3. Clinical Governance
“... a system through which [healthcare]
organisations are accountable for
continuously improving the quality of their
services and safeguarding high standards of
care by creating an environment in which
excellence in clinical care will flourish".
3
Scally, G. and L. Donaldson, Clinical governance and the drive
for quality improvement in the new NHS in England.
British Medical Journal, 1998. 317: 61-65.
4. Clinical Governance
“... a system through which [healthcare]
organisations are accountable for
continuously improving the quality of their
services and safeguarding high standards of
care by creating an environment in which
excellence in clinical care will flourish".
4
Scally, G. and L. Donaldson, Clinical governance and the drive
for quality improvement in the new NHS in England.
British Medical Journal, 1998. 317: 61-65.
5. What is clinical gait
analysis?
Richard Baker
Professor of Clinical Gait Analysis
5
6. Clinical Gait Analysis
The process of determining what is causing
the patient to walk the way they do.
Based on:
• Instrumented measurement
– (essentially objective)
• Biomechanical interpretation
– (considerable subjectivity)
6
7. Clinical Gait Analysis
The process of determining what is causing
the patient to walk the way they do.
Deciding how the results of the analysis
impact on the management of the child is
a separate issue.
7
8. Why separate gait analysis and
clinical decision making?
1. Assurance of the quality of gait analysis
data is difficult enough without having to
worry about what to do with the results.
8
9. Why separate gait analysis and
clinical decision making?
2. Collecting gait data and making clinical
decisions are very different skills requiring
very different competencies from staff.
9
10. Why separate gait analysis and
clinical decision making?
3. Gait analysis has come in for
considerable criticism because it results
in “widely divergent treatment outcomes”.
10
Wright, J.,
Pro: Interobserver variability of Gait Analysis.
Journal of Pediatric Orthopaedics, 2003. 23:288-289.
11. Two models of provision
• Integration of gait analysis and clinical
decision making services
• Separation of gait analysis and clinical
decision making services
11
16. Clinical Gait Analysis
The process of determining what is causing
the patient to walk the way they do.
Identify the impairments that are most likely
to be affecting the walking pattern.
16
17. Clinical Gait Analysis
The process of determining what is causing
the patient to walk the way they do.
Identify the impairments that are most likely
to be affecting the walking pattern.
17
18. Impairment
A problem in body structures or functions
such as significant deviation or loss1.
• Hip flexion contracture
• Gastrocnemius spasticity
• Persistent femoral anteversion
• Gluteus medius weakness
1WHO International Classification of Functioning, Disability and Health, 2001
19. Report
• Primary output of gait analysis
• Often the only product of the gait analysis
that the treating clinician receives
• Should specify the impairments affecting
walking
• Is the result of the biomechanical analysis
• Written by gait analyst
19
20. Treatment recommendations
• Based on gait report and other
considerations
• Responsibility of treating clinician
• Decision by patient/family
20
21. Impairments
Hip flexion contracture
Gastrocnemius spasticity
Persistent femoral
anteversion
Gluteus medius weakness
Recommendations
Hip flexor release
Injection of Botulinum toxin
to gastrocnemius
Femoral derotation
osteotomy
Progressive resistive
strength training
21
23. Relevant
What does the referrer want to know?
– Specific question in referral
– What is wrong with the patient ?
(What are the impairments?)
– What treatment would you recommend?
(only if you are qualified to recommend treatment)
24. Succinct
If the referring surgeon wants to know what
is wrong with the patient then you should tell
him or her.
• Anteverted left femur
• Spasticity of left gastrocnemius
• Tight hip flexors bilaterally
25. Transparent
Because the interpretation has a
considerable subjective element the link
between the conclusions and the underlying
data should be explicit.
The anteverted left femur leads to internal
rotation of the left hip and internal left foot
progression and is confirmed on clinical
exam.
26. Evidence based
The link between conclusion and evidence
should be transparent and based on
rigorous biomechanics or other evidence.
“Good” biomechanical reasoning derives
from the well established laws of physics
and mathematics and should not required
further clinical justification.
27. Evidence based
Good biomechanical reasoning derives from
the well established laws of physics and
mathematics and should not required further
clinical justification.
Verifying biomechanical reasoning through
clinical studies is a strong protection against
poor biomechanics.
28. Comprehensive
Any clinical service has a duty of care to
ensure that nothing of clinical importance
has been over-looked.
This may require consideration of factors
that have not been specifically mentioned in
the referral letter.
29. Within competence of authors
Clinical recommendations should only be
made by clinicians who are competent to
make them (have appropriate training,
qualifications and professional registration).
30. Time efficient
Reports need to be written in way that is:
• time efficient for the author
(team reporting?)
• quickly and clearly understood by the
reader
30
31. Principles of reporting
Reports should be:
Relevant
Succinct
Transparent
Evidence based
Comprehensive
Within the competence of the authors
Time efficient
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