This is Dr. Amanda Witt, here for our third and final installment for gait analysis for the neuromuscular physician. This is another classic case, a very common one. We're moving to a pediatric gait analysis at this point. A lot of times what I'll do to inspire the child to actually leave the room is have the toy cabinet down the hall, and so I'll say, come on, let's go get a toy. And while we're walking to go get the toy, then maybe I'm doing my 10-meter walk time in a Duchenne kid, or I'm just watching their gait while they're unconscious that I'm watching them walk, because children can really alter what they do if they know that you're looking at them. And so that's a good incentive. Sometimes maybe in your office you have a window that has a pretty view. If you just have something they like to go do, or suckers at the end of the floor, or a little piece of candy, it can really help inspire them to show you the ambulation. This is a time when having them walk back and forth multiple times can be a challenge depending on the age and the cooperation of the child, but it's a trick I use for my shy ones, such as this little guy, who our spine is curving to compensate for his hip extensor weakness. So just from gait, we know that his hip extensors are weak, his knee extensors are weak, yeah, we've got a little waddle. We're aware has Duchenne muscular dystrophy. So early in the disease course, when they're maybe three or four, you might see them have trouble getting up from the floor, so they may have a gowers or modified gowers. They also, if they're going to go up and down steps, may rely more on their arms to pull themselves up with the railings. If they're laying down on the ground, they really struggle to pull that head up and just sit up with their trunk flexion. Most of the time, they'll roll to their side and push up from the side. If any of you have had toddlers or been around a toddler, you know that's very unusual. These children pop up and down all the time. Then you start to see a little hyperlipidosis next, and so the proximal to distal gets weak, right? So they have some hip extensor weakness. They start to have a little curve to their back, and that's the first thing I'll see really in any type of progressive muscle issue. Then after they have hyperlipidosis, they start to have the Trendelenburgate where the gluteus medius gets weak, and so the gluteus medius can't stabilize the spine and keep it level anymore. Your stance leg is the one where the gluteus medius keeps that hip pulled, and if it gets weak, it lets it drop because it can't contract and hold it down anymore. Of course, in a muscular dystrophy, that happens on both sides. In Duchenne muscular dystrophy in particular, their knee extensors get weak relatively quickly, and so hyperlipidotic, they get a little Trendelenburg, and then they'll eventually come up on their toes, some of them earlier than others, and that's to compensate for the knee extension weakness. Toe walking is not uncommon in other neuromuscular disorders, and chakramarie tooth children where the ankle dorsiflexors are weak, they will tend to toe walk as well, but they will not have the proximal weakness pattern that we just went through, of course. And eventually, these children will get contractures. Most of us walk during the day with a heel strike, and we stretch those heel cords out throughout the day, and then when we sleep at night, they are plantarflexed and supine, and so they get a little tight, and then we wake up in the morning, and we stretch them out again. Now, if you wear cowboy boots all the time, or you might wear high heels all the time, you also can get heel cord contractures because you're never really stretching out those heel cords. You're either asleep in plantarflexion, or you're up in plantarflexion to walk, and so that you can get contracted. With these children, they're up on their toes to compensate for the weakness, and so they also never stretch their heel cords. That's why we tend to put these boys in resting night splints to help stretch their heel cords at least part of the day. While we can walk and do that, we have to get their stretch when they're asleep, because if we took away that compensatory gait with toe walking, then we could decompensate their gait entirely because they do that for a reason. So daytime splinting is not recommended for Duchenne muscular dystrophy. This boy, at this point, probably had a 10-meter walk of around 7 to 8 seconds, and lost emulation within the next 18 months. So he is relatively late mid to late stage emulation at this point in time. Thank you.

pediatric gait analysis

neuromuscular disorders

Duchenne muscular dystrophy

gait changes

muscle weakness