Walking Through Open Doors
By Susan Verbrugge Guck

Dr. James Gage follows his heart to establish first gait analysis lab

When James Gage was growing up in Minnesota, he wanted to be an engineer. God had a different plan. In His plan, James was to be an orthopedic surgeon. God’s plan worked. After 30 years as a physician and a surgeon, Dr. Gage is world renown for his pioneering work in analyzing, diagnosing and treating the walking disorders of children with cerebral palsy through the establishment of the gait analysis laboratory. His story shows how God opens doors (and labs) to do his work.

"Cerebral palsy is very challenging," says Dr. James Gage. "Like I tell my students, ‘I give the same test every year, I just change the answers.’ This is a very complex disease; one that we still know very little about."

Part of what makes cerebral palsy so complicated is that it’s a neuromuscular problem resulting from an injury to the brain, often before birth. So while these children are born with normal bones and muscles, the connection between their brains and their bodies is broken, causing poor overall balance, an inability to control certain muscles and poor coordination of muscle groups.

A big part of the challenge in treating cerebral palsy is that a physician can’t tell what’s wrong just by looking at a child with the disease. In fact, according to Gage, two children who look the same, walk the same and test the same upon examination may have different outcomes to the same surgical procedure. "In the past, doctors would simply watch the kid walk, then lay him down on the operating table and cut, hoping to make things work," says Gage. "It was like a heart surgeon trying to operate with a stethoscope. Chances are they wouldn’t get it right."

For Gage, operating on chance wasn’t good enough. Through his schooling at Calvin College, followed by four years at Northwestern Medical College and 10 years as a practicing physician and surgeon, he had learned to challenge the status quo. When he joined the Newington Children’s Hospital staff in Connecticut in 1976 and was promoted to director of the cerebral palsy service in 1978, it was apparent to him that they needed a different approach. "The treatment of cerebral palsy at that time was an art, not a science. Nothing existed to do testing," says Gage.

The need for a more scientific approach led Gage to California to study the work of University of California researcher Verne T. Inman. Inman had been examining the way people walk since shortly after World War II. Called "gait analysis," the system involved breaking down the walking cycle by measuring the specific pattern of motion at each major leg joint. The researchers filmed people walking, broke down the film frame by frame and then digitized it by hand so they could analyze it. It was an extremely time-consuming process, making it impractical in a clinical setting.

Dr. Gage, however, had a vision. If he could establish a computer lab to automate the process, this technology could be extremely valuable in analyzing children with cerebral palsy. Setting up a computerized clinical laboratory, however, was no small feat. It required lots of money; money the hospital didn’t have.

Not easily discouraged, Gage contacted the research center at Hartford-based United Technologies Corporation – an unusual choice given UT’s specialty in designing missile tracking systems. However, UT had what he needed most: the engineers and technical expertise to design a computerized system that could strip out all irrelevant information, leaving just the data points which would provide useful information about the most important joints and muscles used for walking. Still, it was a long shot.

"The first thing I remember about meeting Wesley Kurt [head of the research center at UT] was the Gideon pin he was wearing," said Gage. "I remember telling him, ‘You don’t know us, but this is what we do, and we need your help.’ He looked at me and said, ‘Sure I know you. My sister is the head of the physical therapy department at Newington Hospital.’" Open door number one.

But while the original estimate for the project had been $150,000, the revised estimate came back at more than $700,000: $500,000 for the research and computer equipment and another $200,000 for remodeling the physical space for the lab. "When I heard that figure I thought, ‘There goes a dream,’" said Gage.

However, United Technologies agreed to donate their research – a $250,000 gift. After a few basic experiments in UT’s lab, they came up with an elegantly simple solution: attach small round reflectors to the patient at the critical joints and muscles. The patient then walks down a 10-foot long measurement area while being videotaped by eight video cameras, six of which emit infrared light at 60 times per second, collecting information from those essential data points. Information from the cameras downloads into a computer that connects the data points, creating frame by frame stick-figure images that can be viewed on a black computer screen. These images are later broken down into graphs that show where the patient’s gait deviates from normal gait. In addition, the system provides a wealth of information on muscle movement, energy expenditure and the sequence in which nerves fire.

Developing the solution was only part of the issue, however, Gage still needed equipment for the lab and money for the remodeling. Feeling the crunch, Gage placed a call to Tom Kamp, a Christian friend from Minneapolis who was a vice president at Control Data Corporation and who also had been instrumental in leading Gage to UT. Open door number two.

"I called Tom and asked, ‘Tom, what can you give me?’ He immediately pointed out that I needed digital equipment, something Control Data couldn’t offer," said Gage. "But he said he’d place a call to a friend of his -- Ken Olsen, founder and president of Digital Equipment Corporation. The next week the phone rang. It was Olsen’s secretary who said Ken was requesting the hardware list. Mr. Olsen agreed to sell the equipment that we needed for the lab at cost -- $44,000."

This donation was the beginning of solid publicity for the project, and doors started opening everywhere. Soon insurance companies from Hartford were jumping on board, as were other corporations from around the state pledging significant cash contributions to the project. In the end, Gage ended up with more money than was needed, and the first clinical lab of its kind opened in 1981 at Newington Children’s Hospital.

Now 17 years later, there are more than 50 gait analysis labs in the country, nearly half of which are used in clinical settings. Gage has moved on to become the medical director of Gillette Children’s hospital in St. Paul, Minnesota, where he opened the country’s second gait analysis lab in 1987. Gillette’s gait lab is considered to be the busiest in the country. In 1997, more than 360 patients were given a full analysis in the lab, in addition to more than 80 patients who came to the lab for examination by video. These statistics are even more remarkable when you consider that each gait analysis contains three person years of data using the manual processes from the late ’70s.

However, even with the significant advancements in technology, Gage is quick to point out that gait analysis is still in its infancy and the surgical solutions are far from perfect. "These kids are all different, and you need to realize that you can’t fix it all," says Gage. "In this line of work I often think of the prayer by Reinhold Niebuhr: ‘God give me the serenity to accept the things I cannot change, the courage to change the things I can, and the wisdom to know the difference.’ "

Now high in demand as both an expert speaker at medical conferences and as a volunteer surgeon on third-world medical teams, Dr. James Gage and his wife Mary frequently travel to countries around the world where they share their talents and knowledge with others. "When I look back, I see God’s providence," he says. "My ideal job is doing what I’m doing -- helping kids. This is my challenge and my love, and it’s very rewarding to be a part of this long, but exciting journey."