Lecture 6: Gait

What is the purpose of gait analysis?

1. To assist with understanding the gait characteristics of a particular disorder 

2. To assist with movement diagnosis  

3. To inform selection of intervention  

4. To evaluate the effectiveness of treatment

Gait cycle

the time from heel strike to next ipsilateral heel strike

weight acceptance requires…

forward progression, shock absoprtion, stability

single limb support requires…

forward progression, stability

swing limb advancement requires…

foot clearance, limb advancement

reference limb is in IC or LR phase…. opposite limb is in

Pre-swing

reference limb in Mst… CL limb is in…

initial/mid-swing

reference limb in Tst… CL limb is in

terminal swing

reference limb is in Psw… CL limb is in…

IC/LR

reference limb is in Isw/Msw… CL limb is in…

Mst

reference limb is in Tsw… CL limb is in …

Tst

IC

moment when the foot contacts the ground

critical event: heel first contact

• 20 degrees hip flexion

• 5 degrees knee flexion

• 0 degrees of ankle

LR

weight is rapidly transferred onto the outstretched limb, the first period of double-limb support

• 20 degrees hip flexion

• 15 degrees knee flexion

• 5 degrees rapid PF

critical events: hip stability, controlled knee flexion and ankle PF

Mid-stance

the body progresses over a single, stable limb

critical events: controlled tibial advancement

• hip neutral

• 5 degrees knee flexion

• 5 degrees DF (Gastroc muscle demand***)

Terminal stance

progression over the stance limb continues. the body moves ahead of the limb and weight is transferred onto the forefoot

critical events: controlled ankle DF, trailing limb

• 20 degrees apparent hyperextension at hip

• 5 degrees knee flexion

• 10 degrees DF (Gastroc muscle demand***)

Pre swing

a rapid unloading of the limb occurs as weight is transferred to the CL limb

critical events: passive knee flexion to 40 dg, ankle PF to 15 dg

• 10 degrees of hyperextension at hip

• 40 degrees knee flexion

• 15 degrees PF

initial swing

thigh begins to advance as the foot comes up off the floor

critical events: hip flexion to 15 degrees, knee flexion to 60 degrees

• 15 degrees hip flexion

• 60 degrees knee flexion (the most*)

• 5 degrees PF (DF begins for foot clearance)

Mid-swing

thigh continues to advance as the foot comes up off the floor

critical event: further hip flexion to 25 degrees, DF to neutral

• 25 degrees hip flexion

• 25 degrees knee flexion

• DF to neutral at ankle

Terminal swing

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

critical events: knee extension to neutral

• 20 degrees hip flexion

• neutral/5 degrees knee flexion

• neutral ankle

Forefoot or Flatfoot contact

refers to position of the foot with the ground during initial contact

Forefoot or Flatfoot contact can impact…

heel rocker for forward progression and decreased shock absorption

common causes of Forefoot or Flatfoot contact include…

excess PF or knee flexion in terminal swing OR compensation for weak quads

Foot slap

refers to uncontrolled PF after heel contact

foot slap impacts…

forward progression and decreased shock absorption

common cause(s) of foot slap …

weak pretibials

No heel off means…

lack of heel rise during terminal stance/pre swing

No heel off during gait can impact…

progression, step length of CL limb, and decreased pre-swing knee flexion

common causes of no heel off include…

weak calf, lack of ROM in toes, or pain in forefoot/ankle

Foot drag

contact of the toes/foot with the ground during swing

foot drag can impact…

limb advancement; may cause injury or loss of balance

common causes of foot drag…

decreased hip or knee flexion, excessive PF, or impaired proprioception

CL vaulting

rising on the forefoot of opposite (stance) leg during swing phase of reference limb

CL vaulting can impact…

the efficiency with increased muscle demand

cause for CL vaulting

compensatory for limb elongation to achieve foot clearance; decreased swing limb flexion

Knee wobble

refers to alternating flexion/extension during stance

knee wobble impacts…

balance, stability, and forward momentum

common causes of knee wobble include…

impaired proprioception, hypertonicity in PF or quads

extension thrust

refers to forceful extension moment at knee

extension thrust impacts…

shock absorption and forward progression; may lead to injury

common causes of extension thrust…

impaired proprioception, intention for limb stability

• in loading: forefoot contact, weak quads, quad spasticity

• in SL stance: excess PF

Excess CL knee flexion

refers to increased knee flexion during early stance of opposite limbe (during reference limb swing)

excessive CL knee flexion impacts..

foot clearance, limb advancements, and increases energy demand

causes of excess CL knee flexion

compensatory for limb elongation of reference leg to lower single limb to the ground

Past retract

refers to forward then backward movement of the hip at terminal swing

past retract deviation can impact…

step length; generate some passive knee extension

common causes of past retract deviation include…

lack of selective control of hip/knee, impaired proprioception, compensatory to decrease demand and quads for loading response, hamstring hypertonicity,

Circumduction

refers to a composite movement of abduction with ER then followed by adduction and IR in swing phase

Circumduction impacts…

limb clearance and functional leg length

common causes of Circumduction broken down to individual movements: ER

contractures, substitute for weak hip flexors in swing, allows for limb progression with limited DF ROM

common causes of Circumduction broken down to individual movements: Abduction

contracture, compensatory for limb clearance, increase BOS in stance

Common causes of Circumduction broken down to individual movements: IR

contractures, hypertonicity, in stance compensatory for stability with weak quads

common causes of Circumduction broken down to individual movements: Adduction

contracture, hypertonicity, secondary to CL pelvic drop, decreased BOS, excessive CL flexion (refers to increased knee flexion during early stance of opposite limb - during reference limb swing)

Antalgic gait

shortened stance on painful limb

Ataxic gait

unsteady, irregular steps, poor coordination

Athetoid/Choreoform gait

Involuntary writhing movements during ambulation

Festinating Gait

progressive quickening and shortening of steps (PD)

Scissoring gait

narrow BOS, legs cross midline due to spasticity

Shuffling gait

Minimal foot clearance, short sliding steps

Steppage gait

high hip/knee flexion to clear a weak DF foot (foot drop)

Extensor synergy gait

stiff extension pattern dominates limb motion

flexor synergy gait

excessive hip and knee flexion with ankle DF during swing

Features of gait after CVA

• reduced walking speed

• decreased cadence

• increased gait cycle

• increased time in double limb support

• increased time in swing and less time in stance for hemiplegic side

• longer stance phases on unaffected side

• flatfoot

UE flexion synergy pattern after CVA

• scapula retract and elevation

• shoulder abduction, ER

• elbow flexion*

• forearm supination

• wrist and finger flexion

UE extension synergy pattern after CVA

• scap protraction

• shoulder adduction*, IR

• elbow extension

• forearm pronation*

• wrist and finger extension

LE flexion synergy after CVA

• hip flexion*, abduction, ER

• knee flexion

• ankle DF and inversion

• toe DF

LE extension synergy after CVA

• hip extension, adduction*, IR

• knee extension*

• ankle PF*, inversion

• toe PF

Features of Gait after TBI

• slower walking speed

• decreased cadence and step length

• increased time in double limb support

• increased width of BOS

• prolonged stance period on unaffected limb

• shorter step for unaffected limb

• increased trunk anterior/posterior amplitude of movement

• greater and faster medio-lateral COM motion

• reduced peak knee flexion at toe-off

• increased anterior pelvic tilt

• increased peak pelvic obliquity

Features of gait with PD

• slowed speed

• decreased stride

• lack of heel-toe sequence

• shuffling/festinating pattern

• diminish CL trunk movement and arm swing

• overall flexion

Features of gait with MS

• difficulty lifting legs due to hip flexor weakness

• problems with foot clearance due to foot drop

• knee hyperextension and forward trunk flexion due to weak quads

• trendelenberg gait pattern due to hip abductor weakness

• gait deviations due to clonus, spasticity, sensory loss and/or ataxia

Features of gait after SCI

• depends neurological level

• completeness

• spasticity

• proprioception

• contractures/Heterotopic ossification

Forefoot first contact may be result of…

• weak tibialis anterior

• calf spasticity

• diminished proprioception

• limited ankle DF ROM or PF contracture

• weak quads

Outcome Measure: Functional Ambulation Profile And Modifications (FAP)

• designed to examine gait skills on a continuum from standing balance in parallel bars to independent ambulation

• measures the amount of time required either to maintain a position or perform a task

what are the 3 phases of the FAP outcome measure?

• parallel bars: bilateral stance, uninvolved stance, and involved stance

• rapid weight transfer from one LE to the other

• patient is asked to walk 20 ft in parallel bars

OM: Functional Independence Measure (FIM)

• 18 item measure that examines patient’s physical, psychosocial, and social functions

• each of the functional categories are rated on a 7 point scale

• 7 point scale rates patients on performance, taking into account need for assistance and device

• scale quantifies needed assistance (burden of care)

FIM outcome measure assesses…

• walking

  • includes walking on level surface once in a standing position

• wheelchair

  • includes using a wheelchair on a level surface once in a seated position

• record the admission mode and scores based on the frequent mode of locomotion projected at discharge

DGI

• designed to examine the ability to adapt gait to changes in task demand

• this was initially for community dwelling older adults with balance and vestibular disorders

• highest possible score = 24 points

• tasks include

  • steady state walking

  • walking with changing speeds

  • walking with head turns (horizontally/vertically)

  • walking while stepping over and around obstacles

  • pivoting while waking

  • stair climbing

DGI/FGA score 3

no gait dysfunction

DGI/FGA score 2

minimal impairment

DGI/FGA score 1

moderate impairment

DGI/FGA score 0

severe impairment

FGA

• this test is derived from DGI; it is a modification of the DGI developed to improve reliability and decrease the ceiling effect

• 10 item test that comprises 7 of the 8 items from the DGI

• highest score = 30 points

• assessment may be performed with or without and AD ***

OM: High-level Mobility Assessment Tool

• designed to measure high-level mobility skills needed for employment and social roles for younger adults recovering from TBI

• 13 items including walking (FWD,BWD, toes, figure 8, over obstacles), running, a run stop, skipping, hopping FWD, bounding (big leaps), stairs with and without rails

• 5 point scales

• Max score = 54 points

OM: Walking Index for SCI (WSCI → ‘whiskey’)

• assesses the amount of physical assistance needed, as well as AD needed, for walking following paralysis that results from SCI

• designed to be a more precise measure of improvement in walking ability specific to SCI

10 meter walk test

• examines gait speed

• start the time after 2 meters (first 2 meters are warm up)

• stop time at 8 meters (last two meters are cool down)

• repeat up to 3 times and average the times

6 minute walk test

• determines distance ambulated at a comfortable pace for 6 minutes

• it is a measure of endurance and exercise capacity for people with cardiac and pulmonary pathology and walking endurance in clients with underlying conditions such as PD, ABI, and CVA

• alternative tests = 2 min, 3 min, or 12 min

Stability deficits may be found in….

weight acceptance and stance phases of gait

stability deficits in gait can be caused by…

• insufficient hip abduction strength to control mediolateral or frontal plane stability

• insufficient hip and trunk extension torque to support BW (you might see excessive trunk flexion)

• insufficient knee extension torque to support BW

• inadequate/non-ideal foot placements

what are some treatment techniques to target some stability deficits in gait?

• using manual cueing, tactile cueing, and/or verbal cueing

• ROM

• toe spreader (for not ideal foot placements)

• evaluating need for orthotics

• targeting strength

• sensation

what does a “scaling problem” mean?

matching the SIZE of your movement to the SIZE of the challenge.

For example, if I give you:

• a tiny push → you should make a tiny postural correction

• a big push → you need a bigger postural correction

A patient with this may produce a response that is too large or too small for what actually happened.

What is the goal of treatment for scaling problems?

Train the patient to appropriately match the amplitude/size of their movement or postural response to the size of the task or perturbation

How should scaling exercises be progressed for a patient with a cerebellar disorder?

Start with larger-amplitude movements → progress to smaller, more precise movements

How should scaling exercises be progressed for a patient with paresis?

Start with small-amplitude movements → progress to larger-amplitude movements as the patient becomes able to generate more force

feedforward balance strategies

anticipatory: prepares for a known/expected challenge

feedback balance strategies

reactive: responds after an unexpected perturbation occurs

How can stepping target exercise be progressed when treating scaling problems?

Start with larger targets spaced farther apart → progress to smaller targets closer together to require more precise movement scaling

Pre-gait Activities: Tasks for retraining strategies

• weight shifting

  • mirror or flashlight

• alignment

  • use sensory feedback

  • use visual feedback

  • approximation

  • environment set up