EVIDENCE-BASED PHYSIATRY
Evidence-Based Physiatry
Clinical Decision-Making With Instrumented Gait Analysis
James Carollo, PhD, PE, Sayan De, MD, and Venu Akuthota, MD
hen technology and clinical medicine merge, this inter-
W section makes evidence-based physiatry fraught with nu-
ance. Clinical motion analysis is one area where advancements
in technology have changed the way we evaluate and understand
gait and movement pathology, through the use of instrumented
gait analysis (IGA). In the “gait laboratory,” three-dimensional
kinematics (motion), three-dimensional kinetics (forces), and
dynamic electromyography (muscle activations) provide quantita-
tive data for multidisciplinary teams to make clinical decisions.
Most commonly, patients with neuromuscular conditions, such
as cerebral palsy, are evaluated using IGA before undertaking
major interventions that may include clinical neurotoxins, bac-
lofen, or rhizotomy for tone management and single-event
multilevel orthopedic surgery to correct musculoskeletal defor-
mities arising from these conditions. However, any disease or
condition that alters movement biomechanics is a potential
candidate for IGA.
Observational gait analysis in the clinic or the hospital
hallway has been conducted by physiatrists since the inception
of the specialty. IGA is not a replacement for observational
analysis; rather, it provides precise quantification of movement
necessary for comprehensive clinical assessment. When com-
bined with systematic observational skills, IGA can provide
clear physical evidence for developing clinical guidelines for
treatment decisions and evaluating intervention outcomes.
Much of the foundation for IGA came from the prosthetics re-
search of Verne Inman at University of California to improve
walking performance of world war II veterans with limb loss.1
Two of Dr. Inman’s orthopedic residents, Jacqueline Perry and
David Sutherland, took these biomechanical principles and re-
fined them for clinical use in stroke, spinal cord and brain injury,
cerebral palsy, and congenital joint abnormalities at their respec-
tive laboratories in Los Angeles and San Diego.2,3 James Gage
and colleagues in St. Paul, MN, further refined the methods in
common use today.4 When performed properly, clinical recom-
mendations driven by IGA methods have been shown to alter
clinical decision-making and improve clinical outcomes.5–7
Like an electrodiagnostic laboratory, established indepen-
dent standards for measurement systems, evaluation procedures,
From the Center for Gait and Movement Analysis (CGMA), Children’s Hospital
Colorado, Physical Medicine & Rehabilitation and Orthopaedics, University
of Colorado School of Medicine, Aurora, Colorado (JC); Orthopaedic Surgery,
University of Colorado School of Medicine, Aurora, Colorado (SD); and De-
partment of Physical Medicine and Rehabilitation, University of Colorado
School of Medicine, Aurora, Colorado (VA).
All correspondence should be addressed to: Venu Akuthota, MD, University of
Colorado Denver - Anschutz Medical Campus, 12631 E. 17th Ave, Mail Stop
F493, Aurora, CO 80045.
Financial disclosure statements have been obtained, and no conflicts of interest have been
reported by the authors or by any individuals in control of the content of this article.
Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0894-9115
DOI: 10.1097/PHM.0000000000001376
American Journal of Physical Medicine & Rehabilitation • Volume 99, Number 3, March 2020
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
medical and technical team competency, and data integrity must
be met to ensure accuracy and reliability of IGA measurements
and the recommendations that result from them. Organizations,
such as the Commission for Motion Laboratory Accreditation,
can provide such laboratory certification.
WHAT HAS CHANGED RECENTLY?
Clinical gait analysis has always been driven by techno-
logic advancement. However, what has changed is the growing
interest in acquiring movement, activity, and IGA data outside
of the traditional laboratory setting. For example, sensor-based
or “wearable tech” for quantifying human performance has
captured the interest of clinicians, the public, and large technol-
ogy companies because they offer cost savings compared with
traditional IGA techniques and can record data in either the
clinic or in natural environments. The challenge with these in-
novative tools has been that their accuracy is rarely established
before going to market through validation with established
IGA methods or in individuals with gait pathology.
Another trend has been to extend instrumented movement
analysis for other clinical applications, particularly within the
field of sports medicine. Return-to-play decisions can be deter-
mined by data gained through IGA. Again, developing clear
criteria based on quantitative evidence is needed before this ap-
plication of motion analysis is widely accepted.
WHAT HAS NOT CHANGED?
Regardless of technology, a multidisciplinary team is
needed to translate data into clinical decisions. A typical eval-
uation involves gathering medical history, physical examina-
tion data, three-dimensional kinematics and kinetics, dynamic
electromyography, and data interpretation through team re-
view. This team review is fundamental to the process and es-
sential for making clinical recommendations.
WHY IS THIS RELEVANT TO PHYSIATRISTS?
Observational gait analysis can fool even the most sea-
soned clinician. When a major intervention is being considered,
the additional data gathered from IGA can overcome the limita-
tions of observation as it does not inherently quantify the sever-
ity of abnormalities. There is also a significant potential for error
with observational analysis as three-dimensional deformity is
difficult to analyze from multiple planes at the same time. For
example, direct observation of genu valgum from the coronal
or sagittal plane can be confused with hip and knee rotation be-
cause of parallax error associated with the perspective and point
of view of the observer. In addition, understanding IGA can im-
prove your observational skills because the interaction between
coupled motions revealed by IGA becomes more apparent when
accurate quantification is available.
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Carollo et al. Volume 99, Number 3, March 2020

KEY RESEARCH FINDINGS IN GAIT ANALYSIS IN
CEREBRAL PALSY FOR LAST SEVERAL DECADES
In general, soft-tissue lengthening surgeries in young chil-
dren and adolescents with excessive tone, especially at the ankle
and knee, should be postponed or avoided altogether.4 Achilles
lengthening in children with crouch gait reduces the plantar-
flexion knee extension couple, which can potentiate or worsen
the gait abnormality. Managing tone with chemodenervation
and oral tone modifying agents coupled with bracing can delay
the need for orthopedic procedures. Bony surgeries should be
postponed as long as possible to avoid repeat surgeries as chil-
dren grow. During growing years, “guided growth” surgery
can be used to tether growth plates and correct coronal and sag-
ittal plane deformities in lieu of osteotomies. When necessary,
soft tissue and bony procedures should be combined (single-
event multilevel orthopedic surgery) to minimize the anesthetic
risk and improve rehabilitation potential and to avoid the so-
called “birthday surgery” phenomenon. Finally, it has been
noted that gait patterns are remarkably stable after skeletal matu-
rity, so correction of gait abnormalities in adolescence is a high
priority. Walking into adulthood has long-term health benefits
and may reduce the early onset of health conditions, such as di-
abetes and cardiovascular disease.
WHAT FUTURE QUESTIONS NEED
TO BE ANSWERED?
Advances in technology have led to a proliferation of sim-
pler, less expensive data collection tools (markerless motion
capture, sensor-based inertial measurement units) that hold
great promise for increased access to IGA both within and out-
side the traditional gait laboratory. Nevertheless, current com-
mercial systems using these technologies require further
validation in clinical populations and against marker-based
motion capture to clearly demonstrate that they are just as accu-
rate and reliable in the coronal and transverse planes as labora-
tory based systems. The future of IGA will include a range of
technologies matched to the measurement requirements of
the clinical question, with lower fidelity solutions used as
screening tools to identify those individuals who could benefit
from laboratory based assessment.
REFERENCES
1. Inman VT, Ralston HJ, Todd F: Human Walking. Baltimore, MD, Williams & Wilkins, 1981
2. Perry J: Gait Analysis: Normal and Pathological Function. Thorofare, NJ, Slack, Inc., 1992
3. Sutherland D: Gait Disorders in Childhood and Adolescence. Baltimore, MD, Lippincott
Williams & Wilkins, 1984
4. Gage JR, Schwartz MH, Koop SE, et al: The Identification and Treatment of Gait Problems in
Cerebral Palsy. London, Mac Keith Press, 2009
5. Cook RE, Schneider I, Hazlewood ME, et al: Gait analysis alters decision-making in cerebral
palsy. J Pediatr Orthopedics 2003;23:292–5
6. Lofterod B, Terjesen T, Skaaret I, et al: Preoperative gait analysis has a substantial effect on
orthopedic decision making in children with cerebral palsy: comparison between clinical
evaluation and gait analysis in 60 patients. Acta Orthop 2007;78:74–80
7. Wren TA, Otsuka NY, Bowen RE, et al: Outcomes of lower extremity orthopedic surgery in
ambulatory children with cerebral palsy with and without gait analysis: results of a randomized
controlled trial. Gait Posture 2013;38:236–41

Retraction: Sato et al. Am J Phys Med Rehabil 1999;78:317–22, and Sato et al.
Am J Phys Med Rehabil 2001;80:19–24.

Two articles by Sato et al.1,2 have been retracted from the American Journal of Physical Medicine & Rehabilitation due
to concerns regarding research misconduct and lack of ethical oversight. This retraction is supported by the results of an in-
vestigation conducted by Dr. Sato’s university.

REFERENCES
1. Sato Y, Tsuru T, Oizumi K, et al: Vitamin K deficiency and osteopenia in disuse-affected limbs of vitamin D-deficient elderly stroke patients. Am J Phys Med Rehabil 1999;78:317–22
2. Sato Y, Kuno H, Kaji M, et al: Serum ß2-microglobulin reflects increased bone resorption in immobilized stroke patients. Am J Phys Med Rehabil 2001;80:19–24

DOI: 10.1097/PHM.0000000000001348

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Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.