BTS GAITLAB - Analysis Protocols PDF

Analysis Protocols
BTS GAITLAB – Analysis Protocols

Version 1.0.0
Document Number: ERSCL-01348-00
Published: September 2015
Copyright © 2010 - 2015 BTS S.p.A.
All Rights Reserved.
CONTENTS
INTRODUCTION
1. DAVIS PROTOCOL
1.1 Subject preparation pag 05
1.2 Acquisition phase pag 12
1.3 Elaboration phase pag 12
1.4 Reporting phase pag 15
1.5 Checking the marker location pag 16
1.6 Davis protocol with marker on 2nd metatarsal head pag 16
1.6.1 Subject preparation pag 17
1.6.2 Elaboration phase pag 18
1.6.3 Checking the marker location pag 18
Bibliography pag 18
2. HELEN HAYES PROTOCOL (Conventional Gait Model)

2.6 Helen Hayes with Medial Markers pag 31
2.6.1 Subject preparation pag 31
2.6.2 Acquisition phase pag 33
2.6.3 Elaboration phase pag 33
2.6.4 Checking the marker location pag 35
Bibliography pag 35
3. OXFORD FOOT MODEL

3.5 Processing of the standing task pag 43
Bibliography pag 43
4. HELEN HAYES PROTOCOL WITH BI-SEGMENTAL

3D FOOT (SHCG Foot Model)
4.5 Processing of the standing task pag 55
Bibliography pag 55
5. DIGIVEC PROTOCOL - GROUND REACTION
FORCE ANALYSIS
Bibliography pag 60
6. UPPER LIMB PROTOCOL (Modified Rab)

Bibliography pag 71
7. CERVICAL SPINE MOBILITY PROTOCOL

Bibliography pag 80
8. HELEN HAYES PROTOCOL ON TREADMILL

Bibliography pag 92
2
INTRODUCTION
The study of posture and movement in patients with pathologies associated with motor
alterations can give very important information on the level of functional limitation resulting
from their dysfunction and its evolution over time. Furthermore, this study can supply relevant
data for the assessment of applied rehabilitation strategies aimed at recovery of functional
limitations related to specific disorders.
Walk is one of the most significant gaits for investigating patients’ motor ability, as it is a very
complex movement involving the synergy of different joints and refined interactions between
muscles and joints.
Gait analysis has great importance for the identification of patients’ walk features and level
of dysfunction.
This result can be achieved with the BTS GAITLAB, the clinical tool for walk functional
analysis.
BTS GAITLAB is a powerful, modular and scalable solution based on fully integrated
equipment: it is the only system providing native integration of kinematics, kinetics and
surface electromyography all in one device.
In addition to high-resolution, high-frequency and intelligent infrared cameras, digital
3D force plates and wireless electromyography, the system is also equipped with a set of
scientifically approved clinical protocols, which have all been collected in this booklet.
Each protocol allows clinicians to evaluate patients’ joints movement, muscle activity and
energy distribution on a support surface while walking. The protocols provide a multimedia
report containing patient videos, graphs of spatial – temporal parameters, 3D kinematics
and 3D kinetics of joints during the different phases of gait cycle. All analyzed variables
are compared to normative data from time to time, in order to obtain full understanding of
movement compensation activity on different planes and to identify successful follow up
treatments.
This booklet provides guidelines on the correct use of each protocol for each body segment
under investigation. The user is guided step-by-step from patient preparation to data processing
and reporting.
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BTS GAITL A B
4
1.DAVIS PROTOCOL
Protocol overview: the Davis protocol is provided with the BTS SMART-Clinic software
included with the BTS GAITLAB system. This protocol allows the study of the kinematics and
kinetics of human locomotion, along with the electrical activity produced by the muscles
involved in gait. The protocol was developed to provide physicians with quantitative and
objective data needed to analyse any possible gait dysfunction. The work of (Davis et al.
1991), which introduced a particular data collection technique for gait analysis, inspired the
protocol implementation.
Required equipment: the protocol requires the use of a BTS SMART-DX system with a
minimum of 6 video cameras for the kinematic analysis. For the kinetic analysis at least one
BTS P-6000 force platform is needed. The evaluation of the muscular activity requires the use
of the BTS FREEEMG surface electromyogram.
1.1 Subject preparation
 Anthropometric measurements: first of all, patient’s weight [kg] and height [cm] have
to be measured. For the measurement of other anthropometrical parameters, the patient
should lay in supine position on a table, and the following guidelines should be observed:
> ASIS breadth: ask the patient to stay in supine position on a table. Identify the position of
the two anterior superior iliac spines (ASIS) through palpation. If a dermographic pencil
is available, use it to mark the anatomical landmarks. Using a pelvimeter, measure the
distance between the two ASIS [cm] (Figure 1).
Figure 1: To evaluate the ASIS

breadth, identify the anterior-
superior iliac spines through
palpation (left). Then measure
their distance with a pelvimeter
(right).
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BTS GAITL A B
> Pelvis depth: with the subject still in supine position, locate the great trochanter. We
suggest bringing the hip manually into the maximum flexion and intra-rotation position.
Realign the limb trying not to lose the just found anatomical landmark. If a dermographic
pencil is available, use it to mark the landmark. Consider a plane passing through the
great trochanter and parallel to the table (Figure 2). With a measuring tape, measure
the distance between the anterior-superior iliac spine and the great trochanter plane
(vertical distance with the patient in supine position) [cm] (Figure 3).
Figure 2: To locate the great

trochanter bring the patient’s
hip into the maximal flexion
and intra-rotation position
(left). Then realign the limb
trying not to lose the just found
anatomical landmark. Con-
sider a plane passing through
the great trochanter and parallel
to the table (right).
Figure 3: To evaluate the pelvis

depth (blue), measure the
vertical distance between the
anterior-superior iliac spine and
the plane passing through the
great trochanter and parallel to
the table (Figure 2).
6
> Leg length: ask the subject (still lying on the table) to keep his/her knees fully extended.
Using a measuring tape, measure the distance between the anterior-superior iliac spine
(consider the marked point, if available) and the medial malleolus [cm] (Figure 4). If the
subject is not able to fully extend his/her knees, separately measure the thigh and shank
lengths and then consider their summation.
Figure 4: To measure the leg

length the subject’s knees
must be fully extended. With
a measuring tape, evaluate the
distance between the anterior-
superior iliac spine and the
medial malleolus.
> Knee diameter: if possible, ask the subject to stand upright while you take the
measurement. Otherwise, ask him/her to sit on the side of the table. Bring the patient’s
knee in flexed position, then, using a pelvimeter, measure the distance between the
medial and lateral condyle of the femur [cm] (Figure 5).
Figure 5: To evaluate the knee’s

diameter bring the subject’s
knee in flexed position and
identify the medial and lateral
condyle of the femur (left).
Then measure the distance
between the condyles using the
pelvimeter (right).
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BTS GAITL A B
> Malleolus width: if possible, ask the subject to stand upright while you take the
measurement. Otherwise, ask him/her to sit on the side of the table and to place his/her
feet on a fixed support. Using a pelvimeter, measure the distance between the medial
and lateral malleolus [cm] (Figure 6).
Figure 6: To evaluate the

ankle diameter identify
the medial and lateral
malleolus through palpation
(left). Then measure
the distance between
these two anatomical points
using the pelvimeter (right).
 Markers: the Davis protocol uses the so called “Newington marker set” (Davis et al. 1991)
(Figure 7). The updated Davis protocol provided with the BTS GAITLAB will be referred
to as “Davis Heel” protocol. This is the official name used in the BTS SMART-Clinic user
interface, to distinguish between the updated version and the old “Davis” protocol. The
“Davis Heel” protocol, unlike the old one, does not require the removal of the heel marker
after the acquisition of the standing task.
Figure 7: Frontal and posterior

view of the Newington (Davis)
marker set.
8
> “Davis Heel”: requires the positioning of 22 spherical markers on the subject’s body:
3 on the trunk, 3 on the pelvis, 3 on each thigh, 3 on each shank, and 2 on each foot.
Use this version if you wish to evaluate the lower limbs, pelvis and trunk behaviour
during gait.
> “Simple Davis Heel”: requires the same marker set, except for the trunk markers (19
markers must be placed on the subject). Use this version if you wish to evaluate just the
lower limbs and pelvis behaviour.
The markers must be applied while the subject holds an orthostatic position. For correct
positioning of the markers, please refer to the following guidelines:
> Trunk: one marker in correspondence to the 7th cervical vertebra (c7) (when the head
is maximally flexed the C7 vertebra is the most prominent point), one by the right
acromion (r should) and one by the left acromion (l should). The application of these
three markers is required only if the “Davis Heel” version of the protocol is chosen.
> Pelvis: one marker on each ASIS (r asis - l asis). Consider the same points used for
measuring the ASIS breadth. If these points were marked during the anthropometric
measurement, in case of significant skin shifting with respect to the anatomical
landmark, identify again the ASIS location through palpation. Apply one marker on
the back, in correspondence to the second sacral vertebra (sacrum). Start placing
the marker in the middle point between the two dimples identifying the lumbosacral
passage (sacroiliac joint). The positioning of the sacrum marker is crucial to the correct
reconstruction of the pelvis plane. To check if the marker location is correct, look at
the subject from a sagittal point of view and verify if the line connecting the sacrum
marker to the considered ASIS is perpendicular to the lumbar part of the trunk. If not,
reposition the marker a little bit higher or lower in order to obtain the above-mentioned
perpendicularity (Figure 8).
Figure 8: In order to achieve

a correct reconstruction of
the pelvis motion, the line
connecting the marker on
the second sacral vertebra to
each ASIS must be orthogonal
to the lumbar portion of the
trunk. Look at the subject
from a sagittal point of view.
If the orthogonality is not
verified, move the sacrum
marker vertically until the
above-mentioned condition is
satisfied.
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BTS GAITL A B
> Thigh: one marker on the great trochanter (r thigh - l thigh) (if available, consider the
marked point) and one on the lateral femoral condyle (r knee 1 - l knee 1). To locate
the femoral condyle, perform a passive flexion-extension of the subject’s knee. Once the
flexion-extension axis has been identified, find the point where the axis passes through
the lateral part of the knee. If a dermographic pencil is available, mark the just found
point, and verify that the skin displacement effect is minimal. Another marker fixed on a
lateral bar must be securely attached to the thigh using an adaptable strap (r bar 1 - l bar
1). The placement of the lateral bar marker is crucial, since its incorrect positioning may
lead to errors in the definition of the flexion/extension angles of the hip and knee and of
the internal/external rotations of the hip. The bar must lie on the same plane defined by
the virtual line between the hip joint centre and the knee joint centre (refer to the great
trochanter-femoral condyle line), and the line between the medial and lateral femoral
condyles (flexion-extension axis of the knee) (Figure 9). The bar can be placed at an
arbitrary height, but it must not interfere with the movement of the upper limbs. In order
to obtain better stability during motion, we suggest placing the bar on the portion of the
thigh less susceptible to muscle contractions.
Figure 9: The marker on the

lateral bar of the thigh must
be aligned with the great
trochanter and the femoral
condyle markers. The three
markers must be coplanar. If
the bar is correctly positioned,
the line between the medial
and lateral femoral condyle
(knee flexion-extension axis)
belongs to the plane identified
by the three markers.
> Shank: one marker on the head of the fibula (r knee 2 – l knee 2), which can be identified
through palpation, one on the lateral malleolus (r mall – l mall), and one on a lateral bar
(r bar 2 – l bar 2) securely attached to the shank using an adaptable strap. The bar must
lie on the plane defined by the virtual line between the knee joint centre and the ankle
joint centre (refer to the head of the fibula-lateral malleolus line), and the line between the
medial and lateral malleolus (flexion-extension axis of the ankle) (Figure 10). We suggest
placing the bar on the portion of the shank less susceptible to muscle contractions.
10
lateral bar of the shank must
be aligned with the femoral
condyle and malleolus
markers. The three markers
must be coplanar. If the bar
is correctly positioned, the
line between the medial and
lateral malleolus (ankle dorsi-
plantarflexion axis) belongs to
the plane identified by the three
markers.
> Foot: one marker on the fifth metatarsal head (r met – l met) and another marker on the heel
(r heel – l heel). These two markers must lie on the same plane. Look at the subject from
a sagittal point of view and check that the markers on the heel and on the 5th metatarsal
are placed at the same height and identify a line parallel to the sole of the foot (Figure 11).
Figure 11: For a correct

reconstruction of the foot dorsi-
plantarflexion angle, the line
between the heel marker and
the fifth metatarsal marker must
be parallel to the sole of the
foot.
> Electrodes: in order to evaluate the muscular electrical activity, two electrodes need to
be placed on each muscle of interest. Correct electrode positioning for the EMG analysis
is available in specific handbooks (Cram et al. 1998, Freriks et al. 1999). During the
preparation of the subject it is important to pay attention to the correspondence between
the probe number and the muscle.
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BTS GAITL A B
1.2 Acquisition phase
The subject is asked to perform two different tasks:
 Standing task: the subject needs to hold an orthostatic position for at least 3 - 5 seconds.
The feet of the subject must be aligned in order to avoid having one foot in a more anterior
or posterior position with respect to the other. If a force platform is available, the task can
be performed on the top of the platform.
 Walking task: the subject needs to walk normally across the working volume defined
during the calibration phase of the optoelectronic system. If a walkway is present, the
subject is facilitated in following a gait direction. Otherwise, verify that the subject
walks in the straightest way possible. The markers placed on the subject must be clearly
within the field of view of the cameras during the whole acquisition. If one or more force
platforms are available, to allow the kinetic analysis, the subject must perform an entire
stance phase of a single foot on one of the platforms. It is important not to force the subject
to achieve this result, because this could alter his/her walking pattern. The foot strike on
the platform should be spontaneous.
The protocol requires a single acquisition while the subject performs the standing task and at
least one acquisition during a walking sequence.
Recommendations: before starting any acquisition, correct calibration of the system must be
verified. A daily calibration is advisable (at need). Once the markers have been placed on the
subject, their correct location should be verified (see Paragraph 1.5 - “Checking the marker
location”).
1.3 Elaboration phase
The elaboration phase includes the following steps:
 Tracking: firstly, the markers must be tracked. Meaning that they need to be associated
to their corresponding label, on the basis of each marker’s real position, at every point
in time. In both protocol versions this operation is automatically performed (Figure 12).
However, we suggest verifying that labeling is correctly performed during the entire
acquisition. To perform the analysis of joint moments and powers, force data must be
tracked (if available). Meaning that the vector visualized on each force platform must be
assigned to the right (r gr) or left limb (l gr ) according to the corresponding foot contact
on the platform.
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Figure 12: Marker set models
for the “Davis Heel” (on the
left) and “Simple Davis Heel”
(on the right) protocols.
 Calculation protocol selection: the drop-down menu offers four different calculation
protocols for selection choice:
> “Proc_Davis_Standing”: this protocol allows a quick check of the markers position (see
Paragraph 1.5). It is used to elaborate the standing task immediately after its acquisition.
> “Proc_DavisHeel+GaitIndexes”: used to compute the kinematic and kinetic parameters

of gait, as well as the electromyographic analysis. It includes the computation of the
GDI and GPS indexes.
> “Proc_DavisHeel+GI_AE”: the same as the “Proc_DavisHeel+GaitIndexes” but with the

automatic identification of gait events from markers data. We suggest checking that the
identification of the events is correctly performed during the entire duration of each
acquisition.
> “Proc_DavisHeel+GI_AEFP”: the same as the “Proc_DavisHeel+GaitIndexes” but with

the automatic identification of gait events from force platforms data.
If a protocol including the computation of the gait indexes is selected, an appropriate table
named “GaitIndexes-” needs to be chosen from the “Table” drop-down menu. Four tables,
including the normal values needed for the gait indexes calculation and corresponding to four
different age groups, can be selected: children (up to 12 years old), young (from 13 to 54 years
old), adults (from 55 to 64 years old), elderly (≥ 65 years old).
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BTS GAITL A B
 Events: as soon as the elaboration starts, the user is asked to identify the following gait
events:
> eRHS = Right Heel Strike – Right foot initial ground contact (at least two events must be
defined) (Figure 13).
Figure 13: Example of definition

of the right foot initial contact
with the floor (yellow ochre). To
help with the identification, the
knee flexion-extension angle
(green) and the ankle dorsi-
plantarflexion angle (red) are
shown.
> eRTO = Right Toe Off – Right toes are lifted off the ground (one event between each of
Figure 14: Example of definition the two previously defined strikes) (Figure 14).
of the time instant in which the
patient lifts his/her right toes off
the ground (yellow ochre). To help
with the identification, the knee
flexion-extension angle (green)
and the ankle dorsi-plantarflexion
angle (red) are shown. Moreover,
the previously defined heel strike
events can be displayed on the
graph (light blue).
> eLHS = Left Heel Strike – Left foot initial ground contact (at least two events must be

of the left foot initial contact
shown.
> eLTO = Left Toe Off – Left toes are lifted off the ground (one event between each of the
Figure 16: Example of definition two previously defined strikes) (Figure 16).
patient lifts his/her left toes off the
ground (yellow ochre). To help
with the identification, the knee
flexion-extension angle (green)
and the ankle dorsi-plantarflexion
angle (red) are shown. Moreover,
the previously defined heel strike
graph (light blue).
If different walking acquisitions are loaded, several windows will open progressively to define
the events of all trials. If a protocol including the automatic identification of events was
selected, the graphs showed in the event windows will display different curves:
> automatic events from force platform data: graphs will show the vertical ground reaction
force relative to the specific limb (red) and a force threshold of 10 Newton (green).
> automatic events from markers data: graphs will show the vertical position of the heel
marker (red) and the vertical position of the metatarsal marker (green).
14
At least two heel strike events and one toe off event (between the previously defined strikes)
must be defined for the correct protocol processing. Please verify that all events have been
correctly identified by the protocol. It is possible to cancel, modify or add one or more events
to the ones automatically identified.
1.4 Reporting phase
The results of the elaboration are ready to be visualized in the report. To create a report,
the normative bands relative to the kinematics, kinetics and EMG activity must be provided.
Depending on the age of the subject it is possible to choose between two default normal
bands: “Gait-Normal-adults” and “Gait-Normal-children”. Four report models are available:
 “Rep_Gait_Standing”: see Paragraph 1.5 - “Checking the marker location”.
 “Rep_Gait_Consistency”/”Rep_SimpleGait_Consistency”: it must be selected

before visualizing the final clinical report (“Rep_Gait+GaitIndexes”/”Rep_
SimpleGait”+GaitIndexes”) to evaluate the consistency/repeatability of the acquisitions.
Results of both kinematic and kinetic analysis from each trial are shown in two distinct
pages, one for the right limb, and one for the left limb. By using this visualization it is
possible to scan the data and manually check for outlier trials (i.e. trials which deviate
from the subject’s characteristic pattern of gait). In the best case, where no outlier trials are
detected, as well as in case one or more trials present inconsistent deviations, the current
report should be closed. Then the “Rep_Gait+GaitIndexes”/“Rep_SimpleGait+GaitIndexes”
must be selected, making sure that consistent trials only, are loaded.
 “Rep_Gait_EMG”: this report shows EMG signals (millivolts) filtered with a high pass and
a low pass filter, with respect to time (seconds). The vertical solid lines in the graphics
indicate the beginning and the end of the gait cycles defined during the elaboration phase.
The vertical dotted lines represent the toe-off events. The lines related to the right cycle are
green, while the ones related to the left cycle are red. All EMG records are displayed for
each acquisition selected in “Trials to be reported or viewed”.
 “Rep_Gait+GaitIndexes”/“Rep_SimpleGait+GaitIndexes”: the final clinical report is

organized in the following way:
> The first page contains the mean spatio-temporal parameters of all trials selected in
“Trials to be reported or viewed”. These parameters are shown next to the normative
data. In the same page are reported the values of the kinematic parameters measured
during the standing acquisition, along with the list of acquisitions used for the statistical
analysis.
> In the next page are presented two synthetic indexes summarizing the overall quality
of the patient’s kinematic gait. These indexes facilitate the comparison between
pathological and normal gait.
– The Gait Profile Score (GPS) is calculated as the Euclidian distance between the
patient’s kinematic features and the corresponding normative features, for the entire
gait cycle. GPS values higher than 7 degrees indicate compromised gait pattern.
– The Gait Variable Score (GVS) is the root mean square difference between a single
gait feature and the corresponding average gait feature for people with no gait
pathology. The GVS is computed for each gait feature and the results are shown in a
specific table. This table provides useful insights to understand which variables are
contributing to an elevated GPS.
– The Gait Deviation Index (GDI) can be interpreted as follows: GDI≥100 indicates a
subject whose gait features are statistically indistinguishable from the gait features of
the control group. In other words, GDI≥100 indicate a normal subject.
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BTS GAITL A B
> Next, the results of the kinematic analysis are presented. The measurement unit used
in the graphics is the degree (y-axis) and percentage of the gait cycle (x-axis). The mean
curves for each limb (green for the right limb, and red for the left one) are plotted against
the normative data (in grey). The vertical dotted lines in the graphs identify the toe-off
events, while the horizontal lines represent the standing values. The above-mentioned
lines are green for the right limb and red for the left limb. The static values are not
shown in the trunk tilt graph since the offset measured in the static acquisition have
been subtracted from the above-mentioned curve.
> The results from the dynamic data analysis are presented next. The dynamic results are
displayed with the same structure used for the kinematic results. To better interpret joint
moments and powers, the hip, knee and ankle rotations in the sagittal plane (degrees)
are showed at the top of the page. All data are visualized with respect to the percentage
of gait cycle (x-axis). Joints moments and powers are shown divided by the subject’s
weight, i.e. respectively in Newton*meter/kg e Watt/kg. The ground reaction forces are
reported in percentage to the body weight.
> Finally, EMG signals (millivolts) are presented. EMG average envelopes are shown,
time-normalized for the duration of the gait cycle (% gait cycle). In addition, one page
is dedicated per acquisition to the filtered EMG signals normalized on the first gait cycle
for the right and left side. The vertical lines in the graphs indicate the heel strike event
of the contralateral limb. The vertical dotted lines represent the toe-off events (green for
the right limb, red for the left limb). The horizontal black bars identify the EMG normal
activation for the specific muscle. By default only the EMG signal corresponding to the
first step identified in each acquisition is shown. The report can be customized to show
EMG signals corresponding to several steps.
1.5 Checking the marker location
As soon as the standing exercise is acquired, select the “Proc_Davis_Standing” calculation

protocol. This protocol calculates the joint angles held during the static pose. No temporal
event needs to be defined. At the end of the processing please select the “Rep_Gait_Standing”
report. This report shows a table containing the standing angular values next to the normative
data. If the angular values are significantly out of the normality range please check the
following markers:
 For deviation in pelvis angles: check the markers on the ASIS and on S2.
 For deviation in hip/knee angles: verify the position of the markers on the great trochanter
and on the femoral lateral condyle, and especially the alignment of the thigh bar with
these two markers.
 For deviation in knee/ankle and foot progression angles: verify the position of the markers
on the head of the fibula and on the lateral malleolus, and especially the alignment of the
shank bar with these two markers. Furthermore, check the correct alignment of the heel
marker with the 5th metatarsal marker.
1.6 Davis protocol with marker on 2nd metatarsal head
If the patient has a supinated foot we suggest using a slightly different protocol named Davis
protocol with marker on 2nd metatarsal head (Figure 17). This protocol uses a marker between
the heads of the second and third metatarsal, instead of a marker on the fifth metatarsal. With
a supinated foot, the fifth metatarsal is not clearly visible. Moreover, positioning a marker on
it could hinder the gait pattern of the patient. Differences with the “Davis Heel” protocol are
described in the following.
16
1.6.1 Subject preparation
 Markers: two versions of the protocol are available: “Davis Heel 2 met” and “Simple
Davis Heel 2 met”. Use the first version if you wish to evaluate the trunk behaviour in
addition to the pelvis, thigh, leg and foot behaviour during gait. The markers need to be
positioned on the patient as described for the “Davis Heel” version, except for the markers
on the foot:
> Foot: one marker needs to be positioned between the heads of the second and third
metatarsals (r met – l met) and another marker on the heel (r heel – l heel). These two
markers must lie on the same plane. Look at the subject from a sagittal point of view and
check that the markers on the heel and between the metatarsal heads are placed at the
same height and identify a line parallel to the sole of the foot (Figure 18).

view of the Davis protocol with
marker on 2nd metatarsal head.

the metatarsal marker must be
parallel to the sole of the foot.
17
BTS GAITL A B
1.6.2 Elaboration phase
 Calculation protocol selection: the drop-down menu offers three different calculation
> “Proc_Davis_Standing”: this protocol allows a quick check of the markers position
(see Paragraph 1.6.3). It is used to elaborate the standing task immediately after its
acquisition.
> “Proc_DavisHeel2+GaitIndexes”: used to compute the kinematic and kinetic parameters

> “Proc_DavisHeel2+GI_AEFP”: the same as the “Proc_DavisHeel2+GaitIndexes” but

with the automatic identification of gait events from force platforms data.
If a calculation protocol including the computation of the gait indexes is selected, the
appropriate table named “GaitIndexes-” needs to be chosen from the “Table” drop-down
menu.
1.6.3 Checking the marker location
The same indications given for the “Davis Heel” protocol must be followed. Just remember
that, in case of anomalies in the knee, ankle or foot progression angles, the correct alignment
of the heel marker with the 2nd metatarsal marker (not the 5th metatarsal marker) needs to be
checked.
Bibliography
Davis R.B., Ounpuu S., Tyburski D., Gage J.R., 1991. “A gait analysis data collection and
reduction technique”. Human Movement Science, Vol. 10, pp. 575-587
Freriks B., Hermens H.J., Merletti R., 1999. “SENIAM: European Recommendations for Surface
Electromyography”, Roessingh Research and Development Publisher, Vol. 8.
Cram J.R., Kasman G.S. Holtz J., 1998. “Introduction to surface electromyography”, Aspen
Publishers.
Schwartz M.H., Rozumalski A., 2008. “The Gait Deviation Index: a new comprehensive
index of gait pathology”, Gait Posture, Vol. 28, No. 3, pp. 351-357.
Baker R., McGinley J.L., Schwartz M.H., Beynon S., Rozumalski A., Graham H.K., Tirosh O.,
2009. “The Gait Profile Score and Movement Analysis Profile”, Gait Posture, Vol. 30, No. 3,
pp. 265-269.
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2. HELEN HAYES PROTOCOL (Conventional Gait Model)
Protocol overview: the Helen Hayes protocol is provided with the BTS SMART-Clinic software
included with the BTS GAITLAB system. This protocol allows the study of the kinematics and
kinetics of human locomotion, along with the electrical activity produced by the muscles
involved in gait. The protocol was developed to provide physicians with quantitative and
objective data needed to analyse any possible gait dysfunction. The protocol implementation
was inspired by the works of M. Kadaba and R. Davis, respectively developed at the Helen
Hayes Hospital and the Newington Hospital (Kadaba et al. 1989, 1990; Davis et al. 1991).
 Anthropometric measurements: First of all, patient’s weight [kg] and height [cm] have
> ASIS breadth: ask the patient to stay in supine position on a table. Identify the position of
the two anterior superior iliac spines (ASIS) through palpation. If a dermographic pencil
is available, use it to mark the anatomical landmarks. Using a pelvimeter, measure the
distance between the two ASIS [cm] (Figure 1).

(right).
19
BTS GAITL A B
> Pelvis depth: with the subject still in supine position, locate the great trochanter. We
suggest bringing the hip manually into the maximum flexion and intra-rotation position.
Realign the limb trying not to lose the just found anatomical landmark. If a dermographic
pencil is available, use it to mark the landmark. Consider a plane passing through the
great trochanter and parallel to the table (Figure 2). With a measuring tape, measure
the distance between the anterior-superior iliac spine and the great trochanter plane
(vertical distance with the patient in supine position) [cm] (Figure 3).

anatomical landmark. Consider
a plane passing through the
the table (right).
> Knee diameter: if possible, ask the subject to stand upright while you take the
measurement. Otherwise, ask him/her to sit on the side of the table. Bring the patient’s
knee in flexed position, then, using a pelvimeter, measure the distance between the
medial and lateral condyle of the femur [cm] (Figure 5).
20

medial malleolus.
> Malleolus width: if possible, ask the subject to stand upright while you take the
measurement. Otherwise, ask him/her to sit on the side of the table and to place his/her
feet on a fixed support. Using a pelvimeter, measure the distance between the medial
and lateral malleolus [cm] (Figure 6).
21
BTS GAITL A B
Figure 5: To evaluate the knee’s
diameter bring the subject’s
knee in flexed position and
identify the medial and lateral
condyle of the femur (left).
Then measure the distance
between the condyles using the
pelvimeter (right).
Figure 6: To evaluate the

ankle diameter identify
the medial and lateral
malleolus through palpation
(left). Then measure
the distance between
these two anatomical points
using the pelvimeter (right).
22
 Markers: The Helen Hayes protocol uses a “modified Helen Hayes marker set”, or more
precisely, an adaptation of the so called “Helen Hayes marker set” (Kadaba et al. 1989,
1990) (Figure 7). Two versions of the protocol are available:
> “Helen Hayes”: requires the positioning of 18 spherical markers on the subject’s body:
3 on the trunk, 3 on the pelvis, 2 on each thigh, 2 on each shank, and 2 on each foot.
4 of these markers are fixed on a rigid bar. Use this version if you wish to evaluate the
lower limbs, pelvis and trunk behaviour during gait.
> “Simple Helen Hayes”: requires the same marker set, except for the trunk markers (15
markers must be placed on the subject). Use this version if you wish to evaluate just the
lower limbs and pelvis behaviour.

view of the modified Helen
Hayes marker set.
acromion (r should) and one by the left acromion (l should). The application of these
three markers is required only if the “Helen Hayes” version of the protocol is chosen.
23
BTS GAITL A B

satisfied.
> Thigh: one marker on the lateral aspect of the knee flexion-extension axis (r knee 1
– l knee 1). Locate the femoral condyle and perform a passive flexion-extension of
the subject’s knee. Once the flexion-extension axis has been identified, find the point
where the axis passes through the lateral part of the knee. If a dermographic pencil
is available, mark the just found point, and verify that the skin displacement effect
is minimal. Another maker needs to be placed on a lateral bar securely attached to
the thigh using an adaptable strap (r bar 1 – l bar 1). The placement of the lateral bar
marker is crucial, since its incorrect positioning may lead to errors in the definition of
the flexion/extension angles of the hip and knee and of the internal/external rotations
of the hip. The bar must lie on the same plane defined by the virtual line between the
hip joint centre and the knee joint centre, and the flexion-extension axis of the knee
(Figure 9). The bar can be placed at an arbitrary height, but it must not interfere with
the movement of the upper limbs. The use of the bar is recommended, since it allows
a better identification of the above-mentioned plane. However, the (r bar 1 - l bar 1)
marker can also be placed directly on the lateral portion of the thigh, provided that its
placement follows the same alignment cautions. In either case, we suggest placing the
marker on the portion of the thigh less susceptible to muscle contractions, in order to
obtain better stability during motion.
24
lateral bar of the thigh must lie
on the plane defined by the the
hip joint center and the flexion-
extension axis of the knee.
> Shank: one marker on the lateral malleolus (r mall – l mall), and one fixed on a rigid
bar (r bar 2 – l bar 2) attached to the side of the shank using an adaptable strap. The (r
bar 2 – l bar 2) marker must lie on the plane defined by the flexion-extension axis of
the ankle and the virtual line between the knee joint centre and the ankle joint centre
(Figure 10). The use of the bar is recommended, but not mandatory. We suggest placing
the marker on the portion of the shank less susceptible to muscle contractions, in order
to obtain better stability during motion.

lateral bar of the shank must
lie on the plane defined by
knee joint center and the dorsi-
plantarflexion axis of the ankle.
25
BTS GAITL A B
> Foot: one marker in the space between the heads of the second and third metatarsals
(r met – l met), and one on the heel (r heel – l heel). These two markers must lie on
the same plane. Look at the subject from a sagittal point of view and check that the
markers on the heel and between the metatarsal heads are placed at the same height
and identify a line parallel to the sole of the foot (Figure 11). To obtain a correct medial/
lateral alignment, the markers must identify a line parallel to the second metatarsal ray.

 Electrodes: in order to evaluate the muscular electrical activity, two electrodes need to
 Walking task: the subject needs to walk normally across the working volume defined
during the calibration phase of the optoelectronic system. If a walkway is present, the
subject is facilitated in following a gait direction. Otherwise, verify that the subject
walks in the straightest way possible. The markers placed on the subject must be clearly
within the field of view of the cameras during the whole acquisition. If one or more force
platforms are available, to allow the kinetic analysis, the subject must perform an entire
stance phase of a single foot on one of the platforms. It is important not to force the subject
to achieve this result, because this could alter his/her walking pattern. The foot strike on
the platform should be spontaneous.
26
location”).
in time. In both protocol versions this operation is automatically performed (Figure 12)
assigned to the right (r gr) or left limb (l gr) according to the corresponding foot contact on
the platform.

for the “Helen Hayes” (on the
left) and “Simple Helen Hayes”
(on the right) protocols.
> “Proc_HelenHayes_Standing”: this protocol allows a quick check of the markers

position (see Paragraph 2.5). It is used to elaborate the standing task immediately after
its acquisition.
27
BTS GAITL A B
> “Proc_HelenHayes+GaitIndexes”: used to compute the kinematic and kinetic parameters
> “Proc_HelenHayes+GI_AEFP”: the same as the “Proc_HelenHayes+GaitIndexes” but

with the automatic identification of gait events from force platforms data.
including the normal values needed for the gait indexes calculation and corresponding to
four different age groups, can be selected: children (up to 12 years old), young (from 13 to
54 years old), adults (from 55 to 64 years old), elderly (≥ 65 years old).
events:
> eRHS = Right Heel Strike – Right foot initial ground contact (at least two events must
be defined) (Figure 13).

shown.
Figure 14: Example of definition > eRTO = Right Toe Off – Right toes are lifted off the ground (one event between each of
of the time instant in which the the two previously defined strikes) (Figure 14).
patient lifts his/her right toes
off the ground (yellow ochre).
To help with the identification,
the knee flexion-extension
angle (green) and the ankle
dorsi-plantarflexion angle
(red) are shown. Moreover, the
previously defined heel strike
graph (light blue).

shown.
Figure 16: Example of definition > eLTO = Left Toe Off – Left toes are lifted off the ground (one event between each of the
of the time instant in which the two previously defined strikes) (Figure 16).
patient lifts his/her left toes off
the ground (yellow ochre). To
help with the identification,
(red) are shown. Moreover, the
previously defined heel strike
graph (light blue).
28
If different walking acquisitions are loaded, several windows will open progressively to
define the events of all trials. If a protocol including the automatic identification of events
was selected, the graphs showed in the event windows will display different curves.
Specifically, graphs will show the vertical ground reaction force relative to the specific
limb (red) and a force threshold of 10 Newton (green). At least two heel strike events
and one toe off event (between the previously defined strikes) must be defined for the
correct protocol processing. Please verify that all events have been correctly identified
by the protocol. It is possible to cancel, modify or add one or more events to the ones
automatically identified.
2.4 Reporting phase
The results of the elaboration are ready to be visualized in the report. To create a report,
the normative bands relative to the kinematics, kinetics and EMG activity must be provided.
 “Rep_Gait_Standing”: see Paragraph 2.5 - “Checking the marker location”.
 “Rep_Gait_Consistency”/”Rep_SimpleGait_Consistency”: it must be selected

before visualizing the final clinical report (“Rep_Gait+GaitIndexes”/“Rep_
SimpleGait+GaitIndexes”) to evaluate the consistency/repeatability of the acquisitions.
pages, one for the right limb, and one for the left limb. By using this visualization it is possible
to scan the data and manually check for outlier trials (i.e. trials which deviate from the
subject’s characteristic pattern of gait). In the best case, where no outlier trials are detected,
as well as in case one or more trials present inconsistent deviations, the current report
should be closed. Then the “Rep_Gait+GaitIndexes”/“Rep_SimpleGait+GaitIndexes”
must be selected, making sure that consistent trials only, are loaded.
 “Rep_Gait+GaitIndexes”/“Rep_SimpleGait+GaitIndexes”: the final clinical report is

organized in the following way:
analysis.
29
BTS GAITL A B
> Next, the results of the kinematic analysis are presented. The measurement unit used in
the graphics is the degree (y-axis) and percentage of the gait cycle (x-axis). The mean
lines are green for the right limb and red for the left limb. The static values are not
shown in the trunk tilt graph since the offset measured in the static acquisition have
been subtracted from the above-mentioned curve.
of gait cycle (x-axis). Joints moments and powers are shown divided by the subject’s
As soon as the standing exercise is acquired, select the “Proc_HelenHayes_Standing”

calculation protocol. This protocol calculates the joint angles held during the static pose.
No temporal event needs to be defined. At the end of the processing please select the “Rep_
Gait_Standing” report. This report shows a table containing the standing angular values next
to the normative data. If the angular values are significantly out of the normality range please
check the following markers:
 For deviation in hip/knee angles: verify the position of the marker on the femoral lateral
condyle, and check with particular attention the correct alignment of the thigh bar (see the
“Markers” section within Paragraph 2.1).
 For deviation in knee/ankle and foot progression angles: check position of the lateral
malleolus marker and the correct alignment of the heel marker with the metatarsal marker.
Furthermore, verify the correct alignment of the shank bar (see the “Markers” section
within Paragraph 2.1).
30
2.6 Helen Hayes with Medial Markers
If the use of the rigid bars is to be avoided due to the patient condition, or if the acquisitions
need to be sped up by evaluating less anthropometric measurements, a different version of the
protocol, named Helen Hayes with Medial Markers, should be used. In this protocol version
the recommendations of the International Society of Biomechanics, regarding the definition
of the femoral reference system, were followed (Wu et al. 2002). Differences with the Helen
Hayes protocol are described in the following.
2.6.1 Subject preparation
 Anthropometric measurements: as in the Helen Hayes protocol the weight, height,

ASIS breadth, pelvis depth, and total leg length of the patient need to be measured. The
evaluation of the knee and ankle diameter is not necessary.
 Markers: two versions of the protocol are available:
> “Helen Hayes MM”: requires the positioning of 22 spherical markers on the subject’s
body: 3 on the trunk, 3 on the pelvis, 3 on each thigh, 3 on each shank, and 2 on each
foot (Figure 17). Use this version if you wish to evaluate the lower limbs, pelvis and
trunk behaviour during gait.
> “Simple Helen Hayes MM”: requires the same marker set, except for the trunk markers
(19 markers must be placed on the subject). Use this version if you wish to evaluate just
the lower limbs and pelvis behaviour.

view of the “modified Helen
Hayes marker set” with medial
markers. The green markers
must be removed before
acquiring the Walking tasks (see
Paragraph 2.6.2 - “Acquisition
phase”)
31
BTS GAITL A B
The markers need to be positioned on the patient as described for the “Helen Hayes”
version, except for the markers on the thigh and shank:
> Thigh: one marker on the lateral femoral condyle (r knee 1 - l knee 1), and one on the
medial femoral condyle (r knee m – l knee m). To locate the femoral condyles, perform
a passive flexion-extension of the subject’s knee. Once the flexion-extension axis has
been identified, find the points where the axis passes through the lateral and medial
parts of the knee. If a dermographic pencil is available, mark the just found points, and
verify that the skin displacement effect is minimal. Another marker (r bar 1 – l bar 1)
needs to be placed either directly on the lateral portion of the thigh, or fixed on a rigid
bar attached to the thigh through an adaptable strap. In either case, we suggest placing
the marker on the portion of the thigh less susceptible to muscle contractions, in order
to obtain better stability during motion (Figure 18).
> Shank: one marker on the lateral malleolus (r mall – l mall) and one on the medial
malleolus (r mall m – l mall m). Another marker (r bar 2 – l bar 2) can be either fixed on
a rigid bar attached to the side of the shank or placed directly on the lateral portion of
the shank. The same guidelines given for the (r bar 1 - l bar 1) marker must be followed
(Figure 19).
Figure 18: The (r bar 1 – l bar

1) marker is a technical marker;
therefore it does not require
precise anatomical positioning.
To favour its stability during
walking, we suggest positioning
it on a portion of the thigh
where the effect of muscle
contraction is minimal (see the
highlighted red area).
32
Figure 19: The (r bar 2 – l bar
2) marker is a technical marker;
it on a portion of the shank
2.6.2 Acquisition phase
For more details please refer to the “Helen Hayes” protocol.
 Walking task: the indications given for the “Helen Hayes” protocol must be followed.
Before performing this task the medial markers on the knees and ankles must be removed.
2.6.3 Elaboration phase
in time. (Figure 20). In both protocol versions this operation is automatically performed.
the platform.
33
BTS GAITL A B
for the “Helen Hayes MM” (on
the left) and “Simple Helen
Hayes MM” (on the right)
protocols.
> “Proc_HelenHayesMM_Standing”: this protocol allows a quick check of the markers

position (see Paragraph 2.5). It is used to elaborate the standing task immediately after
its acquisition.
> “Proc_HelenHayesMM+GaitIndexes”: used to compute the kinematic and kinetic

parameters of gait, as well as the electromyographic analysis. It includes the computation
of the GDI and GPS indexes.
> “Proc_HelenHayesMM+GI_AEFP”: the same as the “Proc_HelenHayesMM+GaitIndexes”

but with the automatic identification of gait events from force platforms data.
named “GaitIndexes-” needs to be chosen from the “Table” drop-down menu.
34
2.6.4 Checking the marker location
As soon as the standing exercise is acquired, select the “Proc_HelenHayesMM_Standing”

calculation protocol. This protocol calculates the joint angles held during the static pose. No
temporal event needs to be defined. At the end of the processing please select the “Rep_
Gait_Standing” report. This report shows a table containing the standing angular values next
to the normative data. If the angular values are significantly out of the normality range please
check the following markers:
 For deviation in hip/knee angles: verify the position of the markers on the lateral and
medial condyles of the femur.
 For deviation in knee/ankle and foot progression angles: check the correct alignment of
the heel marker with the metatarsal marker. Furthermore, verify the position of the markers
on the lateral and medial malleoli.
Bibliography
Kadaba et al 1989. “Repeatability of kinematic, kinetic and electromyographic data in normal

adult gait”. Journal of Orthopaedic Research, Vol. 7, No. 6, pp. 849-860.
Kadaba M. P., Ramakrishnan H. K., Wootten M. E., 1990. “Measurement of lower extremity
kinematics during level walking”. Journal of Orthopaedic Research, Vol. 8, No. 3, pp. 383-
392.
Wu G., Siegler S., Allard P., Kirtley C., Leardini A., Rosenbaum D., Whittle M., D’Lima D.D.,
Cristofolini L., Witte H., Schmid O., Stokes I., 2002 “SB recommendation on definitions of
joint coordinate system of various joints for the reporting of human joint motion--part I: ankle,
hip, and spine. International Society of Biomechanics.” Journal of Biomechanics, Vol. 35, No.
4, pp. 543-548.
Publishers.
pp. 265-269.
35
BTS GAITL A B
3. OXFORD FOOT MODEL
Protocol overview: the Oxford Foot Model protocol is provided with the BTS SMART-
Clinic software included with the BTS GAITLAB system. This protocol allows the study of
the foot kinematics during human locomotion, along with the electrical activity produced
by the muscles involved in gait. The protocol was developed to provide physicians with
quantitative and objective data needed to analyse foot and ankle pathologies. The foot model
implementation was based on the work of (Stebbins et al. 2006; Carson et al. 2001) and
consists of three segments: the hindfoot (including the talus and calcaneus), the forefoot
(including the cuneiforms and metatarsals) and the hallux (proximal phalanx of the hallux).
minimum of 8 video cameras for the kinematic analysis. The evaluation of the muscular
activity requires the use of the BTS FREEEMG surface electromyogram.
 Markers: two versions of the protocol are available, both of which require the positioning
of 32 markers on the subject’s body: 6 on each shank and 10 on each foot:
> “Oxford Foot Model CALM”: uses a marker placed on the sustentaculum tali (cal m) for
the definition of the hindfoot segment (Figure 1). We suggest selecting this version of
the protocol if the patient has no particular foot deformation (a correct positioning and
a good visibility of the marker are allowed during gait).
Figure 1: Frontal and lateral

view of the “Oxford Foot
Model CALM” marker set.
The green markers must be
removed before acquiring the
Walking tasks (see Paragraph
3.2 - “Acquisition phase”).
36
> “Oxford Foot Model CPEG”: uses a wand marker placed on the posterior aspect of
calcaneus (cpeg) for the definition of the hindfoot segment (Figure 2). We suggest
choosing this version of the protocol, if a proper identification of the sustentaculum tali
cannot be achieved or if the landmark visibility is compromised during the subject’s
locomotion.
Figure 2: Frontal and lateral

view of the “Oxford Foot Model
CPEG” marker set. The green
markers must be removed
before acquiring the Walking
tasks (see Paragraph 3.2 -
“Acquisition phase”)
The markers must be applied while the subject holds an orthostatic position. For the correct
> Shank: one marker on the lateral femoral condyle (r knee 1 – l knee 1). To locate the
femoral condyle, perform a passive flexion-extension of the subject’s knee. Once the
flexion-extension axis has been identified, find the point where the axis passes through
the lateral part of the knee. If a dermographic pencil is available, mark the just found
point, and verify that the skin displacement effect is minimal. One marker on the head
of the fibula (r knee 2 – l knee 2), which can be identified through palpation, another
one on the most anterior aspect of the tibial tuberosity (r tub – l tub), and one more
placed arbitrarily along the anterior crest of the shank (r shin – l shin). Finally, one
marker on the lateral malleolus (r mall – l mall) and one on the medial malleolus (r
mall m – l mall m).
> Hindfoot: one marker on the lateral calcaneus (r cal – l cal). This marker must be
positioned at the same distance from the most posterior point of the calcaneus as
the sustentaculm tali landmark. The sustentaculm tali should be palpable as a small
ridge about 2.5 cm below (distal to) the tip of the medial malleolus (or about 2.5 cm
posteriorly to the navicular tuberosity). Two markers on the posterior aspect of the
calcaneus, specifically one on the distal end of the midline in the sagittal plane (r
heel – l heel) and one on the proximal end of the same line (r pcal – l pcal). If the
“Oxford Foot Model CPEG” version is selected, a marker mounted on a little bar (r
cpeg – l cpeg) needs to be placed midway between the two previously mentioned
markers (the three markers must be collinear) (Figure 3). It is crucial that these three
37
BTS GAITL A B
markers are in line with the sagittal plane of the hindfoot. This plane is defined as the
plane equidistant from both lateral and medial borders of the surface of the posterior
calcaneus and passing by the midpoint between the sustentaculum tali and the lateral
border of the calcaneus (Figure 4). If the “Oxford Foot Model CALM” version is used,
one marker needs to be placed on the sustentaculum tali (r cal m – l cal m). The correct
placement of the lateral calcaneus and sustentaculum markers is critical for the correct
quantification of the hindfoot rotations (Figure 5).
Figure 3: To achieve an
accurate reconstruction of the
hindfoot rotations with the
“Oxford Foot Model CPEG”
protocol, the markers on the
posterior calcaneus should be
positioned along the midline
of the posterior surface of the
calcaneus (equidistant from
both lateral and medial borders
of the surface).
Figure 4: The correct alignment

of the rigid bar (r cpeg – l cpeg)
with the hindfoot sagittal plane
(in blue) is critical to achieve
an accurate reconstruction of
the hindfoot rotations with the
protocol. The sagittal plane is
defined as the plane equidistant
from both lateral and medial
borders of the surface of the
posterior calcaneus and passing
by the midpoint between the
sustentaculum tali and the
lateral border of the calcaneus.
Figure 5: To obtain a correct

reconstruction of the hindfoot
rotations with the “Oxford Foot
Model CALM” protocol, the
marker on the lateral calcaneus
must be positioned at the
same distance from the most
posterior point of the calcaneus
as the sustentaculm tali marker.
38
> Forefoot: one marker on the head of the first metatarsal (r met 1h – l met 1h) and one
on the head of the fifth metatarsal (r met 5h – l met 5h). These markers must be placed
medially and laterally on the foot, respectively. If the markers are correctly positioned,
their centres will fall on the line through the first and fifth metatarsal heads. Looking
at the subject from a sagittal point of view, the markers on the distal calcaneus and on
the fifth metatarsal head should be placed at the same height and should identify a line
parallel to the sole of the foot (Figure 6). One marker placed laterally over the base of
the fifth metatarsal (r met 5b – l met 5b); another marker positioned at the base of the
first metatarsal (r met 1b – l met 1b), just medial to the extensor hallucis longus tendon.
To palpate the tendon, ask the subject to dorsiflex the hallux. One last marker needs to
be placed in the space between the heads of the second and third metatarsals (r met – l
met) (Figure 7).

reconstruction of the foot
(monosegment foot), the line
between the marker on the
distal calcaneus and the marker
on the fifth metatarsal head
must be parallel to the sole of
the foot.
Figure 7: Top view of the

positions of the foot markers
according to the “Oxford
Foot Model CALM” (left) and
marker sets (right). The green
“Acquisition phase”).
39
BTS GAITL A B
> Hallux: one marker on the medial side of the proximal phalanx, midway between the
superior and inferior surface of the hallux (r hallux– l hallux).
 Standing task: the subject needs to hold a static orthostatic position for at least 3 - 5
seconds.
 Walking task: before performing this task, the markers on the head of the first metatarsal,
on the posterior proximal aspect of the calcaneus (r pcal – l pcal) and on the medial
malleolus, must be removed. The subject needs to walk normally across the working
volume defined during the calibration phase of the optoelectronic system. If a walkway
is present, the subject is facilitated in following a gait direction. Otherwise, verify that the
subject walks in the straightest way possible. The markers placed on the subject must be
clearly within the field of view of the cameras during the whole acquisition.
verified. A daily calibration is advisable (at need). Once the markers have been placed on
the subject, their correct location should be verified (see Paragraph 3.5 - “Processing of the
standing task”)
to their corresponding label, on the basis of each marker’s real position, at every point in
time. (Figure 8).
40
for the “Oxford Foot Model
CALM” (left) and “Oxford Foot
Model CPEG” (right) protocols.
 Calculation protocol selection: the drop-down menu offers two different calculation
> “Proc_OxfordFoot_Standing_CALM (CPEG)”: this protocol allows the evaluation of the

joint angles of the subject performing the standing task immediately after the acquisition
phase (see Paragraph 3.5).
> “Proc_OxfordFoot_CALM (CPEG)”: used to compute the kinematic and

electromyographic analysis.
events:

with the floor (yellow ochre).
the shank-hindfoot dorsi-
plantarflexion angle (red) is
shown.
> eRTO = Right Toe Off – Right toes are lifted off the ground (one event between each of
the two previously defined strikes) (Figure 10). Figure 10: Example of
definition of the time instant
in which the patient lifts his/
her right toes off the ground
(yellow ochre). To help with
the identification, the shank-
hindfoot dorsi-plantarflexion
angle (red) is shown. Moreover,
the previously defined heel
strike events can be displayed
on the graph (light blue).
41
BTS GAITL A B
> eLHS = Left Heel Strike - Left foot initial ground contact (at least two events must be

shown.
> eLTO = Left Toe Off - Left toes are lifted off the ground (one event between each of the
two previously defined strikes) (Figure 12).

patient lifts his/her left toes off
the ground (yellow ochre). To
help with the identification,
shown.
define the events of all trials.
3.4 Reporting phase
The results of the elaboration are ready to be visualized in the report. To create a report, the
normative bands relative to the kinematics and EMG activity must be provided. Depending
on the age of the subject it is possible to choose between two default normal bands: “Gait-
Normal-adults” and “Gait-Normal-children”. Four report models are available:
 “Rep_OxfordFoot_Standing”: see Paragraph 3.5 - “Processing of the standing task”.
 “Rep_OxfordFoot_Consistency”: it must be selected before visualizing the final clinical

report (“Rep_OxfordFoot”) to evaluate the consistency/repeatability of the acquisitions.
Results of the kinematic analysis from each trial are shown in two distinct pages, one for
the right foot, and one for the left foot. By using this visualization it is possible to scan
the data and manually check for outlier trials (i.e. trials which deviate from the subject’s
characteristic pattern of gait). In the best case, where no outlier trials are detected, as well
as in case one or more trials present inconsistent deviations, the current report should be
closed. Then the “Rep_OxfordFootModel” must be selected, making sure that consistent
trials only, are loaded.
42
 “Rep_OxfordFoot”: the final clinical report is organized in the following way:
data. The list of acquisitions used for the statistical analysis is also presented.
> In the next page are reported the values of the kinematic parameters measured during
the standing acquisition.
in the graphics is the degree (y-axis) and percentage of the gait cycle (x-axis). The mean
curves for each limb (green for the right limb, and red for the left one) are visualized.
The vertical dotted lines in the graphs identify the toe-off events, while the horizontal
lines represent the standing values. The above-mentioned lines are green for the right
limb and red for the left limb. To qualitatively evaluate these graphs we suggest referring
to the patterns presented in the work of (Stebbins et al. 2006).
3.5 Processing of the standing task
As soon as the standing exercise is acquired, select the “Proc_OxfordFootModel_Standing_

CALM (CPEG)” calculation protocol. This protocol calculates the joint angles held during the
static pose. No temporal event needs to be defined. At the end of the processing please select
the “Rep_FootModel_Standing” report in which a table containing the estimated standing
angular values is shown. These data can be examined to evaluate the presence of atypical
values, which can indicate improper marker positioning. An inaccurate positioning of the
cpeg marker (for the “Oxford Foot Model CPEG” version) or of the cal and cal m markers (for
the “Oxford Foot Model CALM” version) could, for example, lead to major offsets (> 7-10
degrees) in the frontal and transversal plane of shank-hindfoot or hindfoot-forefoot angles.
Bibliography
Stebbins J., Harrington M., Thompson N., Zavatsky A., Theologis T., 2006. “Repeatability of
a model for measuring multi-segment foot kinematics in children”. Gait Posture, Vol. 23, No.
4, pp. 401-410.
Carson M.C., Harrington M.E., Thompson N., O’Connor J.J., Theologis T.N. , 2001. “Kinematic
analysis of a multi-segment foot model for research and clinical applications: a repeatability
analysis”, Journal of Biomechanics, Vol. 34, No. 10, pp. 1299-1307.
Publishers.
43
BTS GAITL A B
4. HELEN HAYES WITH BI-SEGMENTAL 3D FOOT
MODEL (SHCG Foot Model)
Protocol overview: the Helen Hayes with bi-segmental 3D foot model (called “SHCG Foot
Model” in this manual and in the software interface) is provided with the BTS SMART-Clinic
software included with the BTS GAITLAB system. This protocol allows the study of the
kinematics and kinetics of human locomotion, along with the electrical activity produced by the
muscles involved in gait. The protocol was developed to provide physicians with quantitative
and objective data needed to analyse any possible gait dysfunction. The implementation of
the analysis of the pelvis, thigh and leg segments was inspired to the works of M. Kadaba and
R. Davis, respectively developed at the Helen Hayes Hospital and the Newington Hospital
(Kadaba et al. 1989, 1990; Davis et al. 1991). The foot model implementation was based on
the work of (Davis et al. 2007) developed at the Shriners Hospital for Children, Greenville.
The foot model consists of two segments: the hindfoot (including the talus and calcaneus) and
the forefoot (including the cuneiforms and metatarsals, but not the phalanges).
 Anthropometric measurements: first of all, patient’s weight [kg] and height [cm] have
> ASIS breadth: identify the position of the two anterior superior iliac spines (ASIS) through
palpation. If a dermographic pencil is available, use it to mark the anatomical landmarks.
Using a pelvimeter, measure the distance between the two ASIS [cm] (Figure 1).
> Pelvis depth: locate the great trochanter. We suggest bringing the hip manually into the
maximum flexion and intra-rotation position. Realign the limb trying not to lose the
just found anatomical landmark. If a dermographic pencil is available, use it to mark
the landmark. Consider a plane passing through the great trochanter and parallel to the
table (Figure 2). With a measuring tape, measure the distance between the anterior-
superior iliac spine and the great trochanter plane (vertical distance with the patient in
supine position) [cm] (Figure 3).
44
(right).

the table (right).
45
BTS GAITL A B
> Leg length: ask the subject to keep his/her knees fully extended. Using a measuring tape,
measure the distance between the anterior-superior iliac spine (consider the marked
point, if available) and the medial malleolus [cm] (Figure 4). If the subject is not able
to fully extend his/her knees, separately measure the thigh and shank lengths and then
consider their summation.

medial malleolus.
46
 Markers: the “SHCG Foot Model” protocol requires the positioning of 31 markers on
the subject’s body: 3 on the pelvis, 3 on each thigh, 3 on each shank, and 8 on each foot
(Figure 5).

view of the “SHCG Foot
Model” marker set. The green
47
BTS GAITL A B
satisfied.
(Figure 8).
48
Figure 7: The (r bar 1 – l bar 1)
marker is a technical marker;

> Foot: three “anatomical” markers must be positioned: one on the lateral malleolus (r
mall – l mall), one on the medial malleolus (r mall m – l mall m), and one on the heel
(r heel – l heel). The heel marker needs to be positioned on the posterior part of the
49
BTS GAITL A B
calcaneus (its medial/lateral placement is strict). Five additional markers are “technical”
markers and consequently do not require exact anatomical positioning: one marker on
the lateral calcaneus (r cal – l cal) and one on the medial calcaneus (r cal m – l cal m);
one marker at the base of the first metatarsal (r met 1b – l met 1b) and one by the head
of the first metatarsal (r met 1h – l met 1h); lastly one marker by the head of the fifth
metatarsal (r met 5h – l met 5h). We suggest placing these last three markers laterally
with respect to the extensor tendons of the toes, in order to favour their stability during
motion. Looking at the subject from a sagittal point of view, the markers on the heel and
on the first and fifth metatarsal heads should be placed at the same height and should
identify a plane parallel to the sole of the foot (Figure 10). Two more markers must
identify, respectively, the space between the bases of the second and third metatarsals
(r met 23b – l met 23b) and the space between the heads of the same metatarsals (r met
– l met) (Figure 9). The medial/lateral alignment of these two markers is strict.
Figure 9: Top view of the

positions of the foot markers.
The green markers must be
removed before acquiring the
Walking tasks (see Paragraph
4.2 - “Acquisition phase”).

reconstruction of the foot
(monosegment foot), the line
the first metatarsal head marker,
as well as the line between
the heel marker and the fifth
metatarsal marker, must be
50
 Walking task: before performing this task the markers between the heads and bases of the
second and third metatarsals, and the medial markers on the knees and ankles must be
removed. The subject needs to walk normally across the working volume defined during
the calibration phase of the optoelectronic system. If a walkway is present, the subject
is facilitated in following a gait direction. Otherwise, verify that the subject walks in the
straightest way possible. The markers placed on the subject must be clearly within the
field of view of the cameras during the whole acquisition. If one or more force platforms
are available, to allow the kinetic analysis, the subject must perform an entire stance
phase of a single foot on one of the platforms. It is important not to force the subject to
achieve this result, because this could alter his/her walking pattern. The foot strike on the
platform should be spontaneous.
verified. A daily calibration is advisable (at need). Once the markers have been placed on
the subject, their correct location should be verified (see Paragraph 4.5 - “Processing of the
standing task”).
time (Figure 11). To perform the analysis of joint moments and powers, force data must be
the platform.
51
BTS GAITL A B
Figure 11: Marker set model
for the “SHCG Foot Model”
protocol.
> “Proc_SHCGFoot_Standing”: this protocol allows the evaluation of the joint angles of
the subject performing the standing task immediately after the acquisition phase (see
Paragraph 4.5).
> “Proc_SHCGFoot+GaitIndexes”: used to compute the kinematic and kinetic parameters

> “Proc_SHCGFoot+GI_AEFP”: the same as the “Proc_SHCGFoot+GaitIndexes” but with

the automatic identification of gait events from force platforms data.
including the normal values needed for the gait indexes calculation and corresponding to
four different age groups, can be selected: children (up to 12 years old), young (from 13 to 54
years old), adults (from 55 to 64 years old), elderly (≥ 65 years old).
events:
> eRHS = Right Heel Strike – Right foot initial ground contact (at least two events must be
dorsi-plantarflexion angle –
monosegment foot – (red) are
shown.
52
> eRTO = Right Toe Off – Right toes are lifted off the ground (one event between each of Figure 13: Example of definition
the two previously defined strikes) (Figure 13). of the time instant in which the
patient lifts his/her right toes off the
ground (yellow ochre). To help with
the identification, the knee flexion-
extension angle (green) and the
ankle dorsi-plantarflexion angle
– monosegment foot – (red) are
shown. Moreover, the previously
defined heel strike events can be
displayed on the graph (light blue).
dorsi-plantarflexion angle –
monosegment foot – (red) are
shown.
> eLTO = Left Toe Off – Left toes are lifted off the ground (one event between each of the
two previously defined strikes) (Figure 15). Figure 15: Example of definition
patient lifts his/her left toes off the
ground (yellow ochre). To help with
the identification, the knee flexion-
extension angle (green) and the
ankle dorsi-plantarflexion angle
– monosegment foot – (red) are
shown. Moreover, the previously
defined heel strike events can be
displayed on the graph (light blue).
define the events of all trials. If a protocol including the automatic identification of events
was selected, the graphs showed in the event windows will display different curves.
Specifically, graphs will show the vertical ground reaction force relative to the specific
limb (red) and a force threshold of 10 Newton (green). At least two heel strike events
and one toe off event (between the previously defined strikes) must be defined for the
correct protocol processing. Please verify that all events have been correctly identified
by the protocol. It is possible to cancel, modify or add one or more events to the ones
automatically identified.
4.4 Reporting phase
The results of the elaboration are ready to be visualized in the report. To create a report, the
normative bands relative to the kinetics, kinematics, and EMG activity must be provided.
 “Rep_SHCGFoot_Standing”: see Paragraph 4.5 - “Processing of the standing task”.
53
BTS GAITL A B
 “Rep_SHCGFoot_Consistency”: it must be selected before visualizing the final clinical
report (“Rep_SHCGFoot”) to evaluate the consistency/repeatability of the acquisitions.
from the subject’s characteristic pattern of gait). In the best case, where no outlier trials
are detected, as well as in case one or more trials present inconsistent deviations, the
current report should be closed. Then the “Rep_SHCGFoot” must be selected, making sure
that consistent trials only, are loaded.
 “Rep_SHCGFoot+GaitIndexes”: the final clinical report is organized in the following way:
analysis.
curves for each limb (green for the right limb, and red for the left one) are visualized.
The vertical dotted lines in the graphs identify the toe-off events, while the horizontal
lines represent the standing values. The above-mentioned lines are green for the right
limb and red for the left limb. In the two pages dedicated to the lower limbs kinematics,
the curves are plotted against the normative data (in grey). On the other hand in both
pages dedicated to the foot kinematics, the normal values are not shown in the graphs.
To qualitatively evaluate these graphs we suggest referring to the patterns presented
in the work of (Davis et al. 2007). N.B. The ankle dorsi-plantarflexion angle shown in
the right/left limb kinematics page (next to the foot progression angle), is calculated
between the shank and the “single-segment” foot. This angle is also reported in the
subsequent dynamic results. On the other hand, the first three rotations shown in the
foot kinematics pages are evaluated between the shank and the hindfoot.
54
of gait cycle (x-axis). Joints moments and powers are shown divided by the subject
4.5 Processing of the standing task
As soon as the standing exercise is acquired, select the “Proc_SHCGFoot_Standing” calculation

event needs to be defined. At the end of the processing please select the “Rep_SHCGFoot_
Standing” report in which a table containing the estimated standing angular values is shown.
These data can be examined to evaluate the presence of atypical values, which can indicate
improper marker positioning.
Bibliography
392.
Jameson E.G., Davids J.R., Christopher L.M., Rogozinski B.M., Anderson J.P., Davis R.B.,
2007. “Chapter 25. The Design, Development, and Initial Evaluation of a Multisegment Foot
Model for Routine Clinical Gait Analysis.” Foot and Ankle Motion Analysis. Clinical Treatment
and Technology, pp. 425–444. Editors Marks R.M., Harris G.F. and Smith P.A.
Publishers.
pp. 265-269.
55
BTS GAITL A B
5. DIGIVEC PROTOCOL – GROUND REACTION
FORCE ANALYSIS
Protocol overview: the Digivec protocol is provided with the BTS SMART-Clinic software
included in BTS GAITLAB system. Thanks to its increased reality feature, this protocol
allows real-time analysis of walking gait from a dynamic point of view, evaluating the three
components of ground reaction force during the stance phase. The protocol was developed
to provide physicians with the quantitative and objective data needed to analyse possible gait
dysfunctions. The work of (Schwartz et al. 2008; Baker et al. 2009) introduced a particular
data processing technique for the assessment of gait analysis indexes (GDI and GPS) and
inspired the computation of some relevant kinetic parameters in the Digivec protocol.
Required equipment: the protocol requires the use of at least two BTS P-6000 force plates
and one or more BTS VIXTA cameras for video recording. The protocol can be used also with
multiple configurations of force plates (three, four or more…) but this manual will refer to the
most common standard condition based on two force plates. When BTS FREEEMG surface
electromyogram is available, evaluation of the muscular activity can also be performed.
No particular procedure is required. Patients do not need to undress, unless muscle activity
evaluation is performed by placing two electrodes on each muscle. Instructions on electrodes
correct positioning for the EMG analysis are available in specific handbooks (Cram et al. 1998,
Freriks et al. 1999). During patient preparation it is important to check the correspondence
between probe number and muscle.
The subject has to perform the following tasks:
 Standing task: the subject has to hold an orthostatic position for at least 3 – 5 seconds
placing each foot on the corresponding platform (Figure 1).
Figure 1: Standing task for the

“Digivec” protocol.
56
 Walking task: the subject has to walk normally across the working area where platforms
are placed. When a walkway is available, the subject will be facilitated in following
gait direction. Otherwise, the subject will have to make the effort to walk as straight as
possible. In order to have dynamic consistent data, the subject has to perform an entire
stance phase placing one foot on a single platform (Figure 2) or across both platforms. It is
important to avoid forcing the subject into achieving this result, because that could alter
his/her natural walking pattern. Foot strike on platforms should be spontaneous.
Figure 2: Walking task for the

“Digivec” protocol.
The protocol requires a single acquisition of Standing task and one or more acquisitions
of Walking task.
Recommendations: before starting acquisition, correct calibration of the system must be

verified. A daily calibration is advisable (at need).
 Tracking: the 3D force vectors visualized on the platforms and superimposed on the video,
must be tracked. This means that they need to be associated to the corresponding labels (r
gr - l gr). The label has to be selected on the basis of the foot striking each platform. This
operation can be performed directly on video right after recording and before saving the
trial, or at the end of the acquisition phase using the tracking model.
protocols for selection choice: for the computation every protocol requires one Standing
trial and one or more Walking trials.
> “Proc_DigivecClinic2PL”: this protocol computes forces and kinetic indexes related to
the stance phase of the gait cycle.
> “Proc_DigivecClinic2PL_ev”: this protocol gives the same results of the “Proc_
DigivecClinic2PL”, with additional temporal parameters of the gait cycle.
> “Proc_DigivecClinic2PL_ev+EMG”: this protocol gives the same results of the “Proc_
DigivecClinic2PL_ev”, with the additional elaboration of EMG signals.
57
BTS GAITL A B
 Events: on the basis of the selected protocol, time events definition for the identification of
movement phases can be fully automatic or partially manual.
 Time events in “Proc_DigivecClinic2PL” protocol: time events identification is completely

automatic. The following windows open and users just need to perform an accuracy
check.
> eRFS = Event of Right Foot Strike – Single time event when the right foot hits the
platform (Figure 3).
Figure 3: Single time event of

Foot Strike
> eRTO = Event of Right Toe Off – Single time event when the right foot lifts off the
platform (Figure 4).

Toe Off
> eRMS = Event of Right Mid Stance – Single time event when the right side ground
reaction force is totally vertical (Figure 5).

Mid Stance
58
> eLFS = Event of Left Foot Strike – Just as eRFS, it’s the single time event when the left
foot hits the platform (Figure 3).
> eLTO = Event of Left Toe Off – Just as eRTO, it’s the single time event when the left foot
lifts off the platform (Figure 4).
> eLMS = Event of Left Mid Stance – Just as eRMS, it’s the single time event when the left
side ground reaction force is totally vertical (Figure 5).
Time events in “Proc_DigivecClinic2PL_ev” protocol: some of them are identified

automatically and other need to be defined manually.
> eRFS = Events of Right Foot Strike – Two events to be defined when the right foot
hits the floor (Figure 6). They have to be manually identified: the first event is on the
platform at the intersection of the ground reaction force signal with the threshold; the
second event has to be defined looking at the video recording.
Figure 6: Double time event of

Foot Strike
> eRTO = Event of Right Toe Off – Single time event when the right foot lifts off the
platform. The software defines it automatically (Figure 4).
> eRMS = Event of Right Mid Stance – Single time event when the right side ground
reaction force is totally vertical. The software defines it automatically (Figure 5).
> eLFS = Events of Left Foot Strike – Just as eRFS, it’s the double time event when the left
foot hits the floor (Figure 6). They have to be identified manually: the first event is on
the platform at the intersection of the ground reaction force signal with the threshold;
the second event has to be defined looking at the video recording.
> eLTO = Event of Left Toe Off – Just as eRTO, it’s the single time event when the left foot
lifts off the platform. The software defines it automatically (Figure 4).
> eLMS = Event of Left Mid Stance – Just as eRMS, it’s the single time event when the left
side ground reaction force is totally vertical (Figure 5).
Time events in “Proc_DigivecClinic2PL_ev+EMG” protocol: are exactly the same events

defined in “Proc_DigivecClinic2PL_ev” protocol.
When multiple walking trials get loaded for elaboration, several windows will open
progressively to show the events to be defined for all trials.
59
BTS GAITL A B
5.4 Reporting phase
Elaboration results can be visualized in the report. Three report models are available
according to their corresponding processing protocols and each report allows the comparison
of patient’s data with normative (Digivec-Normality).
 “Rep_DigivecClinic2PL”: this report model is organized as follows:
> The first page contains the FPS index (Force Profile Score) for the right and left side:
the FPS index quantifies the difference between patient and normative data, frame by
frame during the stance phase. This global data combines values of the same index
calculated individually for each of the three force components. The FPS index of each
component weighs differently on the computation of the global FPS index: 20% the
anterior-posterior component, 5% the medial-lateral component and 75% the vertical
component.
> The second page contains the FPS index for each force component of the right and left
side. On the left, graphs of the three force components are shown in comparison with
the normative band. These graphs are normalized to the stance phase.
> The COP trace (Centre of Pressure) is shown next. It is possible to visualize the COP
movement directly on the picture of the platforms and evaluate the anterior-posterior
and medial-lateral COP displacements in the graphs normalized to the stance phase.
> The output of the Standing trial is reported next. It is possible to evaluate the patient’s
symmetry on the basis of weight percentage loaded on each platform.
> In the last pages, some video snapshots are reported. They show the ground reaction
force superimposed on the video related to some instants of the right and left stance
phase (foot initial contact, midstance, toe off). Thanks to pictures reporting the normal
behaviour, it is possible to check if the ground reaction force is oriented properly with
respect to each joint.
 “Rep_DigivecClinic2PL_ev”: this report model is organized exactly like “Rep_

DigivecClinic2PL”. In addition, the temporal parameters (stance and swing phase duration)
of right and left gait cycles are shown.
 “Rep_DigivecClinic2PL_ev+EMG”: this report model is organized exactly like “Rep_

DigivecClinic2PL_ev”. In addition, on the last pages right and left muscle activity signals
are reported. The muscle activity is displayed on time axis as well as on gait cycle.
Bibliography
pp. 265-269.
Publishers.
60
6. UPPER LIMB PROTOCOL (Modified Rab)
Protocol overview: the Upper Limb protocol (Modified Rab) protocol is optional and can
be provided with the BTS SMART-Clinic software. This protocol allows the study of upper
limbs kinematics during the performance of significant tasks, along with the electrical activity
produced by the muscles. The protocol was developed to provide physicians quantitative
and objective data needed to analyse upper limbs dysfunctions. The work of (Rab et al. 2002;
Petuskey et al. 2007), introducing a marker-based technique for the kinematic analysis of
upper extremities, inspired this protocol implementation. The computation of some relevant
kinematic parameters was based on the works of (Menegoni et al. 2009; Cimolin et al. 2012;
Rigoldi et al. 2012; Aprile et al. 2014).
minimum of 4 video cameras for kinematic analysis. The evaluation of muscular activity
requires the use of the BTS FREEEMG surface electromyogram.
 Markers: the Modified Rab protocol uses a modified version of the so called “Rab marker
set” (Rab et al. 2002, 2007) (Figure 1). Two versions of the protocol are available:
> “Rab Pointing”: requires the positioning of 16 markers on the subject’s body: 3 on the
head, 3 on the trunk, 3 on each forearm, and 2 on each hand. An additional marker has
to be positioned on the target object the subject will be asked to reach out to and touch.
Three more markers will be positioned on the target plane.
> “Rab Hand To Mouth”: requires the positioning of 17 markers on the subject’s body: 4
on the head, 3 on the trunk, 3 on each forearm, and 2 on each hand.

view of the markers to be
positioned on the patient for
both versions of the Modified
Rab protocol. The “Rab Hand
To Mouth” version requires the
application of an additional
marker on the subject’s chin,
just above the mouth (Figure 3).
61
BTS GAITL A B
For correct positioning of markers, please refer to the following guidelines:
> Head: one marker on the nasion (nasion) and two more markers on the right and left
zygomatic process of frontal bone (r zyg pr – l zyg pr). If the Hand to Mouth task
is performed (see Paragraph 6.2 - “Acquisition phase”), one marker will have to be
placed on the subject’s chin, just under his/her mouth.
> Trunk: one marker on the suprasternal – jugular – notch (sternum), one by the right
acromion (r should) and one by the left acromion (l should).
> Forearm: one marker on the olecranum (r elbow – l elbow). Ask the patient to stand
straight and pull back his/her shoulders. After bringing the subject’s arm in a flexed
position, palpate the posterior aspect. In this configuration the olecranum is the most
prominent point. We suggest positioning the marker slightly below this point, to avoid
significant skin movement. An additional marker should be placed by the radial styloid
process (r radius – l radius) and one by the ulnar styloid process (r ulna – l ulna).
> Hand: one marker to be placed between the second and third metacarpal hands (r
hand – l hand) in a position where the skin movement effect is minimal. Another to be
applied on the index fingernail (r finger – l finger).
> Target: if the Pointing task is performed, one marker should be placed on the target
point/object the subject has to reach out to and touch. Three more markers have to
be positioned on the plane where the target lies. Please note that these three markers
should not be aligned, in order to allow the correct identification of the target-plane.
 Electrodes: in order to evaluate muscular electrical activity, two electrodes need to be

placed on each muscle of interest. Further instructions on electrodes correct positioning
for the EMG analysis can be found in specific handbooks (Cram et al. 1998, Freriks et
al. 1999). During the preparation of the subject it is important to pay attention to the
correspondence between the probe number and the muscle.
62
The subject needs to perform the following tasks:
 Static task: the subject is asked to sit comfortably on a chair placed in front of a table.
He/she needs to lean back on the backrest, keeping the back as straight as possible and
elbows bent at approximately 90°. The subject’s palms must be placed steadily on the
table surface (Figure 2) (Figure 3). This “resting position” must be held for at least 3-5
seconds.
Figure 2: Static task for the

“Rab Pointing” protocol. The
green marker must be removed
before acquiring the Movement
tasks.
Figure 3: Static task for the “Rab

Hand To Mouth” protocol. The
green marker must be removed
before acquiring the Movement
tasks.
63
BTS GAITL A B
 Movement task: before performing this task the target/chin marker must be removed. Two
different tasks can be performed:
> Pointing task: from the resting position the subject has to move one limb at a time and
touch a target point/object placed in front of him/her with the index finger. After having
touched the target, the subject has to return to the resting position with both hands on
the table. This task can be repeated over and over changing the moving arm (Figure 4).
The target must be reachable with a maximum extension of the index finger and elbow
and no trunk flexion. To standardize the task, the target-acromion distance can be fixed
at the 80% of the subject’s arm length.
Figure 4: Execution of the

Pointing task. The target point is
highlighted by the blue “X” on
the table.
> Hand to Mouth task: from the resting position the subject will have to move a hand
towards his/her mouth and touch it with its palm. Then he/she will return to the resting
position. This task can be performed over and over (during the same acquisition)
alternating the moving arm (Figure 5).
The protocol requires a single acquisition of the Static task and at least one acquisition of
the Pointing or Hand to Mouth task.
Figure 5: Execution of the Hand

To Mouth task.
location”).
64
time (Figure 6). This operation must be performed manually.
Figure 6: Marker set models for

the “Rab Pointing” (on the left)
and “Rab Hand To Mouth” (on
the right).
> “Proc_Rab_Static”: this protocol allows a quick check of markers position (see Paragraph
6.5). It is used to elaborate the static task immediately after its acquisition.
> Depending on the protocol version:
– “Proc_Rab_Pointing”: this protocol computes the kinematics and the electromyographic

analysis of the Pointing gesture.
or
– “Proc_Rab_HtM”: this protocol computes the kinematics and the electromyographic

analysis of the Hand to Mouth task.
 Events: identification of movement phase is automatically performed by the protocol.

However, it is advisable to check that events are correctly identified in all the acquisitions.
Specifically, each of the following events should be identified once, for each movement
repetition.
> eRGP2 = R Start of the Going Phase – The instant when the right hand detaches from
Figure 7: Example of events

identifying the start of the going
phase for the right arm (yellow
ochre). The graph shows the
velocity of the right finger
marker during the going phases
(red) along with the default
threshold of 50 mm/s (green).
65
BTS GAITL A B
> eRRP2 = R End of the Returning Phase – Time instant in which the right hand,
returning to its resting position, touches the table (Figure 8).
identifying the end of the
returning phase for the right
arm (yellow ochre). The graph
shows the velocity of the
right finger marker during the
returning phases (red) along
with the default threshold of 50
mm/s (green).
> eLGP2 = L Start of the Going Phase – Time instant in which the left hand detaches
from the table (Figure 9).

identifying the start of the going
phase for the left arm (yellow
velocity of the left finger marker
during the going phases (red)
along with the default threshold
of 50 mm/s (green).
> eLRP2 = L End of the Returning Phase – Time instant in which the left hand, returning
to its resting position, touches the table (Figure 10).

identifying the end of returning
phase for the left arm (yellow
velocity of the left finger marker
during the returning phases
(red) along with the default
threshold of 50 mm/s (green).
> eRMINDIST = Minimum R Finger-Target Distance – Target reach instant with the right
identifying target reaching with
arm (minimum distance of the right finger from the target) (Figure 11).
the right finger (yellow ochre).
The graph shows the distance
between the marker on the
right finger and the target (red).
The beginning of the going
phase and end of the returning
phase events for the right limb
are shown in turquoise blue
and violet respectively.
> eRAPSTART = R Start of the Adjusting Phase – Beginning of the movement phase
aimed at precisely locating the target with the right finger (Figure 12).
Pointing:
Figure 12 Example of events

identifying the beginning of the
adjusting phase for the right
arm (yellow ochre). In the “Rab
Pointing” protocol, the graph
shows the distance between
the marker on the right finger
and the target (red). The green
line represents the default Hand To Mouth:
threshold calculated following
the indications of (Menegoni
et al, 2009). In the “Rab Hand
To Mouth” protocol, the graph
shows the velocity of the right
finger marker during the going
phases (red) along with the
default threshold of 50 mm/s
(green).
66
> eRAPSTOP = R End of the Adjusting Phase – End of movement phase aimed at
precisely locating the target with the right finger (Figure 13).
Pointing:

adjusting phase for the right
the marker on the right finger
Hand To Mouth: line represents the default
right finger marker during the
mm/s (green).
> eLMINDIST = Minimum L Finger-Target Distance – Target reach instant with the left
arm (minimum distance of the left finger from the target) (Figure 14). identifying the target reaching
with the left finger (yellow
distance between the marker
on the left finger and the target
(red). The start of the going
phase and end of the returning
phase events for the left limb
are shown in light blue and
green respectively.
> eLAPSTART = L Start of the Adjusting Phase – Beginning of movement phase dedicated
to precisely locating the target with the left finger (Figure 15).
Pointing:

identifying the beginning of
the adjusting phase for the left
the marker on the left finger
Hand To Mouth: line represents the default
shows the velocity of the left
finger marker during the going
phases (red) along with the
default threshold of 50 mm/s
(green).
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> eLAPSTOP = L End of the Adjusting Phase – End of movement phase dedicated to
precisely locate the target with the left finger (Figure 16).
Pointing:

adjusting phase for the left arm
(yellow ochre). In the “Rab
the marker on the left finger
and the target (red). The green Hand To Mouth:
line represents the default
left finger marker during the
mm/s (green).
> eRPV = R Peak Velocity – Maximum velocity of the right finger during the going phase
(Figure 17).
identifying the peak velocity for
the right limb during the going
phase (yellow ochre). The graph
shows the absolute value of the
right finger velocity (red). The
start of the going phase and of
the adjusting phase for the right
limb are shown in turquoise
blue and purple respectively.
> eRNPV = R Velocity Peaks – Points in time when the right finger velocity exceeds a
threshold represented by the 10% of the average intra-trial peak velocity of the right
finger (Figure 18).
identifying the velocity peaks
for the right hand (yellow
absolute value of the right
finger velocity (red) along
with the threshold (green). The
threshold is defined as the 10%
of the average intra-trial peak
velocity.
> eLPV = L Peak Velocity – Maximum velocity of the left finger during the going phase
(Figure 19).
identifying the peak velocity for
the left limb during the going
phase (yellow ochre). The graph
shows the absolute value of the
left finger velocity (red). Going
phase and adjusting phase
events start for the left limb are
shown in light blue and purple
respectively.
68
> eLNPV = Left Velocity Peaks – Points in time when the left finger velocity exceeds a
threshold represented by 10% of the average intra-trial peak velocity of the left finger
(Figure 20).
identifying the velocity peaks
for the left hand (yellow ochre).
The graph shows the absolute
value of the left finger velocity
(red) along with the threshold
(green). The threshold is defined
as the 10% of the average intra-
trial peak velocity
Should different movement tasks be acquired, several windows will open progressively to
show the identified events for all trials.
6.4 Reporting phase
Elaboration results can be visualized in the report. Four report models are available:
 “Rep_Rab_Static”: see Paragraph 6.5 - “Checking the marker location”.
 “Rep_Rab_Consistency_Pointing” (or “Rep_Rab_Consistency_HtM”): it must be

selected before visualizing the final clinical report (“Rep_Rab_Pointing” or “Rep_Rab_
HandToMouth”) to evaluate acquisitions consistency/repeatability. Results of the kinematic
analysis from each trial are shown in two distinct pages, one for the right limb, and one
for the left limb. By using this visualization it is possible to scan the data and manually
check for outlier trials (i.e. trials which deviate from the subject’s characteristic pattern
of movement). In the best case, where no outlier trials are detected, as well as in case
one or more trials present inconsistent deviations, the current report should be closed.
“Rep_Rab_Pointing” (or “Rep_Rab_HandToMouth”) must then be selected making sure
that consistent trials only, are loaded.
 “Rep_Rab_EMG_Pointing”: this report shows EMG signals (millivolts) filtered with a high
pass and a low pass filter, with respect to time (seconds). The vertical solid lines in the
graphics indicate the beginning and the end of the movement cycles defined during the
elaboration phase. The vertical dotted lines represent the target reaching events. The lines
related to the right cycle are green, while the ones related to the left cycle are red. All EMG
records are displayed for each acquisition selected in “Trials to be reported or viewed”.
 “Rep_Rab_Pointing” (or “Rep_Rab_HandToMouth”): the final clinical report is organized

in the following way:
> The first page contains the mean kinematic parameters of all trials selected in “Trials
to be reported or viewed”. In the same page values of the range of motion (degrees) of
the shoulder joint in the frontal and sagittal plane, and of the elbow joint in the sagittal
plane are reported. At the end of page the subdivision in phases of the movement cycle
for the right (green) and left (red) limb are shown. Here follows a brief description of the
evaluated kinematic parameters:
– Movement Cycle Time (MC) – seconds: movement duration from the start of the going
phase to the end of the returning phase.
– Going Phase (GP) – %MC: transport phase toward the target expressed as a percentage
of the movement cycle.
– Adjusting Phase (AP) - %MC: phase of the movement dedicated to precisely locating
the target expressed as a percentage of the movement cycle.
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– Returning Phase (RP) - %MC: transport phase toward the rest position expressed as a
percentage of the movement cycle.
– Index of Curvature (IC): represents movement straightness during the going phase. An
IC equal to 1 indicates a perfectly rectilinear motion.
– Average Jerk (AJ) - meters per second cubed: measurement of movement smoothness.
The AJ index decreases with increased smoothness.
– Number of Movement Units (NMU): parameter indicating the number of online

corrections performed by the subject during the ongoing phase. A NMU equal to
2 indicates a confident movement, with no corrections in both the going and the
returning phases.
– Mean Movement Velocity (MMV) - meters per second: fingernail marker mean velocity
during the going phase. Increase in MMV generally indicates an improvement in task
performance.
– Peak Velocity (PV) - meters per second: maximum movement velocity achieved
during the going phase.
– Skewness (SK) - %MC: PV time expressed as a percentage of the going time. SK is a

measure of symmetry of the velocity profile.
– Adjusting Sway (AS) - millimeters: adjustment measurements made to reach the target.
The AS decreases as the movement precision increases.
– Arm Elongation (AE) – %, “Rab Pointing” protocol only: arm relative contribution in
reaching the target. It’s computed as the difference between the forward movement
of hand and shoulder and the forward movement of hand only.
– Trunk Forward Inclination (TF) – %, “Rab Pointing” protocol only: trunk relative
contribution in target reaching expressed as a percentage ratio between the sternum
forward displacement and hand forward displacement.
in the graphs is the degree – or meters for the finger-target distance graph - (y-axis) and
percentage of the movement cycle (x-axis). The mean curves for each limb (green for
the right limb, and red for the left one) are plotted in the graphs. Vertical dotted lines
in the graphs identify the target reaching instant (point of minimum distance between
the finger marker and the target), while the horizontal lines represent static values.
The above-mentioned lines are green for the right limb and red for the left limb. The
static values are not shown in the trunk tilt graph since the offset measured in the static
acquisition have been subtracted from the above-mentioned curve.
time-normalized for the duration of the movement cycle (%MC). In addition, one page
is dedicated per acquisition to the filtered EMG signals normalized on the first pointing
or hand-to-mouth cycle for the right and left limb. The vertical solid lines in the graphs
indicate the start and the end of the adjusting phase. The vertical dotted line represent
the target reaching event (green for the right limb, red for the left limb). By default only
the EMG signal corresponding to the first movement identified in each acquisition is
shown. The report can be customized to show EMG signals corresponding to several
pointing or hand-to-mouth movements.
70
 Checking marker location: as soon as the static task is acquired, select the “Proc_Rab_
Static” calculation protocol. This protocol calculates the joint angles held during the
static pose. No temporal event needs to be defined. Once processing is completed the
“Rep_Rab_Static” report should be selected. The report shows a table containing the static
angular values, which data can be examined to determine the presence of atypical values
indicating incorrect marker positioning.
Bibliography
Rab G., Petuskey K., Bagley A., 2002. “A method for determination of upper extremity
kinematics”. Gait and Posture, Vol. 15, pp. 113-119.
Petuskey K., Bagley A., Abdala E., James M.A., Rab G., 2007. “Upper extremity kinematics
during functional activities: Three dimensional studies in a normal population”. Gait and
Posture, Vol. 25, pp. 573-579.
Menegoni F., Milano E., Trotti C., Galli M., Bigoni M., Baudo S., Mauro A., 2009. “Quantitative
evaluation of functional limitation of upper limb movements in subjects affected by ataxia”.
European Journal of Neurology, Vol. 16, No. 2, pp. 232-239.
Cimolin V., Beretta E., Piccinini L., Turconi A.C., Locatelli F., Galli M., Strazzer S., 2011.
“Constraint-induced movement therapy for children with hemiplegia after traumatic brain
injury: a quantitative study”. The Journal of Head Trauma Rehabilitation, Vol. 27, No. 3, pp.
177-187.
Rigoldi C., Molteni E., Rozbaczylo C., Morante M., Albertini G., Bianchi A.M., Galli M.,
2012. “Movement analysis and EEG recordings in children with hemiplegic cerebral palsy”.
Experimental Brain Research, Vol. 223, No. 4, pp. 517-524.
Aprile I., Rabuffetti M., Padua L., Di Sipio E., Simbolotti C., Ferrarin M., 2014. “Kinematic
analysis of the upper limb motor strategies in stroke patients as a tool towards advanced
neurorehabilitation strategies: a preliminary study”. BioMed Research International, Vol.
2014, Article ID 636123.
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7. CERVICAL SPINE MOBILITY PROTOCOL
Protocol overview: the Cervical Spine Mobility protocol is an optional protocol which can
be provided with the BTS SMART-Clinic software. This protocol allows the assessment of
the active range of motion of the head and the analysis of electrical activity produced by
cervical muscles. The protocol has been developed to provide physicians with quantitative
and objective data needed to analyse head and neck motion dysfunctions. The works of
(Ferrario et al. 2002; Tommasi et al. 2009), using marker-based techniques for quantitative
studies on head and cervical spine movements, inspired the implementation of this protocol.
minimum of 4 video cameras for kinematic analysis. The evaluation of muscular activity
requires the use of the BTS FREEEMG surface electromyogram.
 Markers: the cervical spine mobility protocol uses a very simple marker set. The protocol
is available in a single version:
> “Cervical Spine Mobility”: 6 markers to be positioned on the subject’s body: 3 on the
head and 3 on the trunk (Figure 1).
Figure 1: Frontal view of the

“Cervical Spine Mobility”
marker set.
For correct positioning of the markers, please refer to the following guidelines:
> Head: one marker on the nasion (nasion) and two markers on the right and left zygomatic
processes of frontal bone (r zyg pr – l zyg pr).
> Trunk: one marker on the suprasternal – jugular – notch (sternum), one by the right
72
Zygomatic processes as well as acromia markers have to be positioned accurately in order
to avoid incorrect reconstruction of head rotations, which in turn could lead to inaccurate
results.
 Electrodes: in order to evaluate muscular electrical activity, two electrodes need to be

for the EMG analysis can be found in specific handbooks (Cram et al. 1998, Freriks
et al. 1999). During preparation of the subject it is important to pay attention to the
The subject is asked to sit comfortably on a chair with lumbar and arm support. He/she needs
to keep both feet on the ground, with flexed knees and elbows at approximately 90-degree
angle. A firm stabilization of the torso, as well as the use of an adjustable seat to be set at
subject’s height, are essential to ensure test repeatability. The subject has to perform three
different tasks starting from a neutral position. The neutral position must be held for at least
3 seconds before starting task movement. The ability to take that same head neutral position
with the trunk is crucial in order to measure the half-cycle ROM and to properly assess any
asymmetry (Strimpakos 2009).
 Flexion-Extension task: the subject has to perform maximal flexion-extension movements

of the cervical spine at natural speed. This task can be performed numerous times in a
single acquisition (Figure 2).
Figure 2: Head flexion-

extension task.
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 Lateral Bending task: the subject has to perform maximal lateral bending movements of the
cervical spine (right and left side) at natural speed. This task can be performed numerous
times in a single acquisition (Figure 3).
Figure 3: Head right and left

lateral bending task.
 Rotation task: the subject has to perform maximal axial rotation movements of the cervical
spine (right and left side) at natural speed. This task can be performed numerous times in
a single acquisition (Figure 4).
Figure 4: Head right and left

axial rotation task.
The protocol requires a single acquisition of each task.
verified. A daily calibration is advisable (at need).
 Tracking: firstly, the markers must be tracked, meaning that they need to be associated to
their corresponding label, on the basis of each marker’s real position, at every point in
time (Figure 5). This operation must be performed manually.
74
Figure 5: Marker set model of
the “Cervical Spine Mobility”
protocol
 Calculation protocol selection: a single calculation protocol is available from the drop-
down menu:
> “Proc_CervicalMobility”: this protocol allows the evaluation of cervical spine movement
and of the range of motion on Cartesian axes.
 Events: in the Cervical Spine Mobility protocol some events are automatically identified,
while some others need to be manually defined. We suggest checking the correct detection
of automatic events.
> eMOFF = Movement Offset – Identification of the neutral position offset. This event
should be selected before beginning the task movement. The movement offset needs to
be identified for each of the three acquisitions. N.B. the initial and final values of each
curve should be the same to indicate an adequate neutral position ensuring repeatability
(Figure 6).
Flexion-Estension
Lateral Bending
Rotation Figure 6: Example of definition

of movement offset (yellow
ochre). The graph shows
the movement of nasion
marker with respect to the
subject reference system
(red) in the vertical direction,
for the flexion-extension
movement, and in the medio-
lateral direction for the other
movements.
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> eFSTART = Flexion Start – Start of the cervical flexion phase. One event should be
automatically identified for each movement repetition (Figure 7).

of the start of head flexion
(yellow ochre). The graph
shows the flexion-extension
angle of the head with respect
to the trunk (red).
> eESTART = Extension Start – Start of the cervical extension phase. One event should be

of the start of head extension
(yellow ochre). The graph
shows the flexion-extension
to the trunk (red).
> eFRET = Flexion – Start of the Return Phase – Moment in which the maximal flexion is
achieved. One event should be automatically identified for each movement repetition
(Figure 9).

of return to the neutral
position phase, starting with
the achievement of maximal
head flexion (yellow ochre).
The graph shows the flexion-
extension angle of the head
with respect to the trunk (red).
> eERET = Extension – Start of the Return Phase – Moment in which the maximal extension
is achieved. One event should be automatically identified for each movement repetition
(Figure 10).

head extension (yellow ochre).
The graph shows the flexion-
extension angle of the head
> eRBSTART = R Bending Start – Start of the right bending phase. One event should be

of the start of cervical bending
to the right (yellow ochre). The
graph shows the lateral bending
to the trunk (red).
76
> eLBSTART = L Bending Start – Start of the left bending phase. One event should be

of the start of cervical bending
to the left (yellow ochre). The
to the trunk (red).
> eRBRET = R Bending – Start of the Return Phase – Moment in which the maximal
right side bending is achieved. One event should be automatically identified for each
movement repetition (Figure 13).

of return to the neutral position
phase, starting with the
achievement of maximal right
bending (yellow ochre). The
to the trunk (red).
> eLBRET = L Bending – Start of the Return Phase – Moment in which the maximal
left side bending is achieved. One event should be automatically identified for each

of return to the neutral position
phase, starting with the
achievement of maximal left
bending (yellow ochre). The
to the trunk (red).
> eRROTSTART = R Rotation Start – Start of the right rotation phase. One event should be

of the start of head rotation to
the right (yellow ochre). The
graph shows the axial rotation
to the trunk (red).
> eLROTSTART = L Rotation Start – Start of the left rotation phase. One event should be

of the start of head rotation
to the left (yellow ochre). The
graph shows the axial rotation
to the trunk (red).
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> eRROTRET = R Rotation – Start of the Return Phase – Moment in which the maximal
right side rotation is achieved. One event should be automatically identified for each

rotation to the right (yellow
axial rotation angle of the head
> eLROTRET = L Rotation – Start of the Return Phase - Moment in which the maximal
left side rotation is achieved. One event should be automatically identified for each

rotation to the left (yellow
axial rotation angle of the head
7.4 Reporting phase
Results of the elaboration can be visualized in the report. In order to create a report, the
normal motion value ranges have to be provided. Depending on the age of the subject it is
possible to choose between eight normal bands: from “Cervical 20-29” to “Cervical 90-97”
(Luvoni et al., 1990; Youdas et al. 1992). A single report model is available:
 Rep_CervicalMobility: the final clinical report is structured as follows:
> Each of the first three pages is dedicated to the analysis of kinematics of a different
task. Each page contains three tables and two graphics. The tables contain information
about the number, duration (seconds), ROM (degrees) and angular velocity (degrees per
second) of the cycles:
– The first table is dedicated to the entire task cycle, e.g. the flexion-extension cycle
(flexion cycle followed by extension cycle)
– The second table is related to the positive cycle, e.g. the flexion cycle (from neutral
position to maximal flexion + return phase from maximal flexion back to the neutral
position)
– The last one is associated to the negative cycle, e.g. the extension cycle (from neutral
position to maximal extension + return phase from maximal extension back to the
neutral position).
The first graphic shows the three axial rotations of the head with respect to the trunk
(degrees VS cycle percentage): flexion-extension (purple), lateral bending (turquoise
green) and rotation (hot pink). The vertical dotted lines highlight the events (average
values) identifying the maximum rotation achieved during the positive cycle (orange)
and negative cycle (light-blue). The horizontal grey lines define the boundaries of the
normal range of motion. If the subject doesn’t have limitations and is not in pain while
moving, the curve should span the entire normal range.
78
The second graph represents the specific task angle (degrees) at angular velocity (degrees
per second). If the subject doesn’t have limitations and is not in pain while moving, the
curve should be symmetrical to the zero x-axis in all three tasks. Moreover, in case of
multiple repetitions of the same movement, the curve should be superimposable to
itself. In lateral bending and rotation tasks the curves should also be symmetrical to the
zero y-axis.
> The results of the electromyographic analysis are presented next. Two pages are
dedicated to each task:
– In the first page EMG signals filtered with a high pass and a low pass filter are shown
with respect to time (seconds). Specifically, for each cervical muscle, the right
(green) and left (red) activities are shown. The vertical brown lines define movement
transition through the neutral position, while the other vertical lines define the start
of the flexion movement (purple), or of the right bending (turquoise green) or of the
right side rotation (hot pink). The vertical dotted lines highlight the events identifying
the maximum rotation achieved during the positive cycle (orange) and during the
negative cycle (light-blue).
– The focus of the second page is on the comparison between right and left EMG
activities. The mean EMG envelopes normalized for the entire task cycle for right and
left muscles are shown. For bending and rotation tasks right muscles are normalized
on the cycle defined from the start of right side movement to the start of the following
right side movement. In the same way left muscles are normalized on a cycle starting
from the beginning of left side movement, and ending at the start of the next left
movement. For the flexion-extension task both right and left muscles are normalized
on the cycle identified from the start of flexion to the start of the next flexion movement.
Vertical dotted lines highlight the events (average values) identifying the maximum
rotation achieved during both positive (orange) and negative (light-blue) cycles. The
vertical brown line defines movement transition through the neutral position. Below
the envelope graphics, a table collects data on the relationship between average right
muscle activity and average left muscle activity in the form of percentage ratio. In
particular, activities are compared as follows:
~ Flexion Phase – activities are evaluated on the flexion cycle (the return phase is
excluded):
~ Extension Phase - activities are evaluated on the extension cycle (the return phase
is excluded):
~ Ipsilateral Phase: activities are evaluated on cycle phase of movement performed

by the muscle of interest side (the return phase is excluded):
~ Contralateral Phase: activities are evaluated on cycle phase of the movement

performed by the opposite side of the muscle of interest (the return phase is
excluded):
Muscles activity is measured through average RMS of the electromyographic signal.
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Bibliography
Ferrario V.F., Sforza C., Serrao G., Grassi G., Mossi E., 2002. “Active range of motion of the
head and cervical spine: a three-dimensional investigation in healthy young adults”. Journal
of Orthopaedic Research, Vol. 20, pp. 122-129.
Tommasi D.G., Foppiani A.C., Galante D., Lovecchio N., Sforza C., 2009. “Active head and
cervical range of motion: effect of age in healthy females”. Spine, Vol. 34, No. 18, pp. 1914-
1916.
Strimpakos N., 2011. “The assessment of the cervical spine. Part 1: Range of motion and
proprioception”. Journal of Bodywork & Movement Therapies, Vol. 15, pp. 114-124.
Luvoni R., Bernardi L., Mangili F., 1990. “Guida alla valutazione del Danno Biologico e
dell’Invalidità Permanente”, Giuffrè Editore, IV Edizione.
Youdas J.W., Garrett T.R., Suman V.J., Bogard C.L., Hallman H.O., Carey J.R., 1992 “Normal
range of motion of the cervical spine: an initial goniometric study”. Physical Therapy, Vol. 72
No. 11, pp- 770-780.
80
8. HELEN HAYES PROTOCOL ON TREADMILL
Protocol overview: the Helen Hayes protocol on treadmill is optional and can be provided
with the BTS SMART-Clinic software included in the BTS GAITLAB system. This protocol
allows the study of the kinematics of human locomotion, along with the electrical activity
produced by the muscles involved in the movement. The protocol was developed to provide
physicians with quantitative and objective data needed to analyse the walking or running
behaviour of a patient. The use of a treadmill allows the collection of large amounts of gait
or running cycles in a small volume. Because of the large amount of collectable strides in a
single treadmill trial, the auto-identification of gait events saves clinicians a significant amount
of time when processing gait data (Zeni et al. 2008; De Witt 2010). The marker set used for
this protocol was inspired by the works of M. Kadaba and R. Davis, respectively developed
at the Helen Hayes Hospital and the Newington Hospital (Kadaba et al. 1989, 1990; Davis
et al. 1991). For the definition of the femoral reference system, the recommendations of the
International Society of Biomechanics were followed (Wu et al. 2002).
Required equipment: the protocol requires the use of a treadmill and of a BTS SMART-DX
system with a minimum of 6 video cameras for the kinematic analysis. The evaluation of the
muscular activity requires the use of the BTS FREEEMG surface electromyogram.
 Anthropometric measurements: First of all, patient’s weight [kg] and height [cm] have
> ASIS breadth: identify the position of the two anterior superior iliac spines (ASIS) through
palpation. If a dermographic pencil is available, use it to mark the anatomical landmarks.
Using a pelvimeter, measure the distance between the two ASIS [cm] (Figure 1).
> Pelvis depth: locate the great trochanter. We suggest bringing the hip manually into the
maximum flexion and intra-rotation position. Realign the limb trying not to lose the
just found anatomical landmark. If a dermographic pencil is available, use it to mark
the landmark. Consider a plane passing through the great trochanter and parallel to the
table (Figure 2). With a measuring tape, measure the distance between the anterior-
superior iliac spine and the great trochanter plane (vertical distance with the patient in
supine position) [cm] (Figure 3).
81
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(right).

the table (right).
82

medial malleolus.
83
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 Markers: the protocol uses a “modified Helen Hayes marker set”, or more precisely, an
adaptation of the so called “Helen Hayes marker set” (Kadaba et al. 1989, 1990) (Figure
5). Two versions of the protocol are available. Both require the positioning of 22 spherical
markers on the subject’s body: 3 on the trunk, 3 on the pelvis, 3 on each thigh, 3 on each
shank, and 2 on each foot.

view of the “modified Helen
Hayes marker set” with medial
markers. The green markers
must be removed before
acquiring the Walking/Running
> “Treadmill Walk”: use this version if you wish to evaluate the subject’s walking behaviour.
> “Treadmill Run”: use this version if you wish to perform a running analysis.
84
satisfied.

motion, we suggest positioning
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(Figure 8).
> Foot: on the subject’s shoe, place one marker on the posterior heel (r heel – l heel)
and one marker on the tip over the distal second metatarsal (r met – l met). These two
markers must lie on the same plane. Look at the subject from a sagittal point of view
and check that the markers on the heel and on the metatarsal and are placed at the
same height and identify a line parallel to the sole of the foot (Figure 9). To obtain a
correct medial/lateral alignment, the markers must identify a line parallel to the second
metatarsal ray.

motion, we suggest positioning

86
 Electrodes: in order to evaluate the muscular electrical activity, two electrodes need to be
for the EMG analysis can be found in specific handbooks (Cram et al. 1998, Freriks et
al. 1999). During the preparation of the subject it is important to pay attention to the
In order to use this protocol, the static calibration of the system must be performed with the
calibration object placed on the treadmill mat. Depending on the size of the treadmill it may
be necessary to use a 40 cm long triad, instead of a 60 cm triad. Remember to use the same
calibration object for both axis and wand calibration. It is important to align the x-axis of the
triad (with 4 markers) along the gait direction, i.e. the long side of the treadmill.
 Standing task: the subject has to hold an orthostatic position for at least 3 - 5 seconds.
Subject’s feet must be aligned in order to avoid standing with one foot ahead or behind
the other. This task is performed on the stationary treadmill with an inclination of zero
degrees.
 Walking or Running task (depending on the selected version of the protocol): before
performing this task, medial markers on knees and ankles must be removed. A walking/
running velocity must be set on the treadmill by the operator according to the subject’s
physical condition. Acquisitions should start after the subject has reached a steady
walking/running pace on the flat treadmill. Markers placed on the subject must be fully
within field of view of the cameras during the whole acquisition.
The protocol requires a single acquisition while the subject performs the standing task and
at least one acquisition during the walking/running sequence.
subject body, we suggest verifying their correct location (see Paragraph 8.5 - “Checking the
marker location”).
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 Tracking: firstly, the markers must be tracked. Meaning that they need to be associated to
their corresponding label, on the basis of each marker’s real position, at every point in time
(Figure 10). In both protocol versions this operation is performed automatically. However,
we suggest verifying that labeling is correctly performed during the entire acquisition.
Figure 10: Marker set model

for both versions of the Helen
Hayes protocol on treadmill.
> “Proc_Treadmill_Standing”: this protocol allows a quick check of the markers position
(see Paragraph 8.5). It is used to elaborate the standing task immediately after its
acquisition.
> “Proc_Treadmill_Walk” or ”Proc_Treadmill_Run” (depending on the selected protocol

version): used to compute the kinematic parameters of walking or running tasks
respectively, as well as the electromyographic analysis.
88
 Events: for both version of the protocol, all events are automatically identified.
However, we suggest checking the correct identification of events. Methods used for
events determination in the “Treadmill_Walk” protocol differ from the ones used in the
“Treadmill_Run” protocol. For this reason the events windows are different in the two
versions of the protocol:
> eRWMAX = Right Heel Vertical Max – (only for the “Treadmill Run” version) Local
maxima in the vertical position of the right heel marker, used later by the protocol to
identify the right toe off events (Figure 11).

of the local maxima in the
vertical position of the right
heel marker (yellow ochre). In
the graph is shown the vertical
component of the position of
the right heel marker (red).
> eLWMAX = Left Heel Vertical Max – (only for the “Treadmill Run” version) Local maxima
in the vertical position of the left heel marker, used later by the protocol to identify the
left toe off events (Figure 12).

of the local maxima in the
vertical position of the left
heel marker (yellow ochre). In
the graph is shown the vertical
component of the position of
the left heel marker (red).
Treadmill Walk

Treadmill Run with the treadmill mat (yellow
ochre). In the “Treadmill Walk”
protocol, the graph shows the
anterior-posterior component
of velocity of the right heel
(red). In the “Treadmill Run”
distance between the right heel
marker and the sacrum marker
along the anterior-posterior
direction (red).
89
BTS GAITL A B
> eLHS = Left Heel Strike - Left foot initial ground contact (at least two events must be
Treadmill Walk

with the treadmill mat (yellow Treadmill Run
of velocity of the left heel
(red). In the “Treadmill Run”
distance between the left heel
marker and the sacrum marker
along the anterior-posterior
direction (red).
> eRTO = Right Toe Off – Right toes are lifted off the treadmill mat (one event between
each of the two previously defined strikes) (Figure 15)
Treadmill Walk

patient lifts his/her right toes
off the treadmill mat (yellow
of the velocity of the right
metatarsal marker (red). In
Treadmill Run
the “Treadmill Run” protocol,
the graph shows the vertical
component of the acceleration
of the right metatarsal marker
(red). The turquoise green and
violet lines represent the start
and end of the time window
within which the event is
searched for.
> eLTO = Left Toe Off - Left toes are lifted off the treadmill mat (one event between each
of the two previously defined strikes) (Figure 16).
Treadmill Walk

patient lifts his/her left toes
off the treadmill mat (yellow
of the velocity of the left
metatarsal marker (red). In Treadmill Run
the “Treadmill Run” protocol,
the graph shows the vertical
component of the acceleration
of the left metatarsal marker
(red). The turquoise green and
violet lines represent the start
and end of the time window
within which the event is
searched for.
90
If different walking/running acquisitions are loaded, several windows will open
progressively with the events identified for all trials.
8.4 Reporting phase
Elaboration results can be visualized in the report. In order to create a report, normative bands
must be provided. According to the chosen protocol, the “Treadmill_Walk” or the “Treadmill_
Run” normal band must be selected. Four report models are available:
 “Rep_Treadmill_Standing”: see Paragraph 8.5 - “Checking the marker location”.
 “Rep_Treadmill_Consistency”: it has to be selected before visualizing the final clinical

report (“Rep_Treadmill_Walk”/”Rep_Treadmill_Run”) to evaluate acquisitions consistency/
repeatability. Results of the kinetic analysis from each trial are shown in two distinct
from the subject’s characteristic pattern of gait). In the best case, where no outlier trials
are detected, as well as in case one or more trials present inconsistent deviations, the
current report should be closed. “Rep_Treadmill_Walk”/”Rep_Treadmill_Run” must then
be selected, making sure that consistent trials only, are loaded.
 “Rep_Treadmill_Walk” or “Rep_Treadmill_Run”: the final clinical report is organized in

the following way:
data. In the same page the values of the kinematic parameters measured during the
standing acquisition are reported, along with the list of acquisitions used for the
statistical analysis.
lines are green for the right limb and red for the left limb. The standing values are not
shown in the trunk graphics since its rotations, which refer to the gait reference system,
concern the standing angles.
91
BTS GAITL A B
As soon as the standing exercise is acquired, select the “Proc_Treadmill_Standing” calculation

event needs to be defined. Once processing is completed the “Rep_Treadmill_Standing”
report has to be selected. This report shows a table containing the standing angular values
next to the normative data. If the angular values are significantly out of the normality range
the following markers should be checked:
 For deviation in hip/knee angles: verify the position of the markers on the lateral and
medial condyles of the femur.
 For deviation in knee/ankle and foot progression angles: check the correct alignment of
the heel marker with the metatarsal marker. Furthermore, verify the position of the markers
on the lateral and medial malleoli.
Bibliography
Zeni J.A. Jr, Richards J.G., Higginson J.S., 2008. “Two simple methods for determining gait
events during treadmill and overground walking using kinematic data”. Gait Posture, Vol. 27,
No. 4, pp. 710-714.
De Witt J.K., 2010. “Determination of toe-off event time during treadmill locomotion using
kinematic data”. Journal of Biomechanics, Vol. 43, No. 15, pp. 3067-3069.

392.
Publishers.
92
BTS BIOENGINEERING CORP. BTS S.P.A.
147 PRINCE STREET - SUITE 10 VIALE FORLANINI 40
BROOKLYN NY 11201 USA 20024 GARBAGNATE MILANESE MI ITALY
INFO: +1 929.261.6665 TEL. +39 02.366.490.00
HELPDESK: +1 929.261.6665 FAX +39 02.366.490.24
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Analysis Protocols

BTS GAITLAB – Analysis Protocols

2. HELEN HAYES PROTOCOL (Conventional Gait Model)

3. OXFORD FOOT MODEL

4. HELEN HAYES PROTOCOL WITH BI-SEGMENTAL

6. UPPER LIMB PROTOCOL (Modified Rab)

7. CERVICAL SPINE MOBILITY PROTOCOL

8. HELEN HAYES PROTOCOL ON TREADMILL

1.1 Subject preparation

Figure 1: To evaluate the ASIS

Figure 2: To locate the great

Figure 3: To evaluate the pelvis

Figure 4: To measure the leg

Figure 5: To evaluate the knee’s

Figure 6: To evaluate the

Figure 7: Frontal and posterior

Figure 8: In order to achieve

Figure 9: The marker on the

Figure 11: For a correct

The subject is asked to perform two different tasks:

1.3 Elaboration phase

The elaboration phase includes the following steps:

> “Proc_DavisHeel+GaitIndexes”: used to compute the kinematic and kinetic parameters

> “Proc_DavisHeel+GI_AE”: the same as the “Proc_DavisHeel+GaitIndexes” but with the

> “Proc_DavisHeel+GI_AEFP”: the same as the “Proc_DavisHeel+GaitIndexes” but with

Figure 13: Example of definition

Figure 15: Example of definition

1.4 Reporting phase

 “Rep_Gait_Standing”: see Paragraph 1.5 - “Checking the marker location”.

 “Rep_Gait_Consistency”/”Rep_SimpleGait_Consistency”: it must be selected

 “Rep_Gait+GaitIndexes”/“Rep_SimpleGait+GaitIndexes”: the final clinical report is

1.5 Checking the marker location

As soon as the standing exercise is acquired, select the “Proc_Davis_Standing” calculation

1.6 Davis protocol with marker on 2nd metatarsal head

Figure 17: Frontal and posterior

Figure 18: For a correct

> “Proc_DavisHeel2+GaitIndexes”: used to compute the kinematic and kinetic parameters

> “Proc_DavisHeel2+GI_AEFP”: the same as the “Proc_DavisHeel2+GaitIndexes” but

1.6.3 Checking the marker location

2.1 Subject preparation

Figure 1: To evaluate the ASIS

Figure 2: To locate the great

Figure 4: To measure the leg

Figure 6: To evaluate the

Figure 7: Frontal and posterior

Figure 8: In order to achieve

Figure 10: The marker on the

Figure 11: For a correct

2.2 Acquisition phase

The subject is asked to perform two different tasks:

2.3 Elaboration phase

The elaboration phase includes the following steps:

Figure 12: Marker set models

> “Proc_HelenHayes_Standing”: this protocol allows a quick check of the markers

> “Proc_HelenHayes+GI_AEFP”: the same as the “Proc_HelenHayes+GaitIndexes” but

Figure 13: Example of definition

Figure 15: Example of definition

2.4 Reporting phase

 “Rep_Gait_Standing”: see Paragraph 2.5 - “Checking the marker location”.

 “Rep_Gait_Consistency”/”Rep_SimpleGait_Consistency”: it must be selected

 “Rep_Gait+GaitIndexes”/“Rep_SimpleGait+GaitIndexes”: the final clinical report is

2.5 Checking the marker location

As soon as the standing exercise is acquired, select the “Proc_HelenHayes_Standing”