Transcription:
Pediatric Gait Clinic at Marianjoy Rehabilitation Hospital

Melanie Cole (Host): Welcome to Better Edge, a Northwestern Medicine Podcast for physicians. I'm Melanie Cole. And joining me to highlight the services at the Pediatric Gait Clinic at Northwestern Medicine's Marianjoy Rehabilitation Hospital, we have a panel today. Dr. Larissa Pavone, she's a pediatric physiatrist and Program Director of the Physical Medicine and Rehabilitation Residency Program at Marianjoy; and Trinette Carney, she's a physical therapist also at Marianjoy.

Ladies, thank you so much for joining us today. And Dr. Pavone, I'd like to start with you. Can you tell us a little bit about this clinic and the purpose of it? Give us a little background on how it's evolved.

Dr Larissa Pavone: Yeah, absolutely. So, we have an interdisciplinary team in our pediatric gait clinic that includes a physiatrist, which is myself; a physical therapist, Trinette, who's on the call; we also have one other therapist, Jenny, that works with us; an orthotist. And then, the patient and the family are considered part of our team.

What's really nice is also sometimes we will have member therapists in the community, who will join either remotely or in person to witness the gait clinic and also help with their input. The focus really of the clinic is the child. And so, we use a team-based approach to determine the best orthotic or prosthetic for the child.

the gait clinic was designed to provide comprehensive analysis of a patient's gait or walking to determine the best support or treatment options for that child. So, we consider different prosthetics and orthotics. But since I am in the clinic as well, we also look at different medication options, such as muscle relaxers or botulinum toxin treatment. We can determine if they're appropriate for certain types of physical therapy or serial casting. So, really our analysis of their gait is considering all the options to help them achieve their goals. So, this is done through both the physician and the physical therapist, as well as the orthotist, doing an objective gait analysis, utilizing technology called the Zeno Walkway. The Zeno Walkway provides us two-dimensional gait analysis, looking at both the sagittal and the coronal plane of walking, and gives us objective measurements of each step as well as the pressures within those steps.

Melanie Cole (Host): Well, thank you so much for that. And I'd like you to expand a little bit on what makes it so unique, Dr. Pavone. As I understand it, when you're utilizing these techniques for challenging gait patterns, that sometimes you have to use not just subjective data, but objective as well, and using this tech to make real-time decisions. Can you speak a little bit about that?

Dr Larissa Pavone: Absolutely. So, I really love this clinic. I'm a pediatric physiatrist. I was trained to be able to do different brace prescriptions. But especially when we get a challenging, I really appreciate the comprehensiveness of the clinic. I love the insight that the physical therapist brings to the clinic because they think about problems differently than I do, as well as the orthotist. For some of our most challenging gaits, this is where I prefer to assess them because I just don't feel that I can come up with the best prescription for the child just watching them walk in clinic.

What's great about this is if the child has an orthotic and it's not working, we can do a gait assessment to maybe try and problem solve why that one's working or not working for them. And also, it's really great because we're able to follow these children over time, I should say children, adolescents, over time. So, we may come up with a brace prescription or some interventions with that first assessment, but we will bring the child back periodically over the year or two or three to look if the intervention that we decided is working, how we anticipated it to work, and also to see how that child is changing over time. Children are dynamic, they're constantly growing, and their functional abilities are changing as their body changes. And so, we're really able to capture objective measures to see how that child is doing.

And without technology, when I'm assessing a child's gait pattern in clinic, I'm looking and I'm documenting in the chart kind of what I am seeing, maybe the child's up on their toes or they have like a crouched gait. But I can't say how long their step length is or how fast they're going. Or if I do an intervention, how does that change their step length? So, it's really great to have these objective measures because I can see in real time the interventions that we're doing and how that may be modifying the child's gait.

Trinette Carney: Yeah, I agree a hundred percent with Dr. Pavone. The thing that is so unique about the clinic is that we have the whole team there and we really do kind of a deep dive into the analysis. We look at the data, we measure objectively the gait, the Zeno Walkway, plantar pressure mat measures the footsteps. So we measure, like Dr. Pavone said, step length, speed. We can also measure how much a child is turning in or turning out. And then, we utilize the analysis of the video, both on the sagittal and the coronal plane, which gives us a different visual of where their trunk or their limbs are during different phases of the walking gait cycle. Those are things that, as a therapist, even with a lot of years of experience, I can look at a child and think I see what I'm seeing. But this allows us to slow it down, really analyze it, in a very quick and efficient manner. It's not sending the child for a comprehensive 3D gait analysis that takes insurance approval and time to get done. We can do a quick analysis, quick run of the gait, analyze the data and make some real time decisions. And as Dr. Pavone said, it's been really kind of so much fun to watch. Over time, these children change and grow and be able to really hone in our orthotic prescription or other treatment recommendations based on the changes that we see and use the objective data we're gathering to really reinforce that.

Melanie Cole (Host): Thank you for that comprehensive answer. And Trinette, what types of children do you see in the clinic? I think people would assume that this is an ortho population, but not really, yes?

Trinette Carney: So, we work with children from ages two up through adulthood, who have a variety of different impairments in their walking. So anyone under the age of two, we have found is really too small basically in size and weight to get the accurate measurement on the mat. They need to be somewhere around 25 pounds or higher, or it's not getting a good read for us to get the data that we're looking for. And our gait system that we're using with the Zeno Walkway also provides us some normative data on typical gait parameters for children as young as two. So then, we can collect the data that we see with their gait pattern, compare it to what normal ranges are for that child of that age.

The most common diagnosis we do see that come into the clinic are children with cerebral palsy, and those children can come in with a wide variety of presentations. We also work with A lot of different diagnoses. Another one that we see often is different types of toe walking, whether it be idiopathic toe walking, sensory toe walking. We see children with other neurological disorders, traumatic brain injury, spina bifida, childhood cancers. Sometimes progressive neurological disorders are utilizing our clinic, so that we can monitor changes as the child progresses in their disease process and be able to provide them the most support that they need as they change. We occasionally see other arthritic conditions. And, rarely we don't use it often, but we occasionally do have a child with an amputation.

Many of the patients that we see are coming in referrals from either our physicians on site or our therapists who are looking to improve the quality of their walking and really trying to determine the best device or treatment recommendation. But also, as Dr. Pavone had mentioned earlier, we have a lot of outside therapists that refer to our clinic and then, often attend either virtually or phone in, or sometimes come into the clinic, so that we can all be on the same page with what the goals are for the family and the child, and how to make them most efficient in their goals for walking independently.

Dr Larissa Pavone: And I'd also like to add with some of these kids that we're seeing that you might not think about when you're thinking of referring to this type of clinic that we have here, is we can measure children who use walkers or crutches walking and we're able to get the data with them walking with their device. And so, that's also a really nice thing about this technology that we use that the children can walk with their typical condition, and we can get great measurements with that.

Melanie Cole (Host): Well then, Dr. Pavone, how do you choose the best orthotic for your patients? For example, for someone whose gait is changing due to a neuroprogressive disorder or someone who is going to have surgery. Tell us a little bit about how that works. Give us a snapshot of what that looks like.

Dr Larissa Pavone: That's an interesting question because it can be very challenging and that's one of the things that I love having a bunch of different brains to work together because I don't always know the answer and sometimes the answer that I think is right might not be right for the family. And that's why it's so important that the family also has input. Because what I find is you can tell someone like, "I think you need an AFO, you know, and I want this type of AFO," but the family may not like it or may think the child doesn't walk well with it, and then it just goes into the closet. So, I often ask the families the question, "Will you use this?" or "Is the child going to use this?" Or when they come back, I'm like, "Are they using it? And be honest with me because it doesn't matter to me. I want to know what you guys are doing at home." So, we make sure to set the child up for success. And sometimes, it might not be a brace because, even though I may think that the brace is the best option for the child, maybe the family and the child for some reason don't think that it's the best option. So, we really like this technology, sometimes to get the family on board so basically the way this clinic works is they come in, Trinette's in the clinic with me or Jenny, our other physical therapist. They'll do a full physical therapy assessment. We're looking at range of motion, we're looking at strengthening, we're looking at the different devices that we have. And then, we will run the child on the mat, both with and without the orthotic to look at the different gait patterns that they have. If they don't have an orthotic, of course, we're just running them barefoot and sometimes with their shoes, if that changes their gait pattern, to look at what we're starting with. And so, the beautiful thing, not just with Getting the objective measures of stride length and stance and where the foot is contacting, is being able to use just the video to look at the child, both in the coronal and sagittal planes and slowing down the video, so you can actually see what's happening at the hip, knee and ankle during each step of the child's gait pattern.

And so, it depends on the gait pattern when we're choosing the orthotic. I think for people who specialize in choosing different types of orthoses, there's gait patterns that make us go with different types of orthotics. But let's say a child has a crouched gait, for example, is a pretty common gait that we'll utilize. And oftentimes, maybe we'll be looking at a solid AFO or a ground reaction AFO to help that child stand more upright. With having the physical therapist and that assessment, as well as the physician taking the measurement, well, we may actually see that their limitation in gait isn't actually related to the orthotic. Maybe their hamstring is too tight and putting the orthotic on them doesn't change their gait pattern. So, there's a lot of just in-depth analysis that we can do by looking and slowing the videos down and getting those objective measures.

Trinette Carney: I agree. And I think one of the other things that's so nice about the clinic, is that in real time we're analyzing and then we're showing the video to not only the patient, but the family. And that really does help them buy-in into utilization of an orthotic or a more understanding of what we're coming up with within our evaluation and our assessment. So, we can show the patient, for example, like Dr. Pavone is mentioning, if it's a crouched gait and they're on their toes and the problem is really coming from further up the chain at the hamstring or the hip, and we can demonstrate that by slowing down the video. Like we said, we can't see in real time exactly what's going on, even with a trained eye and lots of experience and the parents don't either.

So, we can really sit there and show them in the video, "This portion of the walking is why we're saying it's this or that. And this type of brace can help, this type of brace can't help. And maybe we need to look at some other interventions like Botox to the hamstrings or some stretching or some casting or things like that to help gain success with it." The orthotist also brings a lot to the table with different ideas of having even more intimate knowledge of all the new technology in orthotics, and is there a different kind of joint that's available that we might be able to utilize or a different type of material that will work better for this patient.

A lot of times some of the braces are bigger and more bulky than the patient or the family would like. And sometimes we have to rethink where we'd like to go with supporting them for optimal alignment and efficiency, but also something that they're going to utilize and the orthotist often has many suggestions that we might not think of off the top of our heads. So, it is really nice to have all three brains together and talking with the family. And I think that's something we have heard multiple times from families that they really appreciate about the clinic. They come in, they feel heard, they feel like they've had a good analysis of what's going on, and they come out with a good recommendation. And it might not always work the way we expected, but we'd bring them back and we continue to work on it and address it to get the results that they want.

Melanie Cole (Host): Such an interesting topic and what a comprehensive approach for children with gait issues. I'd like to give you each a chance for a final thought. So Trinette, is therapy part of this clinical evaluation and assessment? Where does that fit into this picture?

Trinette Carney: Yes, absolutely. So as a PT who is in the clinic, we are doing, as Dr. Pavone mentioned earlier, an assessment. If it's the first time I'm meeting the patient, it's a more comprehensive evaluation of their lower extremities, their posture, their balance and, obviously, their walking, their gait. So, we do the assessment, which helps us determine, and starts us on our path of what we're going to be looking at orthotically or also looking at other treatment options. Because they are in the clinic and we are making recommendations as a therapist, I'm often also giving the family some home recommendations that they can be working on that's going to help them, whether it's stretching or a couple strengthening activities that's going to help them improve their walking and their balance for more success. There's a lot of collaboration with the other therapists in the community that are referring them. So, I'm the person that's going to follow up with that therapist, make sure we're working towards the same goal. They know what we're recommending, what therapy services we're recommending.

Occasionally, we are looking at different interventions that come out of the clinic like Botox or serial casting, and often those interventions are delivered at our facility. Sometimes we're doing referrals to orthopedic surgeons because of the many options we've tried, and we are unable to change a patient's alignment or gait because of some really fixed contractures, and then we can demonstrate that to the family and move them on.

And the other thing, as Dr. Pavone mentioned, we have the ability to analyze their walking with devices. So, sometimes these patients come in without a device and I can pull in different devices, gait devices for them, show them how they can utilize that and be more successful, and do some training with that on the spot and then help facilitate them getting the device that the child would be successful with. So, those are the different ways that PT is involved in that clinic.

Melanie Cole (Host): Dr. Pavone, last word to you. I'd like you to speak to referring physicians now about what makes it so unique at this Pediatric Gait Clinic at Northwestern Medicine's Marianjoy Rehabilitation Hospital, and when you feel is the best time for them to refer their patients.

Dr Larissa Pavone: Yeah. I think when we go to medical school, I don't recall having a lot of time spent on actually determining the best type of brace or orthotic. And during residency, I spent a little bit of time on that. But I wouldn't say it's very much a specialty determining a brace. And there are certain types of physicians who do have that specialty, but it's not something everybody does, and it's a small population of children who do need it. And so if you're unsure of what type of brace or prosthetic to give to the child, I think we're a great resource for that. A lot of times children who are in the early intervention services, the therapist will reach out to the primary care physician, the pediatrician, family practice and ask for a brace prescription.

And oftentimes, these EI therapists are very knowledgeable, but not everyone gets the same training. So if there's a question of what type of brace or you're unsure, I think that's a great time to refer to us. I think just when the kid's starting to walk, if they need a different device, that's a good time to refer them. I know we said that children under two are often too light for that device, but then we don't use the Zeno Walkway during that time. But we still will use the coronal and the sagittal cameras to assess the child if they're a new walker or too light for the mat. And we still do have the interdisciplinary team approach by both having the therapist, myself, as well as the orthotist in that clinic. So, we still are taking that approach together.

I would say for clinicians that, one, like orthopedic surgeons who maybe want to measure how the child is doing objectively over time, this could be a good clinic to utilize, because 3D gait analysis, which is a wonderful measure of how a child is walking and great for surgical planning, but it has to be approved through insurance. It is a very involved process and you need specialists who are skilled at running a 3D gait analysis, you can't really use that for real-time clinical decision-making. So if a physician is kind of wanting to see what their intervention is doing over time, we can take a snapshot and have some objective measures of how that kiddo is doing over time. So, I think that's a great utilization of this clinic as well. Also, if you've prescribed something and it's not working or the family isn't accepting of it and you can't really sort out why or if something I hear commonly is "They walk so much worse in the orthotic," and really orthotics for the most part are meant to increase a child's functional abilities. And so when you're hearing the device you're prescribing isn't helping that child functionally, then maybe taking a little bit of a deeper dive instead of just getting rid of the brace, let's take a deeper dive to see if maybe there's something we could do to modify that brace to make it better.

Melanie Cole (Host): Wow. Thank you so much. What an informative episode this was. Thank you both for joining us and telling us about all of the services at the Pediatric Gait Clinic. Thank you again. And to refer your patient or for more information, please visit our website at breakthroughsforphysicians.nm.org/rehabilitation to get connected with one of our providers.

That concludes this episode of Better Edge, a Northwestern Medicine Podcast for physicians. Please always remember to subscribe, rate and review this podcast and all the other Northwestern Medicine podcasts. I'm Melanie Cole.