Anterior Versus Posterior Walkers R. Bachschmidt, G. F. Harris, J. Ackman, S Hassani, M. Carter, A. Caudill K. Reiners, W. Olson, P. Smith Shriners Hospital f or Children Chicago, IL 60707 J. Klein Department of Biostatistics Medical College of Wisconsin Milwaukee, WI 53226 Abstract Many children with cerebral palsy require walkers to achieve functional ambulation, yet little scientific study has been done to understand the mechanics of usage. The objective of this work was to provide a quantitative pilot comparison of ambulation with anterior and posterior walkers in children with cerebral palsy using temporal-spatial gait parameters and an upper extremity joint kinetics. Following informed consent, data were collected for nine children with spastic, diplegic cerebral palsy who were community ambulators and who routinely used posterior walkers. Results of the study showed increased double limb support time (24.3%-30.7%) with the anterior walker, increased walking speed (16.7%-21.4%) with the posterior walker. Elbow extensor and wrist flexor demands were greater with the anterior walker (-0.19 /kg, 0.07 /kg) than with the posterior walker (-0.06 kg, 0.02 /kg). The methodology developed in this study appears to provide improved insight into the effect of upper extremity muscular demands in addition to the traditional lower extremity gait analysis, clinical evaluation, and energy expenditure assessment. Keywords upper extremity kinematics, upper extremity kinetics, walker dynamometer 1. Introduction Impaired equilibrium reactions, balance, postural stability, and abnormal muscle tone are characteristics of children with cerebral palsy. Ambulation in these patients is sometimes limited by these factors, and their mobility may be dependent upon the use of assistive ambulatory devices, such as canes, crutches, or walkers. These aids afford improved balance and theoretically facilitate the forward progression of gait. Though the literature contains information regarding the use of canes and crutches as assistive devices and their biomechanics and determinants on gait, little quantitative data is available on the effect of walkers on gait patterns of children with cerebral palsy. 217 0-7803-6469-4/00/$10.00 0 2000 IEEE The selection of the type of walker, either anterior or posterior, is typically subjective, based upon the observation of the child by the physician and/or therapist. This observation is usually done in the clinic or at school or private therapist with little time for adaptation. Objective data regarding parameters of gait, statiddynamic stability, load borne by the upper extremities, and efficiency of gait are rarely determined. Current studies do not address quantitative three-dimensional upper extremity kinematics or loads borne by the upper extremities. Small population sample sizes also limit application of the findings. The purpose of this study was to obtain insight in children with spastic cerebral palsy who use walkers to assist in their ambulation, comparing the traditional front or anterior walker, with the newer posterior walker. 2. Methods 2.1 Subject Selection and Testing Nine patients aged 8 to 17 (p=l l years) with spastic cerebral palsy and a diplegic distribution were studied using two-wheeled anterior and posterior walkers. Signed informed consent was received from parents or guardians. They were first evaluated on three separate occasions over a three week period while using their posterior walkers. Evaluation consisted of computer-assisted gait analysis and clinical examination. In the gait analysis laboratory, the subjects were asked to walk on a 10 m walkway with an instrumented walker. A minimum of five acceptable bilateral strides were collected for analysis. Following the initial three-test series, the subjects received training in the use of an anterior walker by a physical therapist. After successful completion of training, the subjects used anterior walkers daily within their community environment for a period of one month. The subjects then underwent another three-test series using the anterior walker. 2.2 Walker Dynamometer To study pediatric walker-assisted gait, we modified a pediatric posterior walker (Kaye Model W3B, Kaye Products, Inc., Hillsborough, NC) and an anterior walker (Guardian Products Model 7749, Sunrise Medical, Simi Valley, CA) to accept two 6 axis, strain gage-based, load cells (AMTI Model MCW-6-500), in a cooperative effort with Advanced Mechanical Technology, Inc. (AMTI, Watertown, MA), (Figures 1,2). The results from our finite element study and prototype walker instrumentation were used to position the load cells so that the forces and moments generated at each hand could be accurately detected [l ] [2] [3]. The system was lightweight, with each load cell weighing about 100 grams and were cylindrical in shape with a diameter of 38 mmand height of 60 mm. The load cells were tethered to two AMTI force plate amplifiers (Model OR6-5). The manufacturer-supplied primary sensitivities in units of mV/N(cm). Sensitivities were maximum in the anterior-posterior Fx loading direction and minimum in the vertical Fz loading direction. The specified non-linearity and hysteresis of the loads cells were less than +0.20%. The lowest resonant frequency of a stand-alone cell was 700 Hz. Based on preliminary data collection, system gains of 4000 were set for the 218 vertical force channels and gains of 2000 were selected for the anterior-posterior and medial-lateral force channels. Gains of 1000 were set for all moments.. Mornents applied by the hands were uniquely determined by subtracting from the recorded moment signals the product of applied force and distance from the transducer center to the point of force application. Figure 1. Posterior Walker Dynamometer Figure 2. Anterior Walker Dynamometer 219 2.3 Upper Extremity Biomechanical Model A biomechanical model to calculate sagittal, coronal, and transverse kinetics of the shoulder, elbow, and wrist joints was developed [l]. The upper body segments are modeled as rigid links connected by idealized joints located at stationary, estimated centers-of-rotation. The coordinates of external passive reflective markers are used to determine flexiodextension (sagittal), abductiodadduction (coronal), and internal/external (transverse) rotations of the upper body using a multi-segment rigid body model similar to that used by Kadaba, et al. [4] (Figure 3). Complete joint motion is described with three sequence-dependent Euler angles. The loading of the upper body joints (wrist, elbow, and shoulder) was determined using an inverse dynamics model. Upper Body Kinematic Model Place external reflective markers over anatomical landmarks Estimate internal joint centers fron markers and anthropometric relationships Construct local body reference frames using vector methods Calculate relative joint angles using Euler angle theory n Upper Body KiLetic Model An Inverse Dynamics model incorporating measured with the walker dynamometer Angular and linear Figure 3. Representation of Upper Body Kinematic and Kinetic Models 3. Results 3.1 Gait Metrics Double stance time with anterior walker use was significantly greater than with posterior walker use (p=0.0004) for both the left and right sides. Mean double limb support time increased 24.3% - 30.7% with the anterior walker compared to the posterior walker. Walking speed with posterior walker use was significantly greater than for anterior walker use (p=O.OOOl) for both the left and right sides. Mean increases in speed were 16.7% - 21.4% with the posterior walker. This was accomplished by significant increases in cadence (7.9% - 9.6%) and in stride length (6.1% -7.6%). 3.2 Upper Extremity Kinematics Figure 4 illustrates the mean trunk and elbow sagittal plane joint angles when walking with the anterior and posterior walkers. Group means were plotted at discrete increments of the gait cycle (IO%, 30%, 50%, 70%, 90%). The right side upper extremity kinematics were graphed with respect to the right foot stride (rfc, rfo, rfc) and similarly the left side upper extremity kinematics were graphed with respect to the left foot stride (lfc, Ifo, lfc). 220 trunk 0 left elbow X gait cycle 5 right elbow I , 20 40 60 60 X gait cycle Figure 4. Mean sagittal plane upper extremity kinematics for walking with an anterior and posterior pediatric walker. N=9 subjects with spastic, diplegic cerebral palsy, n=15 per subject, per walker. Flexion (+)/extension (-). Trunk flexiodextension did not differ significantly between the two walkers. Changes in the trunk angle ranged from 0.0" to 2.1". The shoulder was significantly more extended (12.9" - 19.9") with posterior walker use than with anterior walker use. Increases in elbow flexion with the anterior walker ranged from 1.3" to 7.2" and were statistically significant throughout the gait cycle on the non-dominant side. No significant differences in wrist extension were determined for use of the two walkers. 22 1 3.2 Upper Extremity Kinetics A net demand on the shoulder flexors (0.15 /kg) was noted with posterior walker use while a net extensor demand (-0.04 kg) was seen with anterior walker use. Elbow extensor demands were greater with anterior walker use (-0.19 /kg) than with posterior walker use (-0.06 /kg) and the differences were statistically significant throughout the gait cycle on the non-dominant side. Significantly greater demands on the wrist flexors were noted when walking with the anterior walker (0.07 kg) than with the posterior walker (0.02 /kg). Separate trials of hand-to-walker loading for subject ER are shown in Figure 5. For this subject as well as the others, a posteriorly directed shear force (-Fx) was observed during late stance to swing phase when using the anterior walker. In contrast, an anteriorly directed shear force (+Fx) was noted throughout the gait cycle when using the posterior walker. Hand-to-walker vertical forces and moments applied in the sagittal plane were similar in magnitude and morphology for both walkers. Hand-to-Walker ForceFx Posterior Walker, (+) direction of walk Hand-to-Walker ForceFx Anterior Walker, (+) direction of walk W 30 30 -30 .30 -60 -60 gait cycle gait cycle Figure 5. Subject ER sagittal plane hand-to-walker loads for walking with an anterior and posterior walker. 4. Discussion The purpose of this study was to initiate a quantitative comparison of ambulation with anterior and posterior walkers in children with spastic, diplegic cerebral palsy. The walker dynamometer allowed measurement of three-dimensional wrist, elbow and shoulder loads in children and quantitative biomechanical comparison of anterior and posterior walker usage. The system was designed for use within a standard gait analysis laboratory and has proven to be accurate and reliable during preliminary trials. The system is considered appropriate for further clinical application and for analysis of therapeutic surgical and non-surgical treatment. 222 A limitation to this study is the small sample size of nine subjects. However, estimates of parameter variance were used to project appropriate sample sizes for future study design. For a sample size of thirty subjects, conservative estimates of the minimum effect size which can be detected at the 5% significance level with 90% power are a mean upper extremity kinematic change of 6 degrees (3 trunk - 9 shoulder) and a mean upper extremity kinetic change of 0.07 /kg (0.04 / kg wrist - 0.10 /kg elbow). Potential rehabilitation applications which could benefit from this technology may include the optimization of pediatric walker-assisted gait. In order to optimize the function with walkers, we must first understand the details of motion and force transfer. While it is well known that upper extremity work increases energy demands, the relationship of energy expenditure to load distribution among the wrist, elbow, and shoulder joints is not well understood. The walker dynamometer and biomechanical models would potentially allow design of a user-specific structure, optimized to retain the determinants of gait, reduce internal moment demands, and improve efficiency. Reference [l ] R.A. Bachschmidt, G.F. Harris, G.G. Simoneau, J .J . Wertsch. Analysis of Walker-Assisted Gait: Kinetics and Kinematics. IEEWEMBS 1s Annual Conference, Chicago, IL pp.2851-2856, Oct 30-Nov 2, 1997. [2] R.A. Bachschmidt, G.F. Harris, J .A. Ackman, S. Hassani , K. Reiners, W. Olsson, F. Carignan, G. Blanchard. Development of a System for Quantitative Study of Pediatric Walker-Assisted Gait. IEEWEMBS Conference Hong Kong Oct. 1998. [3] RA. Bachschmidt, G.F. Harris, J .A. Ackman, S . Hassani , K. Reiners, W. Olson. Walker-Assisted Kinetics in Children with Spastic Cerebral Palsy: A Preliminary Study. Proc NASGCMA, Dallas, TX, March 10-13, 1999;4. [4] R.A. Bachschmidt, G.F. Harris, J .A. Ackman, S. Hassani, K. Reiners, W. Olson. Walker-Assisted Gait in Children with Spastic Cerebral Palsy. Proc POSNA, Orlando, EL May 17-19 1999. [ 5 ] M.P. Kadaba, H.K. Ramakrishnan, M.E. Wooten. Measurement of lower extremity kinematics during level walking. J Orthop Res, 8:383-392; 1990. 223