Elsevier

Gait & Posture

Volume 23, Issue 1, January 2006, Pages 78-82
Gait & Posture

Validation of a visual gait assessment scale for children with hemiplegic cerebral palsy

https://doi.org/10.1016/j.gaitpost.2004.12.002Get rights and content

Abstract

This study reports the experience of reliability testing and validation of a visual assessment of gait based on the Physician Rating Scale in children with hemiplegic cerebral palsy. Comparison with three-dimensional gait analysis showed excellent correlation between observers and full gait analysis for sagittal plane motion at the knee in stance. Inter and intra-rater reliability showed moderate to almost perfect agreement for foot contact characteristics and ankle in stance. Use of this scale may be helpful in assessment of children where frequent analysis of these characteristics is needed.

Introduction

The accuracy of visual gait assessment has long been called into question [1], [2] and the recognition of this inaccuracy has resulted in the emergence of computer aided three-dimensional gait analysis (3DGA). Such systems have enabled the accurate description of gait events for use in the clinical management of children and adults with neurological disorders affecting gait.

3DGA is, however, arduous and time consuming and not always applicable in very young children, particularly those undergoing frequent reassessment. Repeated measurements are needed to assess the effects of interval treatments such as botulinum toxin injections, serial casting, splinting or following periods of intensive physiotherapy. In these settings there is, therefore, a continuing dependence on visual analysis of gait.

In the context of children with cerebral palsy the Physicians Rating Scale (PRS) has been widely reported [3], [4], [5], [6], [7]. However, the validity and repeatability of this measurement tool have not been established. Koman et al. [5], [6] used the PRS in their trial of botulinum toxin in the absence of repeatability and validity data. Boyd et al. [8] also reported a scale based on the PRS and, although validation was mentioned in their paper, no reference was made to the method of validation. Corry [9], [10] reported the use of the PRS in assessment of children with cerebral palsy (CP) undergoing botulinum toxin treatment. The inter-observer reliability of the PRS, assessed using weighted kappa scores, showed moderate to substantial agreement for foot strike (k = 0.50, 0.67) and moderate agreement for ‘change’ (k = 0.55). An additional problem with the PRS relates to study-specific modifications made to the categories by each researcher; thus limiting the potential for comparing study results.

In summary, the repeatability of the PRS has been investigated but requires further assessment, the issue of validity has not been addressed and no universally accepted divisions for categorisation have been established.

The purpose of the current study was to test the intra and inter-rater reliability of a visual gait assessment scale (VGAS) (Fig. 1). This scale was based upon the PRS previously described [4] with categorical modifications according to normal 3DGA kinematic data. The validity of the scale was assessed by comparing the results with 3DGA data.

Section snippets

Patients and methods

A retrospective analysis was undertaken of bi-planar video recordings of barefoot gait in 31 children with spastic hemiplegia. The cohort comprised the most recent attendees to the gait laboratory who were undergoing clinical gait analysis as part of their routine clinical management. 3DGA was performed at the same visit using a six camera Vicon 370® system and processed using Vicon Clinical Manager® software (Oxford Metrics). Two experienced observers (MFS and WED) reviewed the video tapes

Results

Thirty-one children with spastic hemiplegia were enrolled (20 males, 11 females, mean age 10.6 years, range 5–17 years). Twenty-four children had a type 1 or type 2 hemiplegia, seven had type 3 or 4. For the subset of 11 children (five males, six females, mean age 7.4 years, range 5–9 years), 10 had type 1 or 2 hemiplegia, one child had type 4.

Intra-rater kappa scores are shown in Table 3. Agreement for hip position was poor to slight in swing (k = −0.04, 0.07) and moderate in terminal stance (k = 

Discussion

The limitations of visual gait assessment, in particular accuracy, have been extensively reported [1], [2]. These limitations have led to the development of sophisticated gait analysis, which has become widely accepted as the gold standard for determining precise gait data. However, visual assessment of gait remains an important component of clinical assessment of children with cerebral palsy. Accurate visual assessment is particularly relevant in young children, or where frequent assessment is

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