Stepping out - Murdoch Childrens Research Institute

Stepping Out
The first 18 months of the Gait CCRE
August 2006

Our Goals
Through clinical research, we aim to:
FIND new ways to improve the mobility of Australians with cerebral palsy,
Parkinson’s disease, osteoarthritis, stroke and sporting injuries.
GENERATE knowledge about the measurement, pathophysiology and rehabilitation of walking.
UNCOVER the causes of gait disorders and find new ways to measure them in a clinical setting.
ESTABLISH an improved evidence base for gait analysis and multi-disciplinary treatment of gait disorders.
TRANSLATE our new knowledge to improve walking in children, adults and older people.
TRAIN clinicians in medicine, surgery and allied health in best clinical and
research practices for clinical gait analysis and gait rehabilitation.
PROVIDE excellent research training for post-graduate researchers in
medicine, surgery, allied health and biomechanics.
FOSTER collaboration with top international research, clinical and industry partners.
SHARE resources and bring experts together in a coordinated, priority-driven research plan.
DISSEMINATE our new knowledge to patients, health care organisations, professional
organisations, industry, the scientific community and the general public.
Contents
Director’s Report ...................................................................................................................................................................................................................................................... 1
Research Programmes:
Core Research Programme ...................................................................................................................................................................................................................... 3
Gait Analysis in Paediatric Orthopaedics ................................................................................................................................................................................... 4
Motor Control in Adults with Movement Disorders ......................................................................................................................................................... 5
Gait Analysis and Rehabilitation in Adults in Health and Disease ...................................................................................................................... 6
Gait Analysis in Adults with Osteoarthritis ................................................................................................................................................................................ 7
Muscle Function in Walking ..................................................................................................................................................................................................................... 8
Education:
Seminar Programme ........................................................................................................................................................................................................................................ 9
Doctoral Student Profiles ........................................................................................................................................................................................................................ 10
Translation:
Translation Committee ...............................................................................................................................................................................................................................11
Clinical Research Training Fellowships ........................................................................................................................................................................................11

Director’s Report
Richard Baker PhD CEng, CSci, Director, Gait CCRE
The Centre for Clinical Research Excellence in
Clinical Gait Analysis and Gait Rehabilitation (Gait
CCRE) is now 18 months old. It gives me great
pleasure to provide this report and reflect on what
we have done well and what we plan to do better.
The ability to walk is fundamental to a person’s
quality of life yet a substantial portion of Australia’s
population has difficulty walking. This includes
children with cerebral palsy, people injured playing
sport or older people with Parkinson disease,
osteoarthritis or suffering the effects of stroke.
The process of helping people improve their
walking ability crosses many medical areas. Doctors,
physiotherapists, prosthetists, orthotists and
podiatrists all work together.
In the clinical gait analysis laboratory, video cameras,
force plates, muscle activity sensors and computers
are used to record how people walk. The information
can either be used to support clinical decision making
or for research to evaluate the effectiveness of gait
rehabilitation. The Gait CCRE aims both to improve
the techniques used to make measurements and
to apply these techniques to understand better
our patient’s problems and methods we have to
help them.
Our primary funding is a $2 million, five-year grant
from the National Health and Medical Research
Council. We are now almost a third of the way through
this funding programme.
The early months of the Gait CCRE focussed on
establishing our operational structure and recruiting
post-doctoral research fellows and doctoral students.
The completion of this phase was symbolised by our
formal launch in July 2005. It was a great honour to
have the Federal Treasurer, the Hon. Peter Costello
MP, and the Patron of the Murdoch Childrens
Research Institute, Dame Elisabeth Murdoch AC DBE,
both present. Television and newspaper coverage of
the event was excellent.
Assembling the team
Twelve months on from that launch the real work
of conducting research, training researchers and
ensuring that results are translated into clinical
practice is well underway.
A strong team of researchers has now been
assembled, either directly funded from the CCRE
grant or from other funds that the Chief Investigators
have won. We now have a team of nine post-doctoral
research fellows and 14 doctoral students. This
collaborative working relationship gives us the critical
mass to do some really significant research. The quality
of that research can be judged by the fact that we have
had 59 papers published in peer reviewed journals and
another 21 submitted and awaiting publication.
Our winning record
We also have an excellent record in attracting
grant funding. Significant grants include a Michael
J Fox Foundation Clinical Discovery Grant (more than
$800,000), a project grant from the National Health
and Medical Research Council ($335,000), and others
from the US National Parkinson Disease Association
(more than $100,000) and the Hugh Williamson
Foundation ($300,000). We have also negotiated
research contracts with international companies
Vicon ($200,000) and Allergan ($400,000).
Gait CCRE Chief Investigators Professor Kerr Graham,
Professor Bob Iansek, Professor Meg Morris and Dr Richard Baker
(Professor Marcus Pandy and Dr Rory Wolfe absent)
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Spreading the word
The work of the CCRE has also been presented at
conferences and other scientific meetings around
the globe. Chief Investigators have given keynote
addresses at conferences in Piza (Italy), Salford (UK),
Amsterdam (The Netherlands), Kyoto (Japan), Utah
and Washington DC (USA), Kuala Lumpur (Malaysia),
Buenos Aires (Argentina) and Warsaw (Poland). Many
other papers have been presented at a variety of
other conferences.
The Gait CCRE will also be a key player at one of
the biggest gait analysis meetings ever staged - the
Joint Meeting of the European Society for Movement
Analysis in Adults and Children (ESMAC) and the
(North American) Gait and Clinical Movement Analysis
Society (GCMAS) in Amsterdam in September
2006. Our team will be represented by one keynote
presentation, five podium presentations and six
poster presentations.
Our activities have also attracted local and national
press, along with stories on television, radio and
internet news services. The biggest flurry of publicity
was the Gait CCRE launch in July 2005 by Federal
Treasurer Peter Costello and Murdoch Childrens
Research Institute patron Dame Elisabeth Murdoch
AC DBE. There was also widespread publicity in July
2006 when the US-based Michael J. Fox Foundation
gave $800,000 for research into Parkinson disease.
There were stories in 18 newspapers, with interviews on
Channel 9’s Today Show and evening news service. This
was even mentioned in the Sunday Age quiz section.
Training for the future
We take our role in education and training of clinical
researchers very seriously. All post-doctoral research
fellows have access to our mentoring programme. All
doctoral students are making considerable progress
towards their different research degrees. The monthly
Seminar Programme has been a real highlight of the
CCRE’s activities with a wide range of stimulating
talks. It is estimated that total attendance at the
seminars has now exceeded 600.
Translation of research findings into clinical practice
is a priority. The Translation Committee has now been
established and we thank all those representatives of
patient and professional organisations who have freely
given of their time to support this. The Clinical Research
Training Fellowships have so far given five clinicians
the opportunity to be trained in clinical research
methodology by undertaking small research projects
supervised by the Chief Investigators. This programme
is planned to expand significantly over coming years.
All in all the CCRE can be proud of its achievements
in its first 18 months. We plan to use this as a platform
to move forward. A particular aim over the next twelve
months is to develop our wider educational activities
with courses planned on Clinical Research Methods
in Gait Analysis and Rehabilitation (two days), Three
Dimensional Gait Analysis (three days) and Gait
Rehabilitation (three days).
Our ability to make so much progress in so short a
time is attributable to the support we have had from
many people and institutions, many highlighted in
this report. The Board of Management has worked
constructively and flexibly to support me and to
implement our original vision. The Translation
Committee has also made a valuable contribution.
My greatest delight however comes from working
with the expanding team of researchers, sharing their
excitement in learning more about how our patients
walk and how we can help them to walk better.
It is this that drives our research and it will be this,
ultimately, that leads to improvements in the lives
of Australians who find walking difficult.
Murdoch Childrens Research Institute patron Dame Elisabeth
Murdoch AC DBE and Federal Treasurer Peter Costello with cerebral
palsy patient Olivia Evans
Richard Baker PhD CEng CSci
Director, Gait CCRE
2 STEPPING OUT THE FIRST 18 MONTHS OF THE GAIT CCRE

Research:
Core Research Programme
Making better measurements.
The Gait CCRE is one of the few centres internationally
with the critical mass and resource base to undertake
the work of establishing an evidence base for the next
generation of measurement technology.
Figure illustrating
the theoretical work
of Richard Baker and
Anthony Schache
in relation to three
dimensional joint angles.
Our aim is to develop the best possible
measurements for gait analysis. Our team is testing
whether new technology gives repeatable results
and how valid the results are.
This expertise has led UK-based VICON to use
the Gait CCRE as the major test site for the new
generation of its modelling software.
Despite the advances in technology and
research, there is still very little known about how
an individual’s gait pattern varies during the day or
between days. Researchers are testing how accurate
measuring systems need to be to detect these
subtle changes.
across the world can use the Internet to upload
their own data to the Gaitabase and compare it
either with data collected within the Gait CCRE
or any other international partners they may wish
to work with.
Developed by Gait CCRE post-doctoral research
fellow Oren Tirosh, the Gaitabase will be launched
in Amsterdam in September 2006 at the first Joint
Meeting of the ESMAC and the (North American)
GCMAS.
Gaitabase can be found at
http://gaitabase.rch.org.au.
One of the programme’s most exciting projects
is the Gaitabase. In what is becoming the ultimate
collaborative research project, researchers from
Chief investigators:
Post-doctoral Research Fellows:
Research Assistants:
Richard Baker (MCRI/RCH)
Rory Wolfe (Monash University)
Jenny McGinley (MCRI)
Oren Tirosh (MCRI)
Anthony Schache (MCRI/RCH)
Jill Rodda (RCH)
Hylton Menz (La Trobe University)
Mohammed Azam (Monash University)
Pam Simpson (Monash University
Erika Gosney (MCRI),
Jill Rodda,
physiotherapist
and post-doctoral
research fellow
preparing a child
for gait analysis.
The home page that greets international collaborators when they
log on to the Gaitabase web-site, developed by post-doctoral
research fellow Oren Tirosh, to share data.
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Research:
Gait Analysis in Paediatric
Orthopaedics
Helping children with cerebral palsy.
Internationally there is considerable debate about
the success of orthopaedic surgery on children with
cerebral palsy.
Professor Kerr
Graham, Chief
Investigator and
Chairman of the CCRE
Board of Management
operates on a child
with cerebral palsy.
In a major clinical trial funded by the Hugh
Williamson Foundation, researchers want to find out
if children benefit from having correctional surgery
and post-operative physiotherapy over many years.
We have studied 19 patients so far, with one group
having surgery followed by physiotherapy and the
other group having surgery after a year of intensive
strength training.
Another trial is looking for ways to improve the
Botox ® treatment for children with cerebral palsy.
Specialists in the area know that injecting Botulinum
toxin into a patient’s calves can delay muscle
contractures between the knee and ankle, but it is
not clear how frequently the injections should be
given to children for optimal effect.
The Gait CCRE is planning a randomised controlled
trial to find an answer, but first we must complete
a study of how repeatable our measurements are,
with funding from Allergan PLC, the company that
supplies Botox ® .
We are also developing classification systems for
children with cerebral palsy to improve their clinical
management.
Gait CCRE researchers have also developed an
innovative mobility test which is attracting attention
around the world.
The Functional Mobility Scale monitors how children
with cerebral palsy move about over short, medium
and longer distances, representing home, school
and the wider community. The scale provides a clear
picture of how much a child depends on assistive
devices, such as crutches or wheelchairs.
Centres in Auckland, Chicago and Toronto are using
the scale. It is even being translated into Dutch for
use in the Netherlands.
Possible sites for
surgery for a child
with cerebral palsy.
Gait analysis is used
to decide which child
needs surgery to
which muscles.
Chief Investigator:
Collaborators:
Post-doctoral Research Fellows:
Post-graduate Students:
Research Assistants:
Kerr Graham (MCRI/RCH)
Karen Dodd, Nicholas Taylor (La Trobe University)
Barry Rawicki, Christine Blackburn (Monash Medical Centre)
Anthony Schache, Jill Rodda (RCH)
Adrienne Harvey, Jonathan Robin (MCRI/RCH)
Fiona Dobson (The University of Melbourne)
Pamela Thomason (MCRI/RCH)
Tandy Hastings-Ison (RCH)
The Functional Mobility Scale – Physiotherapist
Adrienne Harvey’s PhD project. This is currently
being translated into Dutch.
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Research: Motor Control
in Adults and Children with
Movement Disorders
How does the brain control walking
Finding out how the brain controls walking is a vital
step in helping people with basal ganglia diseases
such as Parkinson disease, Asperger syndrome and
Frontal Gait Apraxia.
As scientists better understand how these
diseases disrupt the body’s central motor control
mechanisms, it will open the way to better
treatments and rehabilitation.
One study investigates the inter-relationships of
gait variables, speed and ageing. Another project
aims to identify brain areas involved in gait control
mechanisms by use of mapping of electrical
potentials from the skull.
At a more specific level, researchers are using
3D motion analysis to study the biomechanics
and motor control needed to turn while walking
– an action that becomes difficult for people with
Parkinson disease and often causes falls.
The Gait CCRE team is also looking at how
Parkinson disease affects a person’s ability to stop
walking. The results will show whether the disease
scales down the basic stopping mechanism, or if a
completely different mechanism is used.
Another important study is looking for the cause
of frontal gait apraxia, which affects up to 20% of
elderly people.
Chief Investigator:
Biomechanist:
Collaborators:
Post-doctoral Research Fellows:
Post-graduate Students:
Research Assistant:
Children with autism and Asperger syndrome will be
the focus of a large project to improve the diagnosis
of the motor dysfunction aspects of Pervasive
Development Disorders. Researchers will determine
whether gait impairment differs between groups
and identify if gait patterning implicates dysfunction
in regions of the motor system.
There is also work underway on cerebellar-related
gait function in a study of people with the rare
genetic disorder Williams syndrome. The research
applies a number of different conditions and a range
of motor assessment methodologies.
Researchers are also evaluating the clinical outcomes
of deep brain stimulation surgery and conducting a
randomised controlled trial of rehabilitation during
inpatient management of people with Parkinson
disease.
Robert Iansek (Southern Health)
Anna Murphy (Southern Health)
Nicole Rinehart, Nellie Georgiou-Karistianis (Monash University)
David Reutens (Monash Medical Centre)
Meg Morris (The University of Melbourne)
Frances Huxham (Southern Health)
Peter Enticott (Monash University)
Mary Danoudis (La Trobe University)
Ashwini Nayate, Mary Karamitsios,
Darren Hocking, Rachel Chee (Monash University)
Dianne Cameron (Southern Health)
Team that was awarded
the Michael J Fox
Grant. Left to right:
Anna Murphy, Frances
Huxham, Bob Iansek,
Jenny Watts, Hylton
Menz, Meg Morris,
Jenny McGinley
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Research: Gait Analysis
and Rehabilitation in Adults
in Health and Disease
Improving quality of life for people with
Parkinson disease.
Gait rehabilitation is a crucial step in the recovery
process for people with neurological conditions such
as Parkinson disease, Huntington disease and stroke.
Therapists teach people how to walk again
and perform every day tasks in their homes and
communities. In short, they help people regain
quality of life.
This research stream focusses on understanding
gait disorders and falls in older adults in health and
disease. The research also investigates the effects
of different therapy interventions.
A team of researchers is looking at ways to
improve mobility and prevent falls in people
with Parkinson disease who live at home. This large
randomised controlled clinical trial starts with an
eight-week outpatient therapy programme, followed
by a 12-month analysis of walking ability, falls and
quality of life.
Another study is examining visual cues and
attention strategies can affect walking for people
with basal ganglia conditions when they walk or
cross obstacles. This research also explores different
strategies for regaining locomotor skills.
Researchers are also comparing therapies for people
hospitalised with Parkinson disease. The randomised
controlled clinical trial measures the effects of
strength training compared to general exercises
over 12 weeks.
In another important study, researchers have
launched a major study into ways to prevent the
high number of falls by older people and to thereby
reduce injury.
Despite research showing that a third of all
elderly people living in the community fall each
year, there have been few large Australian studies
on the predictors of falls in older adults in retirement
villages or the effects of different falls prevention
and mobility enhancement programmes. This
research will provide answers to this question.
Parkinson disease
patient Mr Donald
Petterson in the
Gait Laboratory
Chief Investigator:
Collaborators:
Post-doctoral Research Fellow:
Post-graduate Students:
Research Assistant:
Meg Morris (The University of Melbourne)
Hylton Menz (La Trobe University)
Louise Ada (University of Sydney)
Sandra Brauer (University of Queensland)
Tim Wrigley, Anthony Schache (The University of Melbourne)
Belinda Bilney (La Trobe University)
Gavin Williams (Epworth Rehabilitation),
Pamela Fok, Brook Galna, Susan Morris, Pagamas Piriyaprasarth
(The University of Melbourne)
Susan Morris, Natalyia Shkuratova (La Trobe University)
Jotika Anand (The University of Melbourne)
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Research: Gait Analysis
in Adults with Osteoarthritis
Finding relief for osteoarthritis.
Described by the World Health Organization
as a potential epidemic, osteoarthritis is a major
contributor to the cost of health care services in
an ageing society.
In Australia, about 3.1 million people live with
arthritis and more than half of these people are
between the working ages of 15 and 64 years.
Gait analysis is an important tool in researching
osteoarthritis – the most common form of arthritis.
Our researchers are studying osteoarthritis in knees
and feet, with a particular focus on the effects of
surgery.
For example, total knee replacement is used as
a last resort to treat osteoarthritic knees, but the
surgery is being performed more and more often
(approximately 25,000 annually in Australia) and in
younger patients. This will mean an increase in more
difficult and less predictable revision procedures
as a result of wear and loosening of the primary
prosthesis.
Researchers are using 3D motion analysis to evaluate
how patients complete a variety of tasks after total
knee replacement surgery. The results will provide
valuable information about how patients alter their
gait after surgery and enable researchers to develop
a standard evaluation protocol for both before and
after total knee replacement surgery.
Another project is looking at how gait patterns
of people with osteoarthritis of the knee can reflect
and/or contribute to their symptoms. A group
of patients undergoing high tibial osteotomy
(realignment surgery) will be evaluated both
before and after surgery.
Researchers are also studying the effect of modified
shoes or orthoses on people with osteoarthritis of
the first metatarsophalangeal joint in the toes.
It is therefore important to understand the reasons
why knee replacement surgery succeeds or fails.
Chief investigator:
Associate Investigator:
Post-graduate Students:
Julian Feller (La Trobe University)
Kate Webster (La Trobe University)
Jodie McClelland, Gerard Zammit (La Trobe University)
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Research:
Muscle Function in Walking
Walking into the future.
New tests showing the specific role of each muscle
as we walk are starting to provide some answers.
Muscle length
modelling as
carried out at the
Centre for Health,
Exercise and
Sports Medicine
at The University
of Melbourne.
Gait CCRE researchers are taking the science further.
Now that they have a biomechanical understanding
of why patients have trouble walking, they are now
able to work on solutions.
Chief Investigator Marcus Pandy built his reputation
on a theoretical model of walking that took months
to run, even on NASA’s super-computers. Now we
are developing models to run on ordinary desktop
computers to determine the function of individual
muscles – this time analysing real people.
Once the software is developed it will open up
a whole new avenue of research looking at the
function of individual muscles in people who have
difficulty in walking. It will also allow us to be more
specific in identifying those problems and proposing
treatments.
Another study is investigating the function
of individual muscles at different speeds. Most
existing studies in this area look at walking at normal
Chief investigator:
Post-doctoral Research Fellows:
Post-graduate Students:
speed. The research will also look at how walking
patterns change as people walk faster. This will help
determine the speed at which people choose to
start running.
In a related development, researchers are looking
at the function of muscles from different angles.
Most existing analyses of muscle function look at the
sagittal plane (as if looking from a side view of the
patient). The new research looks at the coronal plane
as well (as if looking from the front).
X-rays (fluoroscopy) are also being tested as a way to
enhance the measurement of knee joint movement.
Most gait analysis systems are based on measuring
the position of markers placed on the skin, which
can compromise accuracy as the skin moves. This
is a major issue for conditions like osteoarthritis in
the knee, where bone movements of less than a
millimetre can have a profound influence.
Marcus Pandy (The University of Melbourne)
Hyung Joo Kim (The University of Melbourne)
Justin Fernandez (The University of Melbourne)
Lauren Quaranta, Mirjana Jancic, Tam Nguyen,
Massoud Akbarshahi (The University of Melbourne)
Computer mesh
generated from MRI
data.
Segmentation of MRI image to obtain three dimensional
representation of the joint. Work at The University of Melbourne
Department of Mechanical and Manufacturing Engineering
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Education: Seminar Programme
The Gait CCRE is committed to providing the latest
research information to health professionals and the
scientific community.
Every four weeks on a Friday afternoon, the Gait
CCRE hosts seminars covering a range of topics.
Most seminars are presented by the Gait CCRE team,
but they also serve as a forum for Gait CCRE Visiting
Research Fellows, along with occasional speakers from
other organisations.
The following list shows the breadth of knowledge
covered by the seminars since they started in March
2005. Average attendance has been 38.
Speaker
Subject
Meg Morris, Gait CCRE Biomechanics and motor control of gait in Parkinson Disease 1
Jenny McGinley, Gait CCRE
Kerr Graham, Gait CCRE
Bev Eldridge, The Royal Children’s Hospital
Michael Gorman, Gorman ProMed PLC
Adrienne Harvey, Pam Thomason, Tandy Hastings-Ison,
Jill Rodda, The Royal Children’s Hospital
Pam Thomason, The Royal Children’s Hospital
Nick Taylor, Karen Dodd La Trobe University
Observation of push-off in gait following stroke
Remote activity monitoring
Three dimensional kinetics of normal walking
An RCT of single-event multilevel surgery for children with CP.
Progressive resistive strength training for young people with CP
Anthony Schache, Richard Baker, Gait CCRE A systematic approach to interpreting joint angles and moments 2
Seminar (various speakers)
Seminar (organised by Hylton Menz, La Trobe University)
Gait variability
Balance, falls and walking
Nick Taylor, Karen Dodd, Nora Shields, La Trobe University Systematic literature reviews
Oren Tirosh, Gait CCRE
GAITABASE a new web-accessible gait analysis data repository
Richard Baker, Gait CCRE The search for gait abnormalities larger than our measurement errors 3
Peter Hunter, University of Auckland, NZ
David Lloyd, University of Western Australia
David Morgan, Monash University
Meg Morris, Gait CCRE
Moira Clay, Murdoch Childrens Research Institute
Gavin Williams, Epworth Rehabilitation
The Physiome Project and multi-scale musculoskeletal modelling
Neuromuscular biomechanical modelling of knee joint stabilisation
Muscles as brakes: energetics, pain and tear Injuries
Translating research findings to enhance clinical practice
Kerr Graham, Gait CCRE
What is “clinical” gait analysis
Jill Rodda, Adrienne Harvey, The Royal Children’s Hospital
Anna Murphy, Barry Rawicki, Southern Health
Iain Charlton, VICON, Oxford, UK
PhD Forum
Marcus Pandy, Gait CCRE
Nadia Dominici, University of Rome Tor Vergata, Italy
Frances Huxham, Gait CCRE
Rory Wolfe, Gait CCRE
Marcus Pandy, Gait CCRE
Richard Baker, Gait CCRE
BJ Fregley, University of Florida, USA
Advanced kinematic modelling
Presentations from PhD candidates working within CCRE.
The function of individual muscles during walking
Neuromotor physiology: kinematic coordination of human gait
Turning during walking in Parkinson disease
Statistical methods in gait analysis
Biomechanics of the knee
1 A keynote address delivered to the Annual Meeting of the European Parkinson Disease Society, March, 2005.
Clinical trials to establish the efficacy of gait rehabilitation
Computational modelling of knee mechanics
2 A tutorial presented to the combined meeting of the International Society of Biomechanics and the American Society of Biomechanics, Cleveland, Ohio, August, 2005.
3 A keynote address given at Biomechanics of the Lower Limb in Health Disease and Rehabilitation, Salford, UK, September, 2005 and a telephone link address to the
Societá Italiana di Analisi del Movimento in Clinica, Piza, October, 2005.
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Education: Doctoral Student
Profiles
Best of both worlds
Melbourne trainee surgeon Jonathan Robin sees
research expertise as a crucial skill in giving his
patients the best possible treatment.
Fresh from completing his Basic Surgical Training last
year, Jonathan has put his promising surgical career
on hold to focus on research for the Gait CCRE and
the Murdoch Childrens Research Institute.
“The importance of research is really only understood
when there are decisions being made as a doctor and
a surgeon which have a real impact on a person’s life,”
Jonathan explained.
Jonathan is the orthopaedic clinical research fellow
at the Hugh Williamson Gait Analysis Laboratory at
The Royal Children’s Hospital. As part of his Doctorate
of Medicine with The University of Melbourne, he is
working on a major clinical trial to find out if children
with cerebral palsy benefit from having correctional
surgery and post-operative physiotherapy over
many years.
Research on the front line
Physiotherapist Gavin Williams sees the human cost
of road trauma every day at the Acquired Brain Injury
unit at the Epworth Hospital.
As part of his job in rehabilitation, Gavin also saw
victims expecting much more than the ability to walk
again. They wanted to be able to run, play sport and
resume their active lives.
In his recently-completed PhD, working with the
Gait CCRE and La Trobe University, Gavin developed
the HiMAT (High-level Mobility Assessment Tool) to
reflect goals higher than walking. The research has
been published in several brain injury journals and
more than 100 rehabilitation centres around the world
are now using the HiMAT.
Gavin recently started post-doctoral research, this
time using the gait laboratory to analyse walking and
running patterns of people with traumatic brain injury.
Taking our research to the world
Gait CCRE researcher and physiotherapist Jodie
McClelland will present the findings of her two
research projects at Amsterdam’s prestigious
JEGM Meeting in September 2006.
The La Trobe University PhD student used 3D gait
analysis to investigate how people recover from two
different types of knee replacement surgery –
unicompartmental knee replacement (which replaces
half the knee) and total knee replacement.
She investigated suggestions that the half knee
replacement, in preserving the anterior cruciate
ligament, created a more normal outcome for patients
than full replacement. Her study of 19 patients showed
no difference in walking patterns between the two
types of surgery.
Jodie is also researching pressure on the knee
joint after unilateral knee replacements when patients
negotiate small obstacles, compared to regular
walking.
Helping people walk after stroke
Thai academic Pagamas Piriyaprasarth won a
prestigious scholarship from the Thai Government
to complete her PhD with the Gait CCRE.
A physiotherapist with Thammasat University,
Pagamas specialises in neurology and has a particular
interest in gait disorders caused by stroke, which
led her to join Professor Meg Morris’ team at The
University of Melbourne.
Her doctoral research looks at factors influencing
knee control during walking after stroke. She has
already analysed the walking patterns of 25 stroke
patients from the Kingston Centre and Caulfield
General Medical Centre. Her findings are expected
to help physiotherapists manage knee control deficits
more effectively.
Pagamas is looking forward to maintaining links with
her Australian Gait CCRE partners when she returns
to Thailand in 2007.
< Pagamas Pirlyaprasarth
< Gavin Williams (second from
left) and participants in his
research study to assess running
ability in people who have had
a head injury.
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Translation
Turning Research into Reality
Finding ways to enhance the lives of people who
have trouble walking is a key element of our work
at the Gait CCRE.
Our Translation Committee represents an important
link to patient support groups, professional
associations and other stakeholders.
The volunteer committee members play a key role
in helping turn research findings into better clinical
practice. The committee members are listed below.
Meg Morris (Chair)
Camilla Page (Secretary)
Erin Wilson
Kellie Nicola-Richmond
Glenn Mahoney
Jill Hitchcock
Julie Bernhardt
Dawn Prasad
Amanda Bladen
Joanne Pugh
Kate Rickard
Delia Portlock
The University of Melbourne
Southern Health
Research Coordinator, SCOPE
Key Therapist Coordinator, SCOPE
CEO, Parkinson’s Victoria Inc
CEO, Australian Huntington’s Disease Association (Vic) Inc
Physiotherapist, Australian Physiotherapy Association
Physiotherapist, Multiple Sclerosis Australia
Occupational Therapist, OT Australia
Prosthetist/Orthotist, The Royal Children’s Hospital, Melbourne
Occupational Therapist, Southern Health
Headway Victoria
Clinical Research Training Fellowship Scheme
Clinical Research Training Fellowships are offered by
the Gait CCRE to clinicians who want to learn how to
do clinical research.
The scheme offers an opportunity for clinicians to
take time out from clinical responsibilities to work on
small research projects under guidance from senior
researchers within the Gait CCRE.
Clinicians receive up to $6000 to support their
research project, which can be used for any purpose
but is most often used to pay for the clinician’s own
time. In many cases this can be used as leverage
to get a matching contribution from the clinician’s
employer.
Our Fellows
Frances Huxham: (physiotherapist) - to allow completion of PhD looking at turning
in people with Parkinson disease.
Sanjay Raghav (neurologist) – to study step variability leading up to and during
planned stopping in Parkinson gait.
Pam Fok (physiotherapist) – to prepare ethics submission for a project looking at
dual task interference during gait in Parkinson disease. Pam has subsequently gone
on to register for a PhD.
Rachel Ward (biomedical engineer) – to complete a literature review of kinematic
constraints of the joints in the lower limb (accepted for presentation in Amsterdam
in September 2006).
Melanie Farlie (physiotherapist) – to investigate the effects of nutrition, care
and functional progressive resistance exercises on mobility in older adults living
in residential aged care.
From surgeons to biomedical engineers, the
fellowships also build expertise within the Gait CCRE.
STEPPING OUT THE FIRST 18 MONTHS OF THE GAIT CCRE
11

Appendices to Report
Keynote addresses and other invited presentations
HK Graham
• Australian Physiotherapy Association, Perth.
• First POSNA ASEAN Paediatric Orthopaedic Course, Kuala Lumpur, Malaysia.
• Australian Paediatric Orthopaedic Society Annual Meeting, Queensland.
• Childhood Disability Update, Mumbai, India.
• Cerebral Palsy Spasticity Control and Gait Disorders
Course, Buenos Aires, Argentina.
• AACPDM East European and Mediterranean Meeting on Cerebral
Palsy and Developmental Medicine, Warsaw, Poland.
R Iansek
• Queensland Physicians Multidisciplinary Symposium.
• Memory and Movement Specialist Forum, Victoria.
• Aged Care Conference, Victoria.
ME Morris
• American Physical Therapy Association III Step Conference, Utah, USA.
• RESCUE Conference, Newcastle, UK.
• International Parkinson Disease meeting, Washington, USA.
• Parkinson’s Disease Forum, Perth.
• European Parkinson’s Disease Conference, Amsterdam, The Netherlands.
R Baker
• Societa’ Italiana di Analisi del Movimento in Clinica, Piza, Italy.
• Biomechanics of the Lower Limb in Health Disease
and Rehabilitation. Salford, UK.
• First Joint Meeting of ESMAC & GCMAS, Amsterdam, The Netherlands.
• Australian Member Society of the International Society
of Prosthetics and Orthotics. Sydney.
• International Society of Biomechanics. Cleveland, Ohio, USA.
R Wolfe
• Southampton Statistical Sciences Research Seminars, Southampton, UK.
M Pandy
• Alfred Deakin Innovation Lecture, Melbourne.
• Dean’s Lecture, The University of Melbourne.
JA Feller
• Ullevaal University Hospital, Oslo, Norway.
• European Society of Sports Traumatology, Knee
Surgery and Arthroscopy, Innsbruck, Austria.
• Australian Orthopaedic Association Continuing
Orthopaedic Education Program Sydney.
Grants awarded
Clinical gait analysis and gait rehabilitation. Graham, Iansek, Morris, Baker,
Pandy, Wolfe. NHMRC CCRE Grant (Number 264597).$2,000,000 (5 yrs).
Preventing falls & improving mobility in Parkinson disease. Morris, Iansek, Huxham,
Menz, McGinley, Watts, Murphy. Michael J Fox Foundation. $820,000 (3yrs).
Frequency of intramuscular Botulinum Toxin A injections and
preservation of gastrocnemius length in ambulant children with
cerebral palsy: a randomised controlled trial. Hastings-Ison, Graham,
Rawicki, Blackburn, Baker. Allergan PLC. $400,000 (3yrs).
Recovery of walking after stroke using treadmill training. Ada, Morris,
Dean. NHMRC Project Grant (Number 02679). $335,125 (3 yrs).
Orthopaedic surgery for children with cerebral palsy. Baker,
Graham. Hugh Williamson Foundation. $300,000 (3 yrs).
Kinematics and kinetic modelling of gait data. Baker.
Oxford Metrics, UK. $160,000 (4 yrs).
Iansek & Morris. US National Parkinson Disease Association. $110,000 (1 yr).
Biomechanical modelling of hip muscle function during
locomotion in children with cerebral palsy. Baker, Graham,
Schache, Ditchfield. MCRI Project Grant. $58,749 (1 yr).
Gait analysis for knee replacement surgery. Feller,
Webster. Stryker Australia. $30,000 (1 yr).
Three dimensional motion analysis of high-level mobility following traumatic
brain injury. Williams. Royal Automobile Club of Victoria. $29,000 (1 yr).
Training dual tasking in Parkinson’s disease. Brauer, Morris,
Menz. Brain Foundation Research Grant. $20,050 (1 yr).
The validity of the next generation of clinical gait analysis
measurement techniques. Baker, Rodda, Schache, Ditchfield.
MCRI Musculoskeletal Theme Grant. $11,200.00 (1 yr).
Doctorates: Complete
Frances Huxham, Turning during walking in Parkinson’s disease.
Jill Rodda, Severe crouch gait in the sagittal gait patterns of spastic
diplegia: the impact of single event multilevel surgery.
Gavin Williams, The high-level mobility assessment tool for traumatic brain injury.
Doctorates: In progress
Massoud Akbarshahi, Accurate measurement of 3-D knee
kinematics in vivo using biplanar x-ray fluoroscopy.
Fiona Dobson, Gait pattern classification in hemiplegic cerebral palsy.
Pam Fok, Can people with Parkinson’s disease can learn to divide
their attention equally between walking and a cognitive task.
Brook Galna, Obstacle negotiation in PD.
Adrienne Harvey, The functional mobility scale.
Mirjana Jancic, Changes in leg muscle function with walking speed.
Jodie McLelland, Gait analysis after knee replacement surgery.
Susan Morris, Effects of progressive resistive strength
training in traumatic brain injury.
Tam Nguyen, Estimating the external load on the
lumbar spine using inverse dynamics.
Pagamas Piriyaprasarth, Proprioception disturbance in
stroke patients with knee hyperextension.
Lauren Quaranta, Muscle function in walking over obstacles.
Jonathan Robin (MD), Single event multilevel orthopaedic
surgery for children with cerebral palsy.
Natalyia Shkuratova, Age-related changes in balance control during walking.
Gerard Zammit, Osteoarthritis of the first metatarsophalangeal joint.
Post-doctoral research fellows
Karen Culhane, Instrumented monitoring of walking and mobility.
Justin Fernandez, x-ray fluoroscopy and joint pose-estimation
methods to investigate joint kinematics in-vivo.
Frances Huxham, Turning in people with Parkinson’s disease.
Hyung Joo Kim, Identification of muscle forces during
human locomotion using non-invasive techniques.
Jenny McGinley, Repeatability of gait patterns.
Jill Rodda, Crouch gait in cerebral palsy.
Anthony Schache, Musculoskeletal modelling of children with cerebral palsy.
Oren Tirosh, The Gaitabase.
Gavin Williams, Three dimensional motion analysis
of high-level mobility following traumatic brain injury
Book chapters
Feller et al. Proprioception and anterior cruciate ligament reconstruction. In:
Prodromos (ed). Anterior Cruciate Reconstruction: Technique, Fixation, Safety.
Morris et al. Clinical Gait Disorders in neurology. In: Hausdorff & Alexander
(eds). Gait Disorders: Evaluation and Management. Taylor and Francis, 2005.
Morris. Impairments, activity limitations and participation restrictions
in Parkinson’s disease. In: Refshauge, Ada & Ellis (eds) Science-based
rehabilitation: theories into practice. Butterworth Heinemann, 2005.
Morris, et al. Optimizing movement and preventing falls. Parkinson’s
disease: Strategies for patients and care-givers. In: Trail, Protas &
Lai (eds) Neurorehabilitation in Parkinson’s Disease: An Evidence-
Based Treatment Model. Slack Incorporated, 2007.
12 STEPPING OUT THE FIRST 18 MONTHS OF THE GAIT CCRE

Papers published or
accepted for publication
2005
Arnold et al. Muscular contributions
to hip and knee extension during the
single limb stance phase of normal
gait. J Biomech 2005;38: 2181-2189.
Baker. Gait analysis methods in
rehabilitation. J Neuroengineering
Rehabil 2006;3:4.
Bilney et al. Evidence for a disorder
of locomotor timing in Huntington’s
disease. Mov Disord 2005;20:51-57.
Chin et al. Accuracy of intramuscular
injection of botulinum toxin A in
juvenile cerebral palsy. J Pediatr
Orthop 2005;25:286-291.
Cook et al. High reproducibility of
patellar tendon vacularity assessed
by colour Doppler ultrasonography.
Br J Sports Med 2005;39:700-703.
Cook et al. Vascularity and pain
in the patellar tendon of adult
jumping athletes: a five month
longitudinal study. Br J Sports
Med 2005;39:458-461.
Cooper et al. A randomised
controlled trial of proprioceptive
and balance training after surgical
reconstruction of the anterior
cruciate ligament. Res Sports
Med 2005;13:217-30.
Cooper et al. A systematic review
of the effect of proprioceptive
and balance exercises on people
with an injured or reconstructed
anterior cruciate ligament.
Res Sports Med 2005;13:163-178.
Graham. Classifying cerebral palsy.
J Pediatr Orthop 2005;25:127-128.
Dobson et al. Multilevel
orthopaedic surgery in group IV
spastic hemiplegia. J Bone Joint
Surg Br 2005;87-B:548-555.
Howard et al. Cerebral palsy in
Victoria: motor types, topography
and gross motor function. J Paediatr
Child Health 2005;41:479-483.
Menz et al. Determinants of
disabling foot pain in retirement
village residents. Podiatr Med
Assoc 2005;95:573-579.
Menz et al. Foot and ankle
characteristics associated with
impaired balance and functional
ability in older people. J Gerontol A
Biol Sci Med Sci 2005;60:1546-1552.
Menz et al. Footwear characteristics
and foot problems in older people.
Gerontology 2005;51:346-351.
Morris et al. Three-dimensional
gait biomechanics in Parkinson’s
disease: evidence for a centrally
mediated amplitude regulation.
Mov Disord 2005;20:40-50.
Muir et al. Tibiotalocalcaneal
arthrodesis for severe calcaneovalgus
deformity in cerebral palsy. J Pediatr
Orthop 2005;25:651-656.
O’Halloran et al. Moderators of mood
during a 60-minute treadmill run. Int
J Sport Psychol 2005;36:241-250.
Pandy. Mixed forward and inverse
solutions in movement biomechanics.
Theo Iss Ergon Sci 2005;6:325-330.
Pizzari et al. Adherence to
rehabilitation following anterior
cruciate ligament reconstructive
surgery: implications for outcome.
J Sports Rehab 14:201-214.
Plummer et al. Clinical reasoning
processes in physiotherapists’
assessment of unilateral neglect:
Part one. ITJR 2005;12:498-504.
Plummer et al. Clinical reasoning
processes in physiotherapists’
assessment of unilateral neglect:
Part two. ITJR 2005;12:533-541.
Said et al. Control of lead and
trail limbs during obstacle
crossing following stroke.
Phys Ther 2005;85:413-427.
Schache et al. Are anthropometric
and kinematic parameters of
the lumbo-pelvic-hip complex
related to running injuries
Res Sports Med 2005;13:127-47.
Schoo et al. Predictors of home
exercise adherence in older
people with osteoarthritis.
Physiother. Can 2005;57:1-9.
Schoo et al. The effects of mode of
exercise instruction on compliance
with a home exercise program in
older adults with osteoarthritis.
Physiotherapy 2005;91:79-86.
Shelburne et al. Muscle, ligament,
and joint loading at the knee
during walking. Med Sci Sports
Exerc 2005;37:1948-56.
Shelburne et al. Theoretical
assessment of muscle compensation
for knee instability during ACLdeficient
gait. Med Sci Sports
Exerc 2005;37:642-648.
Stolwyk et al. Impact of internal
versus external cueing on
driving performance in people
with Parkinson’s disease.
Mov Disord 2005;20:849-857.
Webster et al. Gait patterns
following anterior cruciate
ligament reconstruction are
related to graft type. Am J Sports
Med 2005;33:247-254.
Webster et al. Impact of measurement
error in the analysis of bone tunnel
enlargement after anterior cruciate
ligament reconstruction. Am
J Sports Med 2005;33:1680-1687.
Webster et al. Validity of the
GAITRite walkway system for the
measurement of averaged and
individual step parameters of gait.
Gait Posture 2005;22:317-321.
Williams et al. The high-level
mobility assessment tool (HiMAT)
for traumatic brain injury. Part 1: Item
generation. Brain Inj 2005;19:833-843.
Williams et al. The high-level
mobility assessment tool (HiMAT)
for traumatic brain injury. Part 2:
content validity and discriminability.
Brain Inj 2005;19:925-932.
Wright et al. Treatments for paediatric
femoral fractures: a randomised
trial. Lancet 2005;365:1153-1158.
2006
Baker & Robb. Foot models
for clinical gait analysis. Gait
Posture 2006;23:399-400.
Davis et al. Paediatric quality
of life instruments: a review of
the impact of the conceptual
framework on outcomes. Dev
Med Child Neurol. 2006; 4:311-8.
Dobson et al. Clinical agreement
on gait pattern ratings in children
with spastic hemiplegia. Dev Med
Child Neurol 2006;48:429-35.
Hopyan et al. Function and
uptime following limb salvage,
amputation and rotationplasty
for paediatric sarcoma. J Pediatr
Orthop 2006;26:405-8.
Huxham et al. Defining spatial
parameters for non -linear walking.
Gait Posture 2006;23:159-163.
Ma et al. Lengthening and
transfer of hamstrings for a flexion
deformity of the knee in children
with bilateral cerebral palsy. J Bone
Joint Surg Br 2006;88-B:248-254.
McGinley et al. Accuracy of clinical
observations of push-off during
gait following stroke. Arch Phys
Med Rehabil 2006;87:779-785.
Menz et al. Footwear
characteristics and risk of indoor
and outdoor falls in older people.
Gerontology 2006;52:174-80.
Pathak et al. Management of
spasticity in adults: Practical
application of Botulinum toxin.
Eur J Neurol 2006;13 Suppl 1:42-50.
Plummer et al. Characterization of
unilateral neglect by physiotherapists.
Disabil Rehabil 2006;28:571-577.
Plummer et al. Physiotherapy
assessment of unilateral neglect:
Insights into procedures and
clinical reasoning. Physiotherapy
2006;92:103-109.
Schache et al. Defining the knee
joint flexion-extension axis for
purposes of quantitative gait
analysis: An evaluation of methods.
Gait Posture 2006;24:100-109.
Schwartz et al. A nondimensional
normalization scheme for
oxygen utilization data. Gait
Posture 2006; 24:14-23.
Soo et al. Hip displacement
in cerebral palsy. J Bone Joint
Surg Am 2006;88:121-129.
Teichtahl et al. Foot rotation:
A potential target to modify the
knee adduction moment. J Sci
Med Sport 2006;9:67-71.
Teichtahl et al. Sagittal plane
movement at the tibiofemoral joint
influences patellofemoral joint
structure in healthy adult women.
Osteoarthr. Cartil. 2006;14:331-336.
Webster et al. Balance confidence
and function after knee
replacement surgery. J Aging
Phys Act 2006;14:181-191.
Webster et al. Gait variability in
community dwelling adults with
Alzheimer disease. Alzheimer Dis
Assoc Disord 2006;20:37-40.
Williams et al. High-level Mobility
Assessment Tool (HiMAT): Interrater
reliability, retest reliability
and internal consistency. Phys
Ther 2006;86:395-400.
Williams et al. The concurrent
validity and responsiveness of the
High-level Mobility Assessment
Tool for measuring the mobility
limitations of people with
traumatic brain injury. Arch Phys
Med Rehabil 2006;87:437-442.
Young et al. The effect of topical
wheatgrass cream on chronic plantar
fasciitis: a randomized, doubleblind,
placebo-controlled trial.
Complement Ther Med 2006;14:3-9.
In press
Briggs et al. The effect of osteoporotic
vertebral fracture on predicted
spinal loads in vivo. Eur Spine J.
Dichiera et al. Kinematic patterns
associated with accuracy of the
drop punt kick in Australian rules
football. J Sci Med Sport.
Dobson et al. Gait classification
in children with cerebral palsy: A
systematic review. Gait Posture.
Fernandez & Pandy. Integrating
Modelling and Experiments to
Assess Dynamic Musculoskeletal
Function. Exp Physiol.
Fosang & Baker. A method for
comparing manual muscle strength
measurements with joint moments
during walking. Gait Posture.
Iansek et al. The sequence effect
and gait festination freezing in
Parkinson’s disease. Contributors
to freezing gait Mov Disord.
Liu et al. Muscles that support
the body also modulate
forward progression during
walking. J Biomech.
Menz et al. Clinical determinants of
plantar forces and pressures during
walking in older people. Gait Posture.
Morris et al. Effectiveness of
physiotherapy, occupational therapy
and speech therapy for people with
motor neurone disease: A systematic
review. Neurorehab Neur Rep.
Morris. Locomotor training in people
with Parkinson’s disease. Phys Ther.
Morris et al. Short-term relationships
between footstep variables in
young adults. Gait Posture.
Piriyaprasarth et al. Assessment of
proprioception in physiotherapists.
Int J Rehab Res.
Rodda et al. Correction of severe
crouch gait in spastic diplegia by
multilevel orthopedic surgery:
outcome at one and five years.
J Bone Joint Surg Am.
Rinehart et al. Gait function in highfunctioning
autism and Asperger’s
disorder: Evidence for Basal
Ganglia and Cerebellar Disorder.
Eur Child Adolesc Psychiatry.
Rinehartet al. Gait function in
newly diagnosed children with
autism (4-6 years of age): Further
evidence for cerebellar and basal
ganglia related motor disorder.
Dev Med Child Neurol.
Schache et al. Differences in lower
limb transverse plane joint moments
during gait when expressed in two
alternative reference. J Biomech.
Schache et al. On the
expression of joint moments
during gait. Gait Posture.
Siebold et al. Anterior cruciate
ligament reconstruction in females:
A comparison of hamstring tendon
and patellar tendon autografts. Knee
Surg Sports Traumatol Arthrosc.
Teichtahl et al. Investigating
the toe-out phenomenon - The
relationship between hip and foot
rotation and the knee adduction
moment during normal walking.
BMC Musculoskelet Disord.

This report has been published by
Gait CCRE, Hugh Williamson Gait Analysis Service,
Murdoch Childrens Research Institute,
The Royal Children’s Hospital,
Flemington Road, Parkville, Victoria 3052, Australia,
Telephone: +613 9345 5354,
Fax: +613 9345 5447,
Email: GaitCCRE@mcri.edu.au
Design by
Educational Resource Centre,
The Royal Children’s Hospital,
061229
Board of Management
Kerr Graham
Bob Iansek
Meg Morris
Rory Wolfe
Richard Baker
Julian Feller
Marcus Pandy,
Anne Cronin
Professor of Paediatric
Orthopaedic Surgery,
The University of
Melbourne
Director of
the Hugh Williamson
Gait Laboratory,
The Royal Children’s
Hospital
Professor of
Geriatric Neurology,
Monash University
Director of Geriatric
Neurology Service
and Geriatric
Research Unit,
Kingston Centre,
Southern Health
Professor of
Physiotherapy,
The University of
Melbourne
Associate Professor
in Biostatistics,
Department of
Epidemiology and
Preventive Medicine,
Monash University
Director of
the Gait CCRE,
Murdoch Childrens
Research Institute
Manager of
the Hugh Williamson
Gait Laboratory,
The Royal Children’s
Hospital
Orthopaedic surgeon
and Director of
The Musculoskeletal
Research Centre,
La Trobe University
Professor and Head
of Department of
Mechanical and
Manufacturing
Engineering,
The University of
Melbourne
Director
of Operations,
Murdoch Childrens
Research Institute