Instrumented gait analysis for management of gait disorders in children with cerebral palsy: A scoping review

Highlights

• IGA (instrumented gait analysis) defined as collection of 3D kinematics during gait.

• 909 studies located investigating IGA and children with cerebral palsy.

• 49 % of studies used IGA to measure the outcome following treatment.

• 33 % of studies described subgroups, change over time, computational modeling.

• 4% (29 total) studied effectiveness of IGA in clinical decision making or treatment.

Abstract

Background

The use of Instrumented Gait Analysis (IGA) for the clinical management of individuals with cerebral palsy (CP) has increased in recent years. Previous systematic reviews have been completed to evaluate and summarize the evidence related to the efficacy of IGA in general. However, a focused summary of research studies on IGA for children with CP related gait disorders is needed.

Research Question

The purpose of the current work was to perform a scoping review to describe and categorize the range of existing literature about IGA as applied to the clinical management of children with CP related gait disorders.

Method

A health sciences librarian developed a search strategy to include four key inclusion criteria of original research study, population included children with CP, study employed IGA, available in English. The available literature was organized into six study categories: reliability and validity, documentation of subgroups or model development, IGA for clinical decision making, effectiveness of treatments that depend on IGA, cost effectiveness, IGA used to evaluate the outcome of surgical, medical or rehabilitation treatment.

Results

909 studies met the inclusion criteria and were placed into the six study categories. 14 % of studies were in reliability and validity, 33 % in subgroups or modeling, 2% in IGA for clinical decision making, 2% in treatments that depend on IGA, 1% in cost effectiveness, and 49 % of studies had IGA used as an outcome measure for treatment.

Significance

This scoping review has documented the wide range, diversity and extent of original research studies investigating the use of IGA for the clinical management of children with CP related gait disorders. The large volume of studies provides a basis for future work to develop a CPG about the use of IGA for the clinical management of children with CP related gait disorders.

Introduction

Cerebral palsy (CP) is the most common neuromotor disorder among children, with a prevalence reported as 1.8–3.2 cases per 1000 live births from several countries [[1], [2], [3], [4], [5], [6], [7], [8]]. The primary neural function disorder of CP can lead to secondary orthopedic conditions such as bony malformation and muscle contractions with both commonly leading to gait disorders. The neurologic and orthopedic impairments lead to a consistently large number of children requiring services such as physical therapy, provision of orthotics and assistive devices, and in many cases, surgical procedures addressing lower extremity structures. An important aspect of all of these treatment decisions is to understand the ongoing interaction between orthopedic, neurologic and developmental considerations related to gait. Treatment of gait issues for children with CP with such complex presentations is often greatly enhanced by careful examination of their gait patterns using instrumented gait analysis (IGA) in addition to the typical history, clinical examination, and visual observation of gait. Identifying, categorizing, and summarizing research on the clinical use of IGA for management of gait disorders associated with CP would help define the current state of IGA.

Since about 1980 [9], clinicians and researchers have used many approaches to conduct IGA, and technical innovations continue to generate more precise, more user-friendly and more cost-effective systems. A vast amount of research has contributed to these technologic developments and has led to an enormous range of approaches to measuring, modeling and otherwise analyzing complex gait disorders. Unfortunately, little evidence-based guidance exists to help clinicians involved in the management of gait disorders in children with CP determine which features of IGA are most critical. Hence, this review is designed to provide direction to clinicians and researchers by describing and organizing the available research literature about the use of IGA for clinical management of children with CP related gait disorders.

As a result of extensive technological developments, a wide variety of instrumentation and data collection protocols exist to evaluate gait dysfunction. Multiple strategies exist for calculating 2-dimensional (2D) and 3-dimensional (3D) joint kinematics including video-based systems (e.g. marker-based and markerless) and the use of wearable sensors. Joint kinetics are often calculated using force platforms/transducers embedded in a walkway or inserting force transducers in shoes and orthotics. For purposes of this review, we define IGA as, at minimum, the collection of 3D kinematics (rotations of multiple joints and segments) recorded during gait activities. Kinematics can be calculated using optoelectronic marker systems as well as inertial and magnetic measurement systems (IMUs and IMMS) as long as multiple joints or segments are tracked in three dimensions. We also consider how 3D kinematics are used in conjunction with other common tools such as clinical examination, force platforms, electromyography (EMG), body worn sensors, along with novel data reduction/analysis techniques that facilitate the integration of IGA information into clinical decision making.

Given our definition, IGA may range from an assessment focused solely on lower extremity kinematics to a more extensive workup using physical exam, spatio-temporal measures of gait, EMG recordings of multiple muscles plus measurement of ground reaction forces, body worn sensors, and ventilatory gasses. Currently, IGA is most likely to be performed in a facility with a dedicated laboratory staffed by a highly trained interdisciplinary team. Often times this team will include a biomedical engineer to run the technical aspects of data collection, analysis and modeling, a pediatric physical therapist to work with the child during the testing, development of treatment plans, and ongoing rehabilitation, plus appropriate medical professionals to consider and administer medical treatment and orthopedic or neurologic surgeries. Many additional disciplines can be involved including kinesiology, orthotics/prosthetics, neurology, physical medicine, and others.

Research evidence evaluating the clinical utility of IGA has included a limited number of previous systematic reviews. In 2011 and 2020, Wren and colleagues performed systematic reviews focusing on the efficacy of IGA for management of gait disorders in a wide array of populations [10,11]. Those reviews included studies that encompassed any condition associated with gait disorders such as CP, spina bifida, clubfeet, and multiple sclerosis, studies that focused only on typically developing children with no gait disorders, as well as all age groups. They found strong evidence of technical accuracy, diagnostic accuracy, diagnostic thinking and treatment efficacy for clinical gait analysis without restriction to a particular population. They also suggested that future research was needed to determine efficacy at the levels of clinical outcomes and societal benefit. Benedetti et al. published a position paper on clinical gait analysis in 2017 using an evidence-based consensus methodology [12]. They addressed three main areas related to IGA: 1) General issues and management, 2) methodology and instrumentation, and 3) clinical appropriateness. They concluded that there was sufficient methodological literature available involving individuals with CP to recommend IGA as a clinical or diagnostic tool. They also determined that for patients with CP, IGA combined with clinical evaluation leads to modifications in treatment decisions and improvements in surgical outcomes. However, they reported that the influence on outcomes of non-surgical treatments using IGA was less clear. McGinley and colleagues partially addressed the clinical surgical outcomes by conducting a systematic review about single event multi-level surgery (SEMLS) for children with CP related gait disorders [13]. Generally, SEMLS is performed after IGA is conducted as the IGA results can help determine which specific soft-tissue or bony surgical procedures should be performed. While focused on evaluating SEMLS, McGinley and colleagues concluded that IGA advances the effectiveness of SEMLS by providing reliable and precise measures of specific gait outcomes that are associated with improvements in participation and function.

Published systematic reviews have also considered the reliability and validity of a wide array of tools for measuring clinical gait disorders, however many of these reviews have used IGA as the reference standard upon which to validate other tools. For example, Rathinam and colleagues evaluated the reliability and validity of clinical tools (for example, Edinburgh Visual Gait Score) for pediatric gait analysis by comparing them to IGA [14]. This approach reflects a common judgement that IGA provides the most accurate and objective method available for documenting kinematic, kinetic and electromyographic components of gait performance.

Previous evidence-based reviews have provided preliminary guidance on the use of IGA for management of children with CP related gait disorders. An initial assessment of the full scope of literature on IGA suggests however that studies about IGA encompass a large range of measurement and analytic techniques while only a small number of studies directly evaluate the clinical utility of IGA [[10], [11], [12]]. Given some ambiguity about how to investigate the applicability of the entire range of IGA to clinical management, we present our initial assessment of the IGA literature as a scoping review, with a long-term goal of developing clinical practice guidelines (CPG) useful to a range of clinicians. A scoping review is a distinct approach to knowledge synthesis with an aim “to summarize a range of evidence in order to understand broadly what is known about a phenomenon” [15]. Scoping reviews are often used when a body of literature is not sufficiently homogenous to analyze via a systematic review process. Some common goals of scoping reviews are to, “to examine the extent, range and nature of research activity” and “to identify research gaps in the existing literature” [16], though additional goals have also been suggested [17].

Given all of these considerations, the current scoping review aims to identify, categorize, and summarize available research evidence on the clinical use of IGA for management of gait disorders associated with CP. This is undertaken to enhance the clinical understanding and treatment of gait disorders in children with CP. Results of this scoping review should assist clinicians in collaborating with IGA personnel, interpreting IGA results, and applying IGA findings to future rehabilitation, medical and surgical plans for children with CP related gait disorders.