Unit 5 - Basic Gait

Rancho Los Amigos Phases of Gait

Review of Typical Gait

Gait Parameters: Temporal

• cadence

• stride and step time

• velocity

Review of Typical Gait

Gait Parameters: Spatial

• velocity

• stride and step length

• step width

• foot angle

Identifying/Documenting Gait Deviations

1. Note WHEN the deviation(s) occur: Swing or Stance Phase and which sub-phase e.g., Initial Contact, Loading Response

   1. Ex: Foot drag noted during swing

2. Describe WHAT the deviation consists of: e.g., rapid ankle plantarflexion during loading response causing a foot slap

   1. Ex: R foot drag during swing

3. Add impact (RESULTS) on 3 functional tasks of gait: (Weight acceptance, SLS, Swing leg advancement)

   1. Ex: L lateral trunk lean during R swing

4. Hypothesize possible Impairments causing (WHY) the gait deviation: e.g., foot slap during loading response could be due to weak ankle dorsiflexors

   1. Ex: Delayed ankle temporal sequencing

Observational Gait Analysis

sagittal and frontal

Gait Analysis

• notice deviations

• determine impairments

• Test, Test, Test!!

• Analyze hypothesized impairments

• Identify what is actually contributing to the deviations

• Develop interventions

  • Task Oriented Approach

  • Motor Relearning Programme

  • Augmented intervention

  • Compensatory strategies

  • Impairment-based interventions

Part to Whole Task

Pre-gait —> gait

Part to Whole Task

Pre-Gait Indications

• Increased comfort

  • LE WB in stance

  • Single Leg Stance

• Proprioception

Part to Whole Task

Gait

• Carryover to whole-task

• Continuous task practice

• Promote Motor Learning

Gait: Strength

Overview

• Gait as a complex, dynamic process

• There should be sufficient strength in the upper and lower extremities for effective gait

• Focus: Impairment management in physical therapy to improve strength and gait performance

Gait Cycle Overview

• Phases of the Gait Cycle:

  • Stance Phase 60%

  • Swing Phase 40%

  • Muscle control important in each phase

Gait: Strength

Upper Extremities

• Reciprocal arm swing

• Muscles: deltoids, trapezius, latissimus dorsi

• Role in trunk rotation, balance, and momentum

Gait: Strength

Lower Extremities

• Stance phase: glutes, quadriceps, calves

• Swing phase: hip flexors, hamstrings, dorsiflexors

• Function: stabilization, propulsion, clearance

Gait: Strength

Arm Swing and Balance

• Counterbalance for lower extremities

• Assist with maintaining posture and forward momentum

Gait: Strength

Strength Contribution

Role of shoulder, elbow, and wrist muscles in supporting gait dynamics

Gait: Strength

Role of Lower Extremities in Gait

• Coordination

• Alternating movement: stance and swing phase

• Strength Contribution

  • Power generation for forward propulsion

  • Stability during stance phase

Gait: Strength

Effects of UE Weakness

• Reduced arm swing → decreased trunk rotation

• Poor balance control

• Compensation via increased trunk motion

Gait: Strength

Effects of LE Weakness

• Gluteus medius weakness → Trendelenburg gait

• Quads weakness → knee instability

• Dorsiflexor weakness → foot drop, toe drag

Gait: Strength

Common Impairments in Gait

• Weakness in Lower Extremities

  • Foot drop

  • Knee instability

  • Decreased hip stability

• Upper Extremity Impairments

  • Reduced arm swing

  • Poor posture affecting balance

• Impact on Gait Patterns

Gait: Strength

Functional Consequences on Gait

• Decreased walking speed

• Increased energy cost

• Higher fall risk

• Altered posture & compensatory movement patterns

Gait: Strength

Assessment of Muscle Strength

• MMT (Manual Muscle Testing)

• Handheld dynamometry

• Functional gait analysis (10MWT, TUG, 6MWT)

Gait: Strength

Strengthening Interventions: UE

• Improve postural control and arm swing

• Exercises: shoulder flexion/extension, lats pulldowns, scapular stability

Gait: Strength

Strengthening Interventions: LE

• Focus muscles: glutes, quads, hamstrings, dorsiflexors, calves

• Examples: bridges, step-ups, resisted marching, toe raises

Gait: Tone

Types

• Normal

• Hypotonia

• Hypertonia (Spasticity, Rigidity)

Gait: Tone

Impairment Management

• Tone’s role in postural control and movement

• Gait:

  • Phases: Stance phase & Swing phase

  • Reciprocal movement

  • Coordination and timing in gait

Gait: Tone

Tone in UE

• Reduced arm swing

• Poor postural control

• May rely on compensatory trunk movements

• Reduced coordination and stability

Gait: Tone

Tone in LE

• Hypertonia (e.g., spasticity in calf muscles): toe walking, stiff-legged gait

• Hypotonia: poor push-off, knee buckling

• Muscle groups commonly affected: gastrocnemius, hamstrings, quadriceps

Gait: Tone

Hypertonicity in Gait (UE) —> Common Presentation & Impact on Gait

• Common Presentation

  • Flexor synergy patterns: shoulder adduction, elbow flexion

  • Minimal arm swing

  • Balance and trunk rotation affected

• Impact

  • decreased efficiency, asymmetry

Gait: Tone

Hypertonicity in Gait (LE) —> Common Presentation & Impact on Gait

• Common Presentation

  • Equinus foot (tight calf)

  • Knee hyperextension

  • Hip adduction (scissoring gait)

• Impact

  • Reduced step length, poor foot clearance

Gait: Tone

Hypotonicity in Gait (UE) —> Common Presentation & Impact on Gait

• Common Presentation

  • Reduced arm swing

  • Poor postural control

• Impact

  • May rely on compensatory trunk movements

Gait: Tone

Hypotonicity in Gait (LE) —> Common Presentation & Impact on Gait

• Common Presentation

  • Poor push-off during terminal stance

  • Difficulty with knee control → buckling

• Impact

  • Wide base

  • Slow, unsteady gait

  • High risk of falls

Gait: Tone

Gait Patterns Seen with Hypertonia

• Spastic hemiplegic gait: Stiff leg, circumduction

• Scissoring gait: legs cross midline due to hip adduction

• Decreased stride length and cadence

• Poor foot clearance

Gait: Tone

Gait Patterns Seen with Hypotonia

• Ataxic gait: Unsteady, wide-based, irregular steps

• Trendelenburg gait: Hip drop due to weak abductors

• Joint hypermobility → compensatory overuse

Gait: Tone

Physical Therapy Goals

• Improve functional mobility

• Normalize tone as much as possible

• Prevent contractures or instability

• Improve reciprocal movement

• Improve postural control

• Enhance gait efficiency and safety

Gait: Tone

Interventions for Hypertonicity

• Passive and active ROM

• Positioning to reduce synergy patterns

• Neuromuscular re-education

• Functional arm tasks during ambulation

• Constraint-Induced Movement Therapy (CIMT)

• Stretching and prolonged positioning

• Weight-bearing and gait training

• Orthotics (e.g., AFOs)

• Functional Electrical Stimulation (FES)

• Botulinum toxin injections

• Task-specific training

Gait: Tone

Interventions for Hypotonicity

• Strengthening and endurance training

• Core stabilization and postural control

• Balance and proprioception exercises

• Assistive devices as needed (canes, walkers)

• Task-specific practice to improve motor learning

Gait: Tone

Common Neurological Conditions Affecting Tone

• Stroke

• Cerebral palsy

• Multiple sclerosis

• Parkinson’s disease

• Spinal Cord Injury

• Other traumatic and neurological conditions

Gait: Ataxia/Incoordination

Ex: Safety Considerations

• Guard the patient appropriately: gait belt, use safety harness when necessary

• Assess for fall risk established outcome measures

• Improve overall balance and postural control with activities

• Improve coordination and overall lower limb progression sequence

• Improve overall confidence in ambulation

• Fall prevention education

Gait: Ataxia/Incoordination

Ex: Interventions —> Pre Gait activities

• Static trunk control: Sitting and Standing

• Weight shifts in standing

• Forward and side stepping with upper limb support > progress to without upper limb support

• Turning around in place: with and without upper limb support

• Initial gait training in parallel bars, focus is on proper lower limb progression

Gait: Ataxia/Incoordination

Ex: Interventions —> Gait training: Improving gait pattern

• Practice stepping over obstacles: initially had a smaller height, progress to at higher height

• Practice weight shifting: front and back, side to side

• Marching in place

• Walking forward with emphasis on feet at shoulder width distance and symmetrical step length

• Use external cues: auditory, tape on ground (visual)

Gait: Ataxia/Incoordination

Ex: Interventions —> Gait training: Progression

• Ambulating in a closed space to ambulating in a busy clinic area

• Continue to evaluate the use of assistive devices with the idea that the patient should be progressed safely to the less use of assistive devices

• Ambulating on hard surfaces to carpeted surfaces and ambulating up and down a ramp

• Use of technology such as VR systems to improve ambulation

Gait: Ataxia/Incoordination

Ex: Home Exercise Program

• Prioritize safety: patient and caregiver education

• Encourage functional performance: ambulating to mailbox, backyard

• Promote confidence and independence

Gait: Somatosensation

Impact on Basic Gait

• These sensations guide limb positioning and movement awareness during gait

• Basic gait involves part-to-whole task training, single leg stance, and continuous task practice

• Deficits in somatosensation impair foot clearance, weight shifting, and balance

Gait: Somatosensation

Ex: Treatment Considerations

• Emphasize proprioceptive retraining for knee and ankle

• Use repetitive, task-specific, and meaningful interventions

• Utilize visual, tactile, and auditory cues

• Incorporate dual-task or sport-relevant elements to enhance saliency

Gait: Somatosensation

Ex: Compensatory Interventions

• Mirror feedback during overground/treadmill walking

• Visual floor targets

• Metronome pacing

• AFO or brace

• Verbal/tactile cues

Gait: Somatosensation

Ex: Restorative Interventions

• Weight-bearing drills

  • Compliant and noncompliant surfaces

• Task specific training

• Dual-task

Gait: Vision

Vision in Basic Gait

• Visual Input for Postural Control and Balance

• Spatial Orientation and Navigation

• Compensatory Gait Strategies Due to Visual Deficits

• Increased Fall Risk and Safety Concerns

Gait: Vision

Ex: Treatment Considerations

• Improve safe and functional ambulation

• Enhance visual-motor integration

• Promote independence in mobility

• Reduce fall risk

• Foster motor learning

Gait: Vision

Ex: Compensatory Interventions

• Environmental Modifications

• Assistive Strategies

• Cueing

Gait: Vision

Ex: Restorative Interventions

• Visual-Motor Retraining

• Task-Oriented Gait Practice

Gait: Balance

Upright Mobility

• Ability to move the body from one place to another while in an upright position:

  • Walking

  • Running

  • Inclined climbing/Stair climbing

Gait: Balance

Upright Mobility requires…

• Progression in the desired direction

• Postural control and balance

• Adaptation to the task and demands of the environment

Gait: Balance

Primary Impairments Affecting Gait

• Muscle weakness

• Decreased joint ROM

• Sensory loss

• Poor control of limb segments

• Difficulty with balance/coordination

• Perceptual impairments

• Cognitive impairments

Gait: Balance

Secondary Impairments Affecting Gait

• Progression of muscle weakness and limitations in joint mobility

• Deconditioning

• Skin breakdown

• Obesity

• Cardiovascular disease

Gait: Balance

Safety Considerations

• Assess for fall risk using reliable and valid assessment tools

  • Include single and dual task activities

  • Use different surfaces: hard tile, carpet, sand etc.

  • Identify intrinsic and extrinsic risk factors

  • Perform home safety assessment

• Fall prevention education

• Guard the patient appropriately: gait belt, use safety harness when necessary

Gait: Balance

Interventions: General Approach —> Develop a plan of care: Intervention approach

• Restoration/Remediation

• Neural plasticity: role of experience in neural plasticity

• Compensatory

• Patient and family education

• Referral to other health care providers

Gait: Balance

Interventions: General Approach —> Rehabilitation Approach

• Therapeutic exercises

• Task-specific functioning training

• Use of devices and equipment to support functional mobility

Gait: Balance

Interventions: General Approach —> Prerequisites for gait

• Strength training: LE, trunk and UE muscles

• Sit to stand training

• Standing balance training

• Pre-gait training

Gait: Balance

Interventions: General Approach —> Assistive devices for gait training

• Overground or body-weight supported treadmill training

• Walkers and canes

• Ankle Foot Orthosis (AFOs) and knee braces

• Functional Electrical Stimulation (FES)

Gait: Balance

Task Specific Functional Training

Body weight-supported treadmill training

• A body weight system includes a harness that is placed around the patient’s low trunk and attached to an overhead mobile frame or ceiling track

• Percentage of body weight-support depends on the patient’s strength and balance control

• Patients practice ambulation without fear of falling

• Improvements seen in muscle strength, balance and mobility

Gait: Balance

Clinical Decision Making

Restorative vs compensatory training considerations

• Patient goals and life roles

• Severity of the condition and/or progressive nature of the condition

• Acuity of the condition

• Secondary complications

• Chronic conditions

• Co-morbidity

• Cognitive and behavioral issues

• Financial support

• Discharge destination

Gait: Perception/Cognition/Communication

Perception Involved in Basic Gait

• Spatial awareness affects step length, direction, and surface navigation

• Visuospatial deficits may cause veering or unsafe foot placement

• Figure-ground challenges hinder obstacle negotiation

• Deficits reduce safety and independence in community ambulation

Gait: Perception/Cognition/Communication

Cognition Involved in Basic Gait

• Attention and memory guide gait sequencing and adaptability

• Divided attention increases fall risk in dual-task settings

• Executive dysfunction reduces hazard detection and motor correction

Gait: Perception/Cognition/Communication

Communication Involved in Basic Gait

• Language comprehension influences response to instructions during gait

• Expressive impairments limit ability to share concerns or discomfort

• Miscommunication can compromise safety and participation

Gait: Perception/Cognition/Communication

Ex: Treatment Considerations

• Emphasize symmetrical gait training and midline orientation

• Incorporate structured visual and tactile cues for foot placement

• Use simplified, step-by-step verbal instructions

• Minimize environmental distractions during early sessions

• Integrate visual scanning and perception drills during gait

• Progressively increase cognitive demands with dual-task practice

Gait: Perception/Cognition/Communication

Ex: Compensatory Interventions

• Use floor markers

• Provide structured verbal cues

• Minimize environmental distractions

• Use visual prompts

Gait: Perception/Cognition/Communication

Ex: Restorative Interventions

• Repetition of symmetrical gait with fading of cues

• Visual scanning tasks to enhance spatial awareness

• Obstacle navigation with cognitive overlay (naming, counting)

• Task-specific training in varied real-world environments

Gait: Movement Disorder

Ex: Gait Impairments in PD

• Reduced step length and arm swing

• Balance impairment and increased fall risk

• Decreased gait speed

• Stooped posture

• Decreased trunk rotation

• Shuffling gait / Festination

Gait: Movement Disorder

Ex: Gait Impairments in PD —> Interventions

• Develop a plan of care

• Approach:

  • Restorative/remediation

  • Compensation

  • Task specific functional training

  • Use of assistive devices and equipment

• Fall prevention education

• Patient and family education

• Home exercise program

Gait: Movement Disorder

Ex: Interventions—> General Approach

• Cues:

  • Auditory: metronome, counting

  • Visual cues: cones, markings on ground, laser light

  • Manual cues: PNF techniques prior to treatment: Rhythmic initiation, contract relax

• Posture: use of mirror or video recording to give cues for upright posture

• Strength: to improve functional performance

• Gait: emphasize larger, bigger steps (focus on normal gait progression)

• Balance and Fall prevention

• Assess for the need for assistive devices: rollator walker, U-step walker

Gait: Movement Disorder

Ex: Interventions—> Task Specific Training

• Freezing of gait: 4S’s

  • Stop

  • Stand tall

  • Sway (sway side to side before stepping)

  • Step big

• Treadmill training, including body weight supported treadmill training

• Overground training

• Obstacle course training

• Dual task training

• Robotic assisted walking

Gait: Extrinsic Feedback Strategies

What is gait?

• A rhythmical, repetitive movement pattern distinguished by a characteristic sequence of limb & trunk movements.

• Involves forward propulsion, postural control & balance, & adaptation to environmental conditions

Gait: Extrinsic Feedback Strategies

Stance phase: IC

Moment the foot contacts the ground

Gait: Extrinsic Feedback Strategies

Stance phase: LR

Rapid transfer of weight onto the stance limb. 1st period of double support

Gait: Extrinsic Feedback Strategies

Stance phase: MSt

Body progresses over a single, stable limb

Gait: Extrinsic Feedback Strategies

Stance phase: Tst

Continued progression over the stance limb. Body moves ahead of the limb; weight transferred onto forefoo

Gait: Extrinsic Feedback Strategies

Swing phase: PSw

Rapid unloading of stance limb as weight transferred onto the contralateral limb. 2nd period of double support

Gait: Extrinsic Feedback Strategies

Swing phase: ISw

Thigh begins to advance as foot clears the floor

Gait: Extrinsic Feedback Strategies

Swing phase: MSw

Thigh continue to advance as the knee begins to extend & foot clears the ground in forward progression

Gait: Extrinsic Feedback Strategies

Swing phase: TSw

Knee extends; the limb prepares to contact the ground for initial contact

Gait: Extrinsic Feedback Strategies

Task Analysis: Stage of Learning —> Initial (Cognitive)

• Provide lots of visual FB

• Demonstrate task

• Emphasize desired outcome & critical task elements

• Provide KR to reinforce successful movement outcomes

• Provide KP when errors are consistent

• Allow for trial-&-error learning

• NOTE: Although constant FB improves performance in early learning, it is important to start incorporating variable FB to improve retention

Gait: Extrinsic Feedback Strategies

Task Analysis: Stage of Learning —> Intermediate (Associative)

• Less dependent on visual FB

• Encourage pt. to self-assess motor performance & focus on the "feel of the movement"

• Provide variable FB to improve retention: summary, faded, bandwidth

• Reduce hands-on assistance

• Continue to provide KR with successful movement outcomes

• Continue to provide KP with consistent errors

• Stress relevance of functional outcomes

Gait: Extrinsic Feedback Strategies

Task Analysis: Stage of Learning —> Advanced (Autonomous)

• Only occasional FB required

• Focus on key errors