints distal to the ankle remains a major challenge for the future [98,99]. The treatment of individuals with pathological gait will steadily change as data are gathered and published from multiple sources. A quantum change has already occurred in the treatment of cerebral palsy. A new generation of multidisciplinary motion analysis teams is forging new standards of quality and pushing the limits of application to a wide variety of disabilities. Rapid changes are occurring in the treatment of myelodysplasia, and improvements in the recognition and treatment of a large variety of neurological disorders are on

3.4. Future
It would be a mistake to assume from the rapid development of 3-D passive marker systems that technological advances in active marker systems are not occurring. There are currently several companies employing active marker systems. Why, with good passive

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the horizon. We now have the tools to perform functional analysis and to replace guesswork with a scientific framework for evaluation and treatment. Oral drug treatment, injections of Botulinum Toxin Type A, intrathecal baclofen pump, physical therapy, orthotic management, orthopedic and neurosurgery must all be evaluated on both a short and long term basis, and gait analysis must play a pivotal role. The changes in treatment will be incremental, wide-ranging, and will come from all parts of the globe. There is much work to do and the beneficiaries will be patients with disorders of movement. It is a source of great satisfaction to patients, their parents, and their physicians to know that locomotion and movement disorders are at last receiving the attention they deserve. Acknowledgements My special thanks to all of the individuals who responded to my letters and phone calls, supplying details that give life to this account. For the administrative assistance provided by Sherill Marciano, Jill Jordano, and Kit Holm, who put up with my many changes to the manuscript, and for Kit’s tenacity with research, which helped immensely with reviewer response and final publication requirements. To bioengineer, Arnel Aguinaldo, and physical therapists, Marilynn Wyatt and Janet Buttermore, for their assistance with the search for details and review of the manuscript. To John Hagy who filed and saved correspondence and other documents from the early days of the San Francisco Gait Lab. Finally, my thanks to Dr Hank Chambers, Medical Director of the Motion Analysis Laboratory at Children’s Hospital, San Diego, for his helpful comments. Appendix A. A partial list of commercial kinematic systems Ariel dynamics 6 Alicante Street Trabuco Canyon, CA 92679 USA Tel.: (949) 858 4216 Fax: (949) 858 5022 BTS Via C. Columbo, 1A 20094 Corsico Milano, Italy Tel.: +39 02458751 Fax: +39 0245867074 CODA Charnwood Dynamics Ltd.

17 South Street, Barrow on Soar Leicestershire, LE12 8LY Tel.: +44 (0) 116 230 1060 Fax: +44 (0) 116 230 1857 Motion analysis corporation 3617 Westwind Blvd Santa Rosa, CA 95403 USA Tel.: (707) 579-6500 Fax: (707) 526-0629 Peak performance 7388 S. Revere Parkway Suite 603 Englewood, CO 80112 USA Tel.: (303) 799 8686 Fax: (303) 799 8690 Primas Motion Studies Laboratory Delft University of Technology P.O. Box 5 2600 AA Delft The Netherlands Tel.: +31 (0) 15 278 9111 Fax: +31 (0) 15 278 6522 Qualisys Inc. 148 Eastern Blvd, Suite 110 Glastonbury, CT 06033 USA Tel.: +1 860 627 5060 Fax: +1 860 627 4041 Qualisys AB Drottninggatan 31 Goteborg 41114 Sweden Tel.: +46 (u) 317743830 Fax: +46 (u) 317014145 Selspot, AB Sallarangsgatan 3 S-431 37 Molndal, Sweden Skill Technologies, Inc. 1202 E. Maryland Ave., Suite IG Phoenix, AZ 85014 USA Tel.: 602-277-7678 Fax: 602-277-2326 VICON motion systems Oxford Metrics Limited Unit 14, MINNS ESTATE 7 West Way Oxford OX20JB

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UK Tel.: +44 (1865) 26 1800 Fax: +44 (1865) 24 05 27

Appendix B B.1. Copy of letter to Raymon Linder, from Dr David Sutherland, dated August 23, 1965.

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B.2. Copy of letter to John Hagy, from Dr E. R. Schottstaedt, dated November 29, 1965.

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Appendix C

176

Description of our first use of a dedicated computer for ‘Diagnostic Gait Analysis’, by Electronic Processors, Inc. (two pages).

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