Real time non-instrumented clinical gait analysis as part of a clinical musculoskeletal assessment in the treatment of lower limb symptoms in adults: A systematic review

Highlights

• Gait analysis is often recommended for musculoskeletal adult lower limb assessment.

• Real time clinical gait analysis may be the most common method employed.

• Review found no protocol or evidence base for this method.

• Further work is required to establish clinical worth and best practice.

Abstract

Background

The aim of this review was to evaluate and summarise the current evidence on non-computerised or non-recorded real time adult gait assessment conducted within the clinical musculoskeletal setting. It was hoped a protocol for best practice and a framework for further research could be developed from this search.

Research question

Can a protocol for best practice and a framework for further research be established from previous literature relating to non-computerised or non-recorded real time adult gait analysis in a musculoskeletal clinical setting.

Methods

A literature review with no limitation on date of publication was conducted on the 18th February 2017.

Results

The review found no significantly informative papers relating to the search

Significance

The lack of research on the accuracy, reliability and therefore worth of this highly recommended area of musculoskeletal assessment raises concerns over current assessment and treatment pathways. Further work to develop a method by which gait analysis can be routinely employed in musculoskeletal clinics as a diagnostic tool is required, with any new approach undertaking robust methodological testing.

Introduction

Clinicians are often recommended to conduct gait analysis as part of a general or lower limb musculoskeletal (MSK) adult patient assessment [[1], [2], [3], [4], [5], [6], [7], [8], [9]]. The analysis of gait may be conducted with or without the use of computerised recording analysis equipment with aims to aid in diagnosis, determine treatment goals and evaluate treatment outcomes [[2], [6], [7], [10]].

The clinical use of gait analysis is thought to be highly variable [11] not only due to the perceived lack of supporting evidence, but also lack of availability, reimbursement and training [12]. Lower limb MSK clinics are suggested to place more value on the merit of gait analysis due to the increased incidence of literature relating gait dysfunction to lower limb injury and the obligatory use of the lower limb in normal gait [[4], [5], [13], [14]]. Taro et al. [15] investigated the status of National Health Service (NHS) physiotherapy gait analysis of children and adults within the UK. Their findings showed that although gait analysis made up a major aspect of physiotherapy outpatients practice, there was no systematic use of a standardised gait analysis tool or recognised methodology or protocol.

The gait of children with or without neurological disorders differs from adults and is also often assessed in more specialised paediatric clinics [[16], [17]]. This sample is therefore seen as a separate group than that of adults assessed in a MSK clinical setting, and excluded from this review for this reason.

The terminology used to describe the clinical gait analysis may be misleading to the practitioner working in a therapeutic setting. ‘Clinical’ gait analysis could be interpreted to mean gait analysis ‘pertaining to a clinic’. Whittle [9] stated that ‘clinical gait analysis’ usually consists of videotape examination, measurement of gait parameters, kinematic analysis, kinetic measurement and electromyography. The term ‘clinical gait analysis’ therefore does not appear to reflect the assessment undertaken in the majority of therapy clinics or centres, but is more associated with assessments conducted in specialised gait laboratories [[2], [18]]. The accepted definition seems counter intuitive and exclusive to the possible majority of MSK assessments conducted in a clinical setting. For clarity there appears a need for terminology to differentiate between ‘clinical gait analysis’ and ‘gait analysis conducted within most clinics’. For the purpose of this paper the term Clinical Gait Analysis (CGA) includes all gait analysis which requires computerised or videotaped recording or analysis, while Real Time Clinical Gait Analysis (RTCGA) pertains solely to gait analysis visually assessed and concluded upon without computerised or recorded aid.

In a systematic review published in 2011, Wren et al. [12] concluded that the existing evidence, although sparse at higher levels of efficacy, supports the worth of CGA. They also state visual, or RTCGA, to be less efficacious than that using computerised gait assessment technology. The supposition is limited to just two investigations. Both of these use specific sample groups, either children with cerebral palsy or amputees [[19], [20]]. These investigations were looking for specific markers to determine surgical approaches, and therefore limited to these sample populations and treatment options. Results may be different from a more general MSK patient population. However, these findings support the apparent consensus regarding RTCGA being the less valid and reliable of the methods available [[2], [21]].

The aim of this systematic review was to evaluate and summarise the methods of RTCGA used in adult musculoskeletal clinics treating the lower limb. It was hoped from these findings a protocol of best practice in a clinical setting could be established and also provide a foundation for further work and investigation if required.