Gait Study Inter Form
(Date)
(Name and address of referring physician, if indicated)
RE: Physician Review and Interpretation of Motion Analysis and Team Conference for Gait Study on (Patient’s name).
Date of Conference: (Date)
Date of Study: (Date)
Dear Dr. ____,
(Text of MD’s analysis and recommendations)
Sincerely,______, M.D.
Keck School of Medicine
University of Southern California
Childrens Hospital Los Angeles
NAME:
DATE OF BIRTH:
MR#:
DATE OF GAIT STUDY:
DIAGNOSIS:
REFERRING PHYSICIAN:
REASON FOR REFERRAL:
PREVIOUS SURGERIES:
GAIT HISTORY:
TODAY’S TEST:
(Codes for procedures performed)
PHYSICAL THERAPY EVALUATION
PHYSICAL STATUS:
Leg lengths: left: = cm, right: = cm measured ASIS to medial malleolus.
Height = cm; Weight= kg
FOOT POSITION:
Left / RightHindfoot
Forefoot
Longitudinal Arch
RANGE OF MOTION: / Left / Right
hip flexion / WNL / WNL
hip extension / ° / °
hip abduction, knees extended / ° / °
hip abduction, knees flexed / ° / °
hip internal rotation (prone) / ° / °
hip external rotation (prone) / ° / °
popliteal angle (with opposite hip extended) / ° / °
popliteal angle (with opposite hip flexed) / ° / °
knee flexion / WNL / WNL
knee extension / ° / °
dorsiflexion, knee flexed / º inverted,
° neutral / º inverted,
° neutral
dorsiflexion, knee extended / º inverted,
° neutral / º inverted,
° neutral
forefoot inversion / ° / °
forefoot eversion / ° / °
hindfoot inversion / ° / °
hindfoot eversion / ° / °
femoral anteversion / ° / °
transmalleolar angle / º ternal / º ternal
hindfoot-thigh angle / º ternal / º ternal
thigh-foot angle / º ternal / º ternal
(Photos of feet inserted here, if needed)
SELECTIVITY/STRENGTH** selectivity graded 0 = no selective control, 1 = partial selective control, 2 = full selective control. Strength rated on traditional 5 grade scale, in mass pattern when unable to isolate movement.
Left /Right
Selectivity / Strength / Selectivity / Strengthhip flexion / NT / /5 / NT / /5
hip extension / /2 / /5 / /2 / /5
hip abduction / /2 / /5 / /2 / /5
knee flexion / /2 / /5 / /2 / /5
knee extension / /2 / /5 / /2 / /5
dorsiflexion / /2 / /5 / /2 / /5
plantarflexion / /2 / /5 / /2 / /5
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Motion Analysis Laboratory Patient Name:
Gait Analysis Study Medical Record Number:
Childrens Hospital Los Angeles
Division of Orthopaedic Surgery
4650 Sunset Blvd.
Los Angeles, California 90027
(323) 361-4120 XXX
NEUROLOGICAL SIGNS. Rated according to the modified Ashworth scale (please see key below).
Left / RightSpasticity:
Hip adductors
Hamstrings
Quadriceps
Duncan-Ely (rectus test)
Plantarflexors
Posterior tibialis
NEUROLOGICAL SIGNS.
Modified Ashworth Scale for Grading Spasticity:
Grade Description
0 No increase in muscle tone.
1 Slight increase in muscle tone, manifested by a catch and release
or by minimal resistance at the end of the range of motion when
the affected part(s) is moved in flexion or extension.
1+ Slight increase in muscle tone, manifested by a catch, followed by
minimal resistance throughout the remainder (less than half) of
the ROM.
2 More marked increase in muscle tone through most of the ROM,
but affected part(s) easily moved.
3 Considerable increase in muscle tone, passive movement difficult.
4 Affected part(s) rigid in flexion or extension.
SLOW MOTION VIDEOTAPE ANALYSIS
(Narrative of observational gait assessment)
======
Motion Analysis Laboratory Patient Name:
Gait Analysis Study Medical Record Number:
Childrens Hospital Los Angeles
Division of Orthopaedic Surgery
4650 Sunset Blvd.
Los Angeles, California 90027
(323) 361-4120 XXX
INFORMATION ANALYSIS
STRIDE CHARACTERISTICS : / Barefoot.velocity (m/min) / (%N)
cadence (steps/min) / (%N)
stride length (m) / (%N)
step length (m) /
Left Right
gait cycle time (s) / (%N)double limb stance (% gc)
(initial + terminal) / %gc (%N)
single limb stance (% gc) / Left
%gc (%N) / Right
%gc (%N)
gc = gait cycle
STRIDE CHARACTERISTICS : / Braced.velocity (m/min) / (%N)
cadence (steps/min) / (%N)
stride length (m) / (%N)
step length (m) /
Left Right
gait cycle time (s) / (%N)double limb stance (% gc)
(initial + terminal) / %gc (%N)
single limb stance (% gc) / Left
%gc (%N) / Right
%gc (%N)
gc = gait cycle
FOOT FLOOR CONTACT PATTERNS:
Barefoot.
Left side:
Right side:
(Kinematic graphs inserted here)
(Kinetic graphs inserted here)
(EMG graphs inserted here)
SUMMARY AND TEAM CONFERENCE
The pertinent findings of the gait analysis data include:
______
(PT’s name)
Motion Laboratory
Physical Therapist
======
Motion Analysis Laboratory Patient Name:
Gait Analysis Study Medical Record Number:
Childrens Hospital Los Angeles
Division of Orthopaedic Surgery
4650 Sunset Blvd.
Los Angeles, California 90027
(323) 361-4120 XXX