The GAITRite Portable Walkway System Footprints You See

Why Measure Gait “During walking, more than 1000 muscles are synchronized to move over 200 bones around 100 moveable joints. Gait adaptation as seen in the elderly population may be associated with the general decrease in muscle strength due to loss of motor neurons, muscle fibers and aerobic capacity…Even if walking is considered a very complex task, a healthy person walking at self selected velocity, performed this task at a minimal energy cost. ” Francois Prince, Hélène Corriveau, Réjean Hébert, David A. Winter “ Review Article - Gait in the elderly” Gait and Posture, Pages 128 -135, May 1997 “A decline in economy of mobility indicates that more physical work is required for a task (i. e. walking) and may suggest an abnormal gait pattern. A normal gait pattern is essential for maintaining independence in older adults. ” Michael J. Davies, MS; Gail P. Dalsky, Ph. D. , “Economy of Mobility in Older Adults” JOSPT Volume 26, Number 2, August 1997 © 2010 CIR Systems, Inc.

Why Measure Gait (Continued) “Walking is one of the most common of all human movements… Falls are a major cause of morbidity in the elderly and in almost all incidences of falls, some aspects of locomotion have been implicated. With the increased life expectancy of the elderly and their more active lifestyle there is now an emphasis on determining any changes that occur in their gait patterns in order to reduce the frequency of falls, to identify diagnostic measures that are reliable predictors of fall-prone elderly and finally to develop programs for preventing such falls. ” Francois Prince, Hélène Corriveau, Réjean Hébert, David A. Winter “ Review Article - Gait in the elderly” Gait and Posture, Pages 128 -135, May 1997 © 2010 CIR Systems, Inc.

Functional Measures Over Time (9 Tests) Velocity Consistent, Steady Gait Left Step Length Right

Health Status Change Over Time (9 Tests) Velocity WHY? Left Big Decrease in Gait

The Problem “There is a defined need for objective measurement of gait because without it the quality of treatment decisions is reduced because of the subjective and often unreliable nature of the assessment. Objective measures must also be employed if one is to demonstrate the efficacy of a treatment protocol, a function that will become increasingly important as health care resources become more strained and health care providers are held more accountable. . . Gait assessment is an everyday responsibility for the practicing therapist. Visual assessment, which is almost universally used for this purpose, has been shown to be unreliable at best. Measurement of the temporal and distance factors of gait have been found to be clinically useful. ” James C. Wall, Ph. D. , Denis Brunt, PT, Ed. D. ; Chapter 17, Clinical Gait Analysis: Temporal and Distance Parameters. Assessment in Occupational Therapy and Physical Therapy edited by J. V. Van Deusen, 1996 © 2010 CIR Systems, Inc.

The Solution GAITRite effortlessly provides valid and reliable measurements in real-time, such as: cadence, step length, velocity and many other important gait parameters! Now you can objectively quantify functional ambulatory status and document treatment outcomes by incorporating GAITRite into your clinical evaluations. © 2010 CIR Systems, Inc.

What is the GAITRite System? • The GAITRite system automates measuring temporal (timing) and spatial (distance) gait parameters via an electronic walkway connected to the USB port of a Windows® XP/Vista/7 personal computer. • The standard GAITRite electronic walkway contains eight sensor pads encapsulated in a roll up carpet to produce an active area 24 inches (61 cm) wide and 192 inches (488 cm) long. In this arrangement the active area is a grid, 48 sensors by 384 sensors placed on. 5 inch (1. 27 cm) centers, totaling 18, 432 sensors. The walkway is portable, can be laid over any flat surface, requires minimal setup and test time, and requires no placement of any devices on the patient. © 2010 CIR Systems, Inc.

Walkway connections © 2010 CIR Systems, Inc.

How does GAITRite work? • As the patient ambulates across the walkway, the system captures the geometry and the relative arrangement of each footfall as a function of time. The application software controls the functionality of the walkway, processes the raw data into footfall patterns, and computes the temporal (timing) and spatial (distance) parameters. The software’s relational database stores tests individually under each patient, and supports a variety of reports and analyses. • Testing patients with or without shoes, including those patients using assistive devices and ambulatory aids such as: crutches, walkers, or canes. In addition, testing patients pre- and post-treatment is quickly, and easily performed when utilizing this versatile and ingenious measurement tool. © 2010 CIR Systems, Inc.

The GAITRite in Action Roll it up…take it with You! © 2010 CIR Systems,

Consistent and Reliable Data In the above graphical mock-up, the footfall patterns are almost

Footfalls - Close-up Right Foot Left Foot Pressure Level 1= lowest 2 Color 3

One Completed Walk See the next two slides for parameter definitions © 2010

Temporal (Timing) Parameters • 1) Step Time is the time elapsed from the first contact of one foot to the first contact of the opposite foot. • 2) Gait Cycle is the elapsed time between the first contact of two consecutive footfalls of the same foot. • 3) Ambulation Time is the time elapsed between the first contacts of the first and the last footfalls. • 4) Velocity is obtained after dividing the Distance by the Ambulation time. • 5) Mean Normalized Velocity is obtained after dividing the Velocity by the Average Leg Length and it is expressed in leg length per second (LL/sec). The average Leg Length is computed (left leg length + right leg length)/2. • 6) Single Support time is the time elapsed between the Last Contact of the current footfall to the First Contact of the next footfall of the same foot. This is equal to the Swing Time of the opposite foot. • 7) Double Support is the time elapsed between First Contact of the current footfall and the Last Contact of the previous footfall, added to the time elapsed between the Last Contact of the current footfall and the First Contact of the next footfall. • 8) Stance Time is the time elapsed between the First Contact and the Last Contact of two consecutive footfalls on the same foot. It is also presented as a percentage of the Gait Cycle of the same foot. • 9) Swing Time is the time elapsed between the Last Contact of the current footfall to the First Contact of the next footfall on the same foot. It is also presented as a percentage of the Gait Cycle of the same foot. The Swing Time is equal to the Single Support time of the opposite foot. © 2010 CIR Systems, Inc.

Spatial (Distance) Parameters • 1) Step Length is measured on the horizontal axis of the walkway from the heel point of the current footfall to the heel point of the previous footfall on the opposite foot. The step length can be a negative value if the patient fails to bring the landing foot heel point forward of the stationary foot heel point. • 2) Stride Length is measured on the line of progression between the heel points of two consecutive footfalls of the same foot (left to left, right to right). • 3) Step/Extremity Ratio is Step Length divided by the Leg Length of the same leg. • 4) Toe In / Toe Out is the angle between the line of progression and the line connecting the heel point to the forward point of the footfall. This angle is reported positive for toe out and negative for toe in. • 5) H-H Base of Support is the perpendicular distance from heel point of one footfall to the line of progression of the opposite foot. • 6) Distance is measured on the horizontal axis from the heel point of the first footfall to the heel point of the last footfall. © 2010 CIR Systems, Inc.

All data fields can be exported in comma delimited ASCII format © 2010 CIR

I use GAITRite because. . . “The Functional Ambulation Performance score (FAP) that’s part of the GAITRite, gives me a single objective number that allows me to quickly and easily track my patients progress. The FAP is a valid and reliable clinical measure that identifies asymmetries and deviations from normal time and distance values. On many occasions, I have successfully petitioned HMO and compensation carriers for continued care based on the GAITRite data. My clinical practice includes both adult and pediatric orthopedic and neurological patients. By integrating objective gait measures into my evaluations and daily operations, I gain tremendous insight into understanding and treating the underlying cause of my patient’s dysfunction. ” Arthur J. Nelson, Ph. D. , PT; FAPTA — Staten Island, NY © 2010 CIR Systems, Inc.

Compare Two Conditions Heel Toe Left Foot Without Orthotics Toe Without Orthotics High Pressure/Less Control Toe With Orthotics High Pressure/Less Control Heel Lower Pressure/More Control Right Foot Heel Toe With Orthotics Lower Pressure/More Control © 2010 CIR Systems, Inc.

Normals. . Reports. . Narratives • Each parameter is deemed within or outside of the normal range. • The normal range has been extracted from documented peerreviewed scientific literature, as well as from the GAITRite database. • Numerous client-specific normal databases can be created and compared against. • The coefficient of variation is checked to validate data consistency. • The results of these comparisons can be viewed on the computer monitor or printed in conjunction with a narrative report. • These parameters can be tracked over time to produce progress and status reports. © 2010 CIR Systems, Inc.

Quick Comparison Report Test 1 Test 2 Numerical Change Symmetry Change vs Normal Range

Example: Injured Right Knee 10% increase in left single support time (should be equal) Increased left stance percentage of gait cycle (should be around 60%) In the example above, a patient was tested on the GAITRite prior to right knee surgery. All values outside of the normal range are noted with a red arrow. The results are consistent with the patient not applying weight on his right leg due to the pain caused by a torn right meniscus (cartilage). Instead of moving straight across the walkway, he see-sawed up and down in an inefficient gait © 2010 CIR Systems, Inc. pattern.

Comparison To Normal Chart (Continued) Symmetrical Asymmetrical Individual footfall values and coefficient of variation are presented in the above chart. The normal range for the variable is highlighted in teal, while the actual bilateral value for the variable is identified as a vertical line. © 2010 CIR Systems, Inc.

Example: Injured Right Knee (Continued) At the footfall level, the footfall transition line illustrates that the patient rocked backwards (due to pain) during his right step, as indicated by the “Z” -like pattern. © 2010 CIR Systems, Inc.

Footfall Timing (Continued) Averaged left heel contact time = 590 ms, which is 49% of gait cycle Unloading - Toe Contact Loading - Heel Contact Averaged right heel contact time = 394 ms, which is 33% of gait cycle Clearly, the heel contact times/lines are much shorter for the right foot. The patient unloaded his right heel significantly quicker than his left heel. He wanted to get his injured right leg off the ground as fast as possible. © 2010 CIR Systems, Inc.

Example: Elderly Ambulator 56 year old male, 3 months post stroke, right side affected Wide base of support (should be +/- 20 cm for him ) and prolonged stance phase (norm = +/- 60%) Very slow (norm = +/- 130 cm/s) © 2010 CIR Systems, Inc.

Short Steps, Slow Times, Numerous Asymmetries (Continued) Total symmetry means that L/R vertical lines are on top of each other. Colored boxes indicate normal range for each variable. © 2010 CIR Systems, Inc.

Individual Footstep Information Left foot is driving their gait; right side is along for

Falls The frail elderly individual is prone to accidents and trauma of many types. The most costly injury to this group is the accidental fall. Falls account for as much as 71 percent of the total costs of all injuries for the population over the age of 60. One especially serious complication of accidental falls is hip fractures. Rizzo, John A. , et al. Health Care Utilization and Costs in a Medicare Population by Fall Status. Medical Care August 1998; 36(8): 1174 -1188. © 2010 CIR Systems, Inc.

Characteristics Associated With Falls As individuals age, they become prone to accidental falls and fall-related injuries. Factors that contribute to these falls are decreased vision, loss of flexibility and muscle tone, and environmental factors such as rugs and stairs. Almost one-third of community-dwelling elderly fall each year and over half of long term care residents fall. Around half of those who fall will fall again. . . This study was conducted in Finland to determine characteristics associated with falls in the Finnish population over the age of 50. . . Results indicated a 284 percent increase in fall-related injuries over a twenty-five year period. The authors suggest preventive measures are necessary to deal with this continuing increase in injury rate. Kannus, Pekka, et al. Fall-Induced Injuries and Deaths Among Older Adults. JAMA May 26, 1999; 281(20): 1895 -1899 © 2010 CIR Systems, Inc.

Gait Changes - Fear - Risk of Falls "Of all the gait measures, the single best predictor of falling was stride-to-stride variability in velocity. Using this predictor, fallers and non-fallers were classified at an accuracy of 71%, similar to the results achieved using the postural-sway measure that was identified as the best predictor in previous analyses…Combination of the sway and gait measures in a single logistic model led to a small but statistically significant improvement in predictive accuracy (73%). Variability in speed was also the single best predictor of falling while walking (65% accurate). For these falls, inclusion of a second gait measure - variability in stride width - in the logistic model significantly improved the predictions (75% accurate); however, inclusion of the postural-sway measure failed to provide any additional benefit. ” Maki, Brian E. , Ph. D. , “Gait Changes in Older Adults: Predictors of Falls or Indicators of Fear? ” J Am Geriatric Society 45: 313 -320, 1997 © 2010 CIR Systems, Inc.

Gait Changes - Fear - Risk of Falls (continued) The present results have some important practical implications for clinicians. In terms of identifying high-risk individuals, measures of stride-to-stride variability show promise as a screening tool, at least for ambulatory patients, providing predictive accuracy similar to the postural-sway measure found to be the best predictor of falling in an earlier study. Although variability in velocity was the single best predictor of falling, variability in double -support time was also a strong predictor and has the advantage of requiring only temporal (e. g. , footswitch) data; hence, it may be more feasible in some clinical settings. It seems clear from the present results that it is essential to have a measurement system that can record stride-to-stride changes; determination of an average speed of gait (or stride length) or visual assessment of performance is unlikely to be very successful in predicting falling in a moderately mobile older population. Maki, Brian E. , Ph. D. , “Gait Changes in Older Adults: Predictors of Falls or Indicators of Fear? ” J Am Geriatric Society 45: 313 -320, 1997 © 2010 CIR Systems, Inc.

GAITRite Measures These Parameters And Many Other Important Gait Characteristics Double-support time Stride velocity

Gait Changes - Fear - Risk of Falls (concluded) “Measurement of stride-to-stride variability may also be useful in evaluating or monitoring interventions aimed at improving balance and gait. Future studies should address whether the variability in gait, and the associated risk of falling, is amenable to change through specific interventions such as gait or balance training, changes in footwear, or use of assistive devices or sensory aids. " Maki, Brian E. , Ph. D. , “Gait Changes in Older Adults: Predictors of Falls or Indicators of Fear? ” J Am Geriatric Society 45: 313 -320, 1997 © 2010 CIR Systems, Inc.

Falls Predict Nursing Home Admission According to a study by researchers at Yale University School of Medicine, falls and injuries caused by falls are strong predictors of long term placement in a nursing facility for community-living older persons. The study, published in this week's New England Journal of Medicine, found that even a single fall without injury offered almost five times greater risk of admission to a nursing facility. Researchers examined 1, 103 people over 71 years old living in the New Haven, CT, community during a three-year period. A total of 133 study participants had longterm admissions to nursing facilities in the study period. The risk of admission for those who suffered one noninjurious fall was 4. 9 times greater than those in the study sample with no falls. Those who experienced multiple noninjurious falls had an 8. 5 times greater risk, while those who suffered at least one fall causing serious injury had a 19. 9 times greater risk. Today's Gazette October 29, 1997. Section: Health © 2010 CIR Systems, Inc.

Falls - Psychoactive Medications There are several risk factors contributing to the incidence of accidental falls in nursing facility residents. Dementia, arthritis, incontinence, stroke, use of some medications, and irregular gait and balance problems are good indicators of and contributors to falls in facilities. One suggestion to reduce the number of falls has been the creation of a fall risk assessment for residents. Incorporating psychoactive medications in this assessment is important…The study was conducted by a consultant pharmacist on 182 residents in one nursing facility. Initially, the rate of falls ranged between one fall and 19 falls per resident. Medications were implicated as a contributor in 257 falls in 83 residents. Alternative drug therapy recommendations were made in several cases. In the group for whom recommendations were accepted, the number of falls was reduced from 91 to 13 over the study period. Results indicate that falls were reduced when pharmacotherapy change recommendations were accepted during the one-year study period. Cooper, James. Consultant Pharmacist Assessment and Reduction of Fall Risk in Nursing Facilities. The Consultant Pharmacist November 1997; 12(11): 1294 -1304. © 2010 CIR Systems, Inc.

Costs - Psychoactive Medications. . . Eighty-three residents had 257 falls in which medications were a contributing factor. In 57 residents, 195 falls were attributed to psychotropics. There were 97 fall-related injuries with this group. In 62 falls, 27 injuries were attributed to psychoactives that were non-psychotropic in nature. The costs of all falls averaged $754 per fall. Those falls associated with psychotropics averaged $858 and those associated with psychoactives averaged $427 per fall. Falls were reduced from 91 to 13 when recommendations of alternative pharmacotherapy were accepted. This lead to a possible cost savings to the facility of $58, 812 for the year (using a figure for a reduction of 78 falls at a cost of $754 per fall). Cooper, James. Consultant Pharmacist Assessment of Psychoactive Fall Injury Incidence and Costs Within the Nursing Facility. The Consultant Pharmacist November 1997; 12(11): 1305 -1309. © 2010 CIR Systems, Inc.

GAITRite Documents Compensation Patterns “One of the most powerful features of the GAITRite is its ability to simultaneously measure both step time and step length. Muscle weakness, pain or limb shortening, may lead to reduction in stance time on the affected side. To compensate, patients either reduce their step time which in turn reduces their step length, or they increase their joint angular velocity without reducing their step length. In essence, the patient moves faster in a shorter period of time. Visual inspection of these compensation patterns just isn’t accurate. With my GAITRite, I can objectively measure if there is compensation for a gait abnormality. ” Anil Bhave, PT — Rubin Institute For Advanced Orthopedics © 2010 CIR Systems, Inc.

Example: Left Spastic Equinovarus Deformity © 2010 CIR Systems, Inc.

Left Spastic Equinovarus Deformity (Continued) Poor Heel Contact Good Heel Contact © 2010 CIR

Example: Right Transtibial Amputee R Flex-Foot L ü Increased stance time and single support time (as a % of the gait cycle) on the sound side ü Decreased swing time on the prosthetic side ü Narrow base of support ü Overall symmetry for many other parameters ü Efficient footfall transitions for both feet © 2010 CIR Systems, Inc.

Example: Right Transfemoral Amputee The subject was asked to walk at a fast pace. Several asymmetries are evident, most notably there was a 9 cm step length differential. In the footfalls to the right, notice the differences in heel strike, transition center and toe off transition on the right. © 2010 CIR Systems, Inc.

Example: Right Transfemoral Amputee (Continued) © 2010 CIR Systems, Inc.

Walkway Specifications (16 -Foot Platinum) GAITRite Platinum 16' Portable Walkway System Overall Dimensions: 228 x 35. 5 x. 25 inches (L x W x H) Active Area: 192 x 24 inches (L x W) Weight: 55 lbs. for this model (65 lbs. with wheeled carrying case) Sampling Rate: 60 Hz, 120 Hz, 180 Hz and 240 Hz Communications: USB Sensor: . 4 inches square, dual control Number of Sensors: 18, 432 sensors, placed on. 5 inch centers arranged in a 48 x 384 grid Power Requirements: 12 Vdc Top Cover: Vinyl with square thread reinforcement, waterproof and chemical resistant Bottom Cover: Open cell foam rubber BNC synch out - Synchronize to other devices; Analog-in and integrated metronome circuit GAITVideo software + USB Camera (merge digital video files w/ GAITRite footfall replay); Includes 2 years of warranty. © 2010 CIR Systems, Inc.

In Summary • Peer-reviewed scientific literature cites gait function as an important outcome measure. Numerous injuries, illnesses and drug interactions may contribute to gait deviations and falls. • Measuring and tracking walking function can help keep people independent longer, while significantly reducing medical costs. • GAITRite can become an indispensable part of your day to day operations because it will aid you in: Documenting gait patterns prior to any intervention Measuring functional ambulation immediately after treatment/intervention Documenting that intervention did or did not have a carry-over effect Matching objective gait parameters with subjective findings Refining proper alignment and fit of prosthetics & orthotics Selecting the appropriate assistive device Justifying reimbursement for services rendered and/or for continuance of care • So many other ways, that they all can’t be mentioned here! • • © 2010 CIR Systems, Inc.

What’s Next? Contact: GAITRite - CIR Systems, Inc 60 Garlor Drive Havertown, PA 19083

Plotting Measurements over Time – Bringing Clarity to Functional Measurements Michael Rowling, Vice-President GAITRite - CIR Systems, Inc 60 Garlor Drive Havertown, PA 19083 www. gaitrite. com 610. 449. 4879 © 2010 CIR Systems, Inc.

GAITRite is ideal for: • Establishing baseline function • Documenting gait patterns pre/post intervention • Matching objective gait parameters with subjective findings • Refining alignment and fit for prosthetics and orthotics • Justifying decisions for devices/services provided • Helping patients understand their problem © 2010 CIR Systems, Inc.

Walking a Fine Line… © 2010 CIR Systems, Inc.

Can you tell the walks apart? © 2010 CIR Systems, Inc.

Temporospatial Parameters © 2010 CIR Systems, Inc.

Plotting Measurements Over time • Several important things happen when you plot data over time. First you have to ask… – What data to plot? – Where are the data? – What do they mean? – To whom? – Who should see them? – Why? • These are questions that integrate and clarify aims and systems all at once. © 2010 CIR Systems, Inc.

Real-Time Results • Second you get a leg up on improvement. • When important indicators are continuously monitored, it becomes easier and easier to study the effects of innovation in real time, without the deadening delays of setting up measurement systems or obsessive collections during baseline periods of time. • Tests of change get simpler to interpret when we use time as a teacher. • The plot over time is a powerful supplement to the randomized trial. • Pick a measurement that you care about and begin to plot it regularly over time… you won’t be sorry. © 2010 CIR Systems, Inc.

Why is Gait so Important? • Outcome measures… evidence based medicine… these are today’s buzzwords. What do they really mean, and are they actually being deployed? • The ability to walk is an extremely functional task, and when this ability is compromised, there often is a loss of independence or the need for an assistive device or ambulatory aid, such as a cane or walker. • When evaluating people with gait impairments and disabilities in the clinical setting, subjective descriptions fail to provide the clinician with any quantifiable evidence that can be readily communicated. © 2010 CIR Systems, Inc.

Why is Gait so Important? • Therefore, it is vital to quantify these gait

Agreement Between the GAITRite Walkway System and a Stopwatch–Footfall Count Method for Measurement of Temporal and Spatial Gait Parameters • “MEASUREMENTS OF TEMPORAL and spatial gait parameters are commonly used by rehabilitation professionals to identify gait deviations, to screen elderly people for risk of falling, to monitor patient progress, and to determine the effectiveness of therapy interventions. The GAITRite analysis system is a popular computerized walkway system for the quantification of temporal and spatial gait parameters. The standard system is a portable, carpeted electronic walkway embedded with pressure sensors that detect a series of footfalls. The walkway is connected to a personal computer with application software that calculates the temporal and spatial gait parameters. Recently, numerous investigators have examined the validity and reliability of the GAITRite system. © 2010 CIR Systems, Inc. James W. Youdas, PT, MS, John H. Hollman, PT, Ph. D, Monica J. Aalbers, MPT, Holly N. Ahrenholz, MPT, Rebecca A. Aten, MPT, Joseph J. Cremers, MPT Arch Phys Med Rehabil 2006; 87: 1648 -52

Agreement Between the GAITRite Walkway System and a Stopwatch–Footfall Count Method for Measurement of Temporal and Spatial Gait Parameters • The GAITRite has shown high levels of concurrent validity for obtaining measurements of temporal and spatial parameters when compared with (1) a 6 -camera motion analysis system (Vicon 512), (2) a single-camera video-based system (Peak Performance 3. 1), (3) a Clinical Stride Analyzer composed of a pair of insoles inserted within a subject’s shoes, (4) a paper -and-pencil method, and (5) a standard video camera. Furthermore, investigators have quantified the test–retest reliability of temporal and spatial parameters obtained with the GAITRite over a 2 -week period, over a 1 -week period, over a 24 -hour period, and on the same day. These repeated measurements were highly reliable, indicating there is minimal error variation associated with the measurement of temporal and spatial parameters when using the GAITRite system. © 2010 CIR Systems, Inc. James W. Youdas, PT, MS, John H. Hollman, PT, Ph. D, Monica J. Aalbers, MPT, Holly N. Ahrenholz, MPT, Rebecca A. Aten, MPT, Joseph J. Cremers, MPT Arch Phys Med Rehabil 2006; 87: 1648 -52

Agreement Between the GAITRite Walkway System and a Stopwatch–Footfall Count Method for Measurement of Temporal and Spatial Gait Parameters • DATA ANALYSIS: . . . to quantify a clinically significant difference between the methods for the 3 temporal and spatial parameters, we calculated the minimal detectable change (MDC), or the minimal amount of change not likely to be attributed to chance variation in a measurement. DISCUSSION: . . . Unlike the GAITRite system, the stopwatch– footfall count technique will not provide a clinician with information about symmetry between the right and left sides during the gait cycle. © 2010 CIR Systems, Inc. James W. Youdas, PT, MS, John H. Hollman, PT, Ph. D, Monica J. Aalbers, MPT, Holly N. Ahrenholz, MPT, Rebecca A. Aten, MPT, Joseph J. Cremers, MPT Arch Phys Med Rehabil 2006; 87: 1648 -52

Agreement Between the GAITRite Walkway System and a Stopwatch–Footfall Count Method for Measurement of Temporal and Spatial Gait Parameters • CONCLUSION: This study showed that the stopwatch–footfall count method is valid for estimating walking speed on the basis of MDC in a group of healthy participants walking at their selfselected speeds. Clinicians who require the precise measurement of cadence and stride length should consider using the GAITRite system as opposed to the stopwatch–footfall method. ” © 2010 CIR Systems, Inc. James W. Youdas, PT, MS, John H. Hollman, PT, Ph. D, Monica J. Aalbers, MPT, Holly N. Ahrenholz, MPT, Rebecca A. Aten, MPT, Joseph J. Cremers, MPT Arch Phys Med Rehabil 2006; 87: 1648 -52

Spatio-Temporal Clinical Guidelines • Quantifying spatio-temporal gait parameters in stationary and ambulatory geriatric settings may aid the early identification of potential fallers, as well as the documentation of illness-specific gait disorders and intervention-related changes in rehabilitative medicine. Bringing gait analysis out of the laboratory and into a clinical setting is the goal of the European GAITRite network group, initiated in 2003 in Geneva. To enhance reproducibility of gait measures and for better comparability of outcomes in clinical environments, a consensus on data collection was formulated and presented at the 2 nd European GAITRite Meeting in Marseilles. • Jennifer Anders, Hamburg, Germany; Olivier Beauchet, St. Etienne, France; Veronique Feipel, Brussels, Belgium; Ellen Freiberger, Erlangen, Germany; Thomas Fruehwald, Vienna, Austria; Claudine Geser, Zurich, Switzerland; Jorunn Helbostad, Trondheim, Norway; Inger Holm, Oslo, Norway; Michael Jamour, Ehingen, Germany; Reto W. Kressig, Geneva, Switzerland; Ulrich Lindemann, Stuttgart, Germany; Lillemor Lundin-Olsson, Umea, Sweden; Rolf Moe. Nilssen, Bergen, Norway; Katharina Pils, Vienna, Austria; Tischa Van der Cammen, Rotterdam, The Netherlands; Marianne Van Iersel, Nijmegen, The Netherlands © 2010 CIR Systems, Inc. Kressig RW, Beauchet O; European GAITRite Network Group Aging Clin Exp Res. 2006 Apr; 18(2): 174 -6

Environmental Measure Conditions and safety Issues • Light • Measurements should be performed in a reproducible, well-lit environment. Indirect lighting is preferable, as are intensity-controlled artificial light and the capacity to control for changing day-light conditions by covering windows with black-out shades. • Noise and visual distraction • Data collection in a quiet, preferably closed room, with no auditory or visual interference for participants, is recommended • Clothing and footwear • Clothing should be comfortable and non-restrictive. Participants should be allowed to walk in their own footwear. Appropriate types of footwear include closed walking shoes (no slippers), with heel height not exceeding 3 cm (12). For follow-up gait analyses, we highly recommend using the same footwear as worn at baseline. • Safety • Depending on participants’ fall risk, we recommend safety measures such as a safety-belt around the participant’s waist for easy grabbing by an observer in case of an imminent fall. © 2010 CIR Systems, Inc.

Measurement Procedures • Steady-state gait at different velocities • We recommend measuring steady-state gait at different gait speeds, preferably in randomized order (i. e. , slow, normal, fast), which allows for normalization of gait data for speed. True steady-state gait can be observed by starting data collection after two complete gait cycles. • Standardized walking instructions • We suggest the use of simple, clear, standardized walking instructions to explain the various tasks to participants, i. e. , “Please start walking at your usual speed towards the cone, now!”, “Please start walking as fast as possible, without running or taking risks, towards the cone, now!” or, “Please start walking slowly, as if you were waiting for the bus, towards the cone, now!”. • Assistive devices • We recommend allowing participants to use their own glasses and hearing aids, if worn. we suggest either including only participants without assistive devices, or specifically describing the type of assistive device participants used in the study. © 2010 CIR Systems, Inc.

Measurement Procedures • Stride-to-stride variability • In order to evaluate stride-to-stride variability, we recommend the highest possible number of gait cycles from a practical standpoint, with a minimum of three consecutive gait cycles for both left and right sides (i. e. , a total of six gait cycles). • Gait analysis in association with simultaneous cognitive tasks • For dual-tasking in association with walking, we suggest commonly used and validated cognitive tasks such as counting backwards from 50 out loud, and a verbal fluency task such as enumerating as many animal names as possible • Description of study population • In studies of gait performance in older individuals, we suggest describing or categorizing older participants with a frailty classification (i. e. , Fried, et al. 2001) and/or by their living condition (e. g. , community dwelling, sheltered housing, geriatric hospital, long term care etc. ). © 2010 CIR Systems, Inc.

Quantitative Gait Markers and Incident Fall Risk in Older Adults • Background. Identifying quantitative gait markers of falls in older adults may improve diagnostic assessments and suggest novel intervention targets. © 2010 CIR Systems, Inc. Joe Verghese , Roee Holtzer , Richard B. Lipton , and Cuiling Wang J Gerontol A Biol Sci Med Sci Accepted January 7 , 2009

Quantitative Gait Markers and Incident Fall Risk in Older Adults • Methods. We studied 597 adults aged 70 and older (mean age 80. 5 years, 62% women) enrolled in an aging study who received quantitative gait assessments at baseline. • Association of speed and six other gait markers (cadence, stride length, swing, double support, stride length variability, and swing time variability) with incident fall rate was studied using generalized estimation equation procedures adjusted for age, sex, education, falls, chronic illnesses, medications, cognition, disability as well as traditional clinical tests of gait and balance. © 2010 CIR Systems, Inc.

Quantitative Gait Markers and Incident Fall Risk in Older Adults • Results. Over a mean follow-up period of 20 months, 226 (38%) of the 597 participants fell. • Mean fall rate was 0. 44 person-year. • Slower gait speed (risk ratio [RR] per 10 cm/s decrease 1. 069, 95% confidence interval [CI] 1. 001 – 1. 142) was associated with higher risk of falls in the fully adjusted models. • Among six other markers, worse performance on swing (RR 1. 406, 95% CI 1. 027 – 1. 926), double-support phase (RR 1. 165, 95% CI 1. 026 – 1. 321), swing time variability (RR 1. 007, 95% CI 1. 004 – 1. 010), and stride length variability (RR 1. 076, 95% CI 1. 030 – 1. 111) predicted fall risk. • The associations remained significant even after accounting for cognitive impairment and disability. © 2010 CIR Systems, Inc.

Quantitative Gait Markers and Incident Fall Risk in Older Adults © 2010 CIR Systems,

Quantitative Gait Markers and Incident Fall Risk in Older Adults • • Although gait may be a marker for fall risk factors such as age, illness, or frailty, our results suggest that our gait markers are also directly involved in fall mechanisms. Increased stride length and swing time variability were the most robust predictors of falls, and the only predictors of injurious falls. Stance time variability has been reported to predict incident mobility disability in older adults. These results suggest that measures of temporal and spatial gait variability have specific relationships with different mobility outcomes. However, our factor analysis approach also indicates that the variability domain overall has utility in predicting outcomes and providing insights into pathology. Regulation of gait variability is thought to be automated with minimal cognitive input in healthy adults. Increased gait variability may lead to unstable gait or poor balance , increasing fall risk. Increased variability of step length was associated with greater burden of subclinical brain vascular abnormalities in high-functioning older adult. Neurodegenerative processes may also result in disturbed gait regulation. © 2010 CIR Systems, Inc.

Quantitative Gait Markers and Incident Fall Risk in Older Adults • Conclusions. Quantitative gait markers are independent predictors of falls in older adults. • Gait speed and other markers, especially variability, should be further studied to improve current fall risk assessments and to develop new interventions. © 2010 CIR Systems, Inc.

Quantitative Gait Markers and Incident Fall Risk in Older Adults • In this prospective study of a large well-characterized cohort of community-residing elders, quantitative gait markers were independent and strong predictors of incident falls. • Each 10 cm/s decrease in gait speed was associated with a 7% increased risk for falls. Participants with slow gait speed ( ≤ 70 cm/s) had a 1. 5 -fold increased risk for falls compared with those with normal speed. • The association between gait speed and falls remained robust after accounting for several risk factors that are strongly associated with falls as well as traditional clinical tests of gait and balance. • We have observed in our previous study that not all quantitative gait abnormalities have clinical correlates or the subtle clinical signs associated with quantitative gait dysfunction may be under recognized by clinicians. © 2010 CIR Systems, Inc.

Quantitative Gait Markers and Incident Fall Risk in Older Adults • Although dependent on availability of equipment, quantitative gait measures can be easily and quickly collected in clinical and research settings without requiring attachment of monitoring devices or extensive training. • Gait speed is a simple and quick option for measuring fall risk. • Although we measured gait speed using an instrumented walkway, it can be easily measured using a stopwatch. • Our analyses also identified gait variables such as swing phase, double support phase, and gait variability that better predicted falls than speed. • Our complementary factor analysis identified three gait domains; of which variability and rhythm domains were associated with increased fall risk. • The incremental validity from gait variables reported in this and other studies over traditional risk factors and clinical tests of gait and balance support further exploration of these measures. © 2010 CIR Systems, Inc.

Objective Assessment of Gait in Normal-Pressure Hydrocephalus • Objectives: Gait abnormalities are an early clinical symptom in normal pressure hydrocephalus (NPH), and subjective improvement in gait after temporary removal of CSF is often used to decide to perform shunt surgery. We investigated objective measures to compare gait before and after CSF drainage and shunt surgery. Williams MA, Thomas G, de Lateur B, Imteyaz H, Rose JG, Shore WS, Kharkar S, Rigamonti D: Am J Phys Med Rehabil 2007; 86 © 2010 CIR Systems, Inc.

Objective Assessment of Gait in Normal-Pressure Hydrocephalus • Design: Twenty patients and nine controls were studied. Quantitative gait measures were obtained at baseline, after 3 days of controlled CSF drainage, and after shunt surgery. Decision to perform surgery was based on response to drainage, and patients were assigned to shunted or unshunted groups for comparison. © 2010 CIR Systems, Inc.

Objective Assessment of Gait in Normal-Pressure Hydrocephalus • Results: There was no improvement after CSF drainage in the unshunted group (n 4). In the shunted group (n 15) velocity, double support time, and cadence improved significantly after drainage, and improved further after shunt surgery. The degree of improvement after drainage significantly correlated to the degree of improvement postshunt for velocity, double -support time, cadence, and stride length. © 2010 CIR Systems, Inc.

Objective Assessment of Gait in Normal-Pressure Hydrocephalus • Conclusions: There are significant, quantifiable changes in gait after CSF drainage that correspond to improvement after shunt surgery for patients with NPH. Use of objective gait assessment may improve the process of identifying these candidates when response to CSF removal is used as a supplemental prognostic test for shunt surgery. © 2010 CIR Systems, Inc.

Objective Assessment of Gait in Normal-Pressure Hydrocephalus © 2010 CIR Systems, Inc.

Reliability of Spatiotemporal Gait Outcome Measures in Huntington’s Disease • Gait impairments are very important in Huntington’s disease (HD), because loss of independence in gait is an important predictor of nursing home placement. Reliable outcome measures are also useful in designing clinical trials. Whereas existing methods of using motion analysis systems provide accurate outcome measures, however, they not likely to be available at most clinical facilities. • Given the functional importance of gait impairments in HD, it is imperative to test reliable and sensitive outcome measures that can be tested easily in various clinical environments. Ashwini K. Rao, Ed. D, OTR, Lori Quinn, Ed. D, PT, and Karen S. Marder, MD, MPH 3 Movement Disorders, Vol. 20, No. 8, 2005 © 2010 CIR Systems, Inc.

Reliability of Spatiotemporal Gait Outcome Measures in Huntington’s Disease • Gait impairments in HD are typically examined by measuring spatial and temporal parameters during walking. • For spatial measures, subjects with HD demonstrate: – shorter and more variable stride length at preferred, fast, and slow speeds – a wide base of support. • For temporal measures, subjects with HD demonstrate: – lower cadence – greater variability in stride time, swing time, and double support time. • Subjects with HD are able to modulate their gait speed, however, their overall gait velocity is lower than control subjects. • These impairments place individuals with HD at a greater risk for falls, yet they may be amenable to improvement through rehabilitation therapy. © 2010 CIR Systems, Inc.

Gait analysis in multiple sclerosis Characterization of temporal–spatial parameters • Background: Gait impairment is a significant problem in multiple sclerosis (MS), leading to decreased activity and limitations in function. However, specific characterization of abnormal gait in MS patients has only been described in small groups of patients, mainly using observational tools. • Objective: The aim of the current study was to characterize the spatio-temporal gait parameters in MS patients and ascribe them to clinical variables, in order to enable target-oriented management. © 2010 CIR Systems, Inc. Uri Givon, Gabriel Zeilig, Anat Achiron Gait & Posture 29 (2009) 138– 142

Gait analysis in multiple sclerosis Characterization of temporal–spatial parameters • Methods: Eighty-one MS patients with relatively short disease duration (5. 3; S. E. = 0. 3) able of independent walking and 25 agematched healthy subjects were evaluated using the GAITRite System. • Results: MS patients demonstrated significant impairments in all spatio-temporal gait parameters compared to able-bodied healthy subjects. © 2010 CIR Systems, Inc.

Gait analysis in multiple sclerosis Characterization of temporal–spatial parameters • Rehabilitation is an important part of the treatment in MS, and gait training is a major part of this process. • Gait studies allow the identification of the gait pathology in individual patients, and determination of goal oriented physical therapy. • Spatio-temporal studies can also be useful in evaluating the efficacy of the rehabilitation process. • Our study data related more accurately to disease parameters compared to data provided by the widely used physical therapy tests. • Observational tools such as the 500 m walk or observational gait analysis provide only qualitative data. © 2010 CIR Systems, Inc.

Gait analysis in multiple sclerosis Characterization of temporal–spatial parameters • These tools rely on the observers’ experience, are time consuming and are difficult to use in large patients populations. • Evaluation of spatio-temporal parameters is an accurate and useful tool for clinical evaluation and routine follow-up of MS patients. • Moreover, in patients that complain of gait deterioration but show only minimal clinical abnormalities gait spatiotemporal evaluation could provide quantitative information to support clinical assessment. • Significant changes in the FAP and the spatio-temporal parameters would indicate MS relapse or deterioration. © 2010 CIR Systems, Inc.

NPH Example • Mr. * was admitted for a 3 -day external lumbar drainage (ELD), from 9/10/07 to 9/13/07, to evaluate the response of cognitive and gait functions in order to predict his response to eventual ventriculoperitoneal shunting (VPS) placement. • This 76 -year-old man has had progressive gait difficulties since January of 2006, when he noted balance difficulties during golfing. • His function substantially deteriorated over the last three months prior to • admission for ELD, with worsening of gait, new urinary incontinence (two episodes), and forgetfulness. • He also had a left hemispheric stroke after his visit in May, which rendered him right hemiparetic. He has recovered the strength of the right arm but is still mildly weak on the right leg, which is contributing to this walking impairment. • A brain MRI done after the stroke reportedly showed increase in the ventricular size. © 2010 CIR Systems, Inc.

NPH Example Line of Progression should pass through the front of the foot ©

NPH Example • Most measures of gait performance in NPH were improved by the 3 -day ELD procedure. Stolze et al (Stolze et al, • Clin Neurophyisiol 2000; 111: 1678 -86) identified gait velocity (increase), stride length (increase), and double-limb • support (decrease) as the three gait parameters most sensitive to changes induced by CSF drainage in patients with • NPH. Velocity and stride length were highly responsive to lumbar drain. Also Mr. *’s parkinsonism improved by • 31%, as measured by the UPDRS. These findings render him an adequate candidate for VPS placement from a • motor perspective. Full neuropsychological evaluation is needed before a final decision can be made. © 2010 CIR Systems, Inc.