(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 / Right
Hindfoot
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 / Strength
hip 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

======

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 / Right
Spasticity:
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