Gait & ADs

Inpatient Environment

What position should the elbow of the UE holding the AD be in?

20-30 degree flexion

Human walking: locomotion

movement from one place to another

Gait

1. Requires a formalized examination to develop an intervention plan

2. Describes gait patterns & deviations.

gait analysis looks at

The mechanisms are causing the gait deviations.

Gait analysis includes

1. ADs

2. Level of assistance

3. Orthotics & prosthetics

4. energy expenditure

Energy expenditure in gait looks at

physiological efficiency of gait; look for fatigue

parameters of gait analysis include

1. time (temporal)

2. space/distance (spatial)

3. events

Inpatient settings lend themselves to _____-____ ________of gait assessment.

lower-tech versions

Stride (L-L)

Period of time from when one foot contacts the floor to the next contact of the floor with the same foot.

1 stride is equivalent to ___ gait cycle

one

Step (L-R)

One foot stationary, the other foot steps forward

Gait phases are looked at by the ______ & _____ phases

rancho los amigos & traditional

Traditional gait phases are as follows:

1. heel strike

2. foot flat

3. midstance

4. heel off

5. toe off

6. acceleration

7. midswing

8. deceleration

kinetics

used to determine the forces that are involved in producing gait (high tech)

kinematics (motion)

qualitative or quantitative data

kinematics is described as

movement of the body/body segments relative to each other to describe the gait cycle (low tech)

Kinematics Qualitative

Advantage: used clinically, low cost, low-tech, quick

Disadvantage: reliability depends on skill, experience, & training, low reliability and validity

Kinematics examines

patterns of movement, postural deviation, & joint angles (specific to joint and body segment in phase of gait cycle)

Observational gait analysis goal:

identify structural + activity limitations

Observational gait analysis steps:

1. Identify gait pattern & deviations

2. Identify the causes

3. Develop a plan to address the causes (intervention)

kinematics: NYU classification of observed gait

can note if there is no deviation (from normal), noticeable, or very noticeable deviation

kinematics: traditional or Rancho Los Amigos

can note specific gait deviations based on joint and portions of the gait cycle

Traditional or Rancho Los Amigos describe

1. toe drag, excessive plantar flexion/dorsiflexion

2. varus/valgus angulation of the knee or ankle

3. presence of hip hiking or circumduction to clear a limb in swing

gait activity tolerance & endurance is assessed with the ___ test

6 MWT

Why does gait examination matter?

1. Help identify impairments→ intervention planning

2. Quantify disability severity

3. predict future functional status

4. safe discharge

5. Track progress

the handle should be approximately in line with which anatomical structure?

Greater Trochanter

When guarding, a person should be on the ___ side.

weak side, slightly behind

When determining a persons AD, you should consider the persons

balance or to unweight a restricted limb (determines unilateral/bilateral AD)

Using a gait belt;

hold the belt at the contralateral hip with 1 hand, anterolateral shoulder or lateral trunk on the ipsilateral side with other.

when guarding a provider should have a

wide BOS & high alertness.

The saying when gait on elevation especially on stairs

up with the good, down with the bad

Curb/single step (no rail) weight bearing

ascend forward→ walker 1st, uninvolved leg, then involved leg.

Curb/single step (no rail) non-weight bearing

forward: NWB LE has to be flexed behind the individual, walker goes up first then uninvolved LE follows.

Backward: back up to the step, hold the NWB LE off the ground in front “hop” up backwards with uninvolved limb

protocols are so individuals do not

bump non-weighting bearing leg on structures (i.e. steps)

Elevation: stairs with rail weight bearing

Elevation: stairs with rail non-weight bearing

Gait deviation: lack of heel strike

weak dorsiflexor (can’t pull toes to shin)

when a person has weak dorsiflexors,

The toes drag (swing phase), no heel strike

Gait deviation: heel lift in midstance

plantar flexor spasticity or contracture

contracture

limitation at a joint due to muscle shortening (chronic issue)

Gait deviation: no push-off (bringing leg forward)

decreased ankle ROM, plantarflexor weakness

Gait deviation: toe drag in swing

impaired strength and/or ROM at hip/knee/ankle

Gait deviation: decreased stance phase WB ipsilaterally & decreased swing time/distance contralaterally

antalgic gait (pain in stance LE)

antalgic gait/limp

R leg issue decreases WB, L leg decreased leg to get weight off R

Gait deviation: knee flexion at heel strike

weak quad, hamstring spasticity, joint pain

Gait deviation: knee hyperextension

(genu recurvatum) at foot flat or midstance: quad weakness or overactive gastroc

Gait deviation: circumduction, hip hiking, excessive hip flexion

used to clear the foot in swing if there is hip, knee, or ankle weakness or ROM impairments; dorsiflexion weakness

Gait deviation: trendelenburg

stance side gluteus medius weakness results in ipsilateral trunk lean to compensate and contralateral (swing) side pelvic drop

Observing gait analysis, a provider must

1. Observe both the sagittal and frontal views (BILATERALLY)

2. Have a stopwatch so you can record the time and specified distance

Special population for gait: stroke

weak dorsiflexors

1. toe drag

2. foot drop/slap

3. knee instability (buckle or hyperextension)

4. Trendelenburg gait

Special population for gait: LE amputation pre prothetic

1st phase

1. Same as an individual that is NWB due to orthopedic conditions.

Special population for gait: LE amputation prothesis

2nd phase

Special population for gait: LE orthopedic surgery

Antalgic gait (limp); decreased single-limb stance time, gait speed, and knee ROM

1. Impaired toe clearance in swing

Special population for gait: LE wound

on plantar surface of the foot, assume NWB unless ordered otherwise

NWB status applies for:

1. LE wound

2. new partial foot amputation

3. foot osteomyelitis

4. plantar wounds

Kinematics quantitative data is

more reliable, valid, objective, and reproducible than observational analysis

Kinematic quantitative dtat holistic assessment:

gait speed

gait speed is the

most clinically useful and applied method for kinematics

gait speed measures

time (temporal) & distance (spatial)

Functional mobility: independent

patient can safely complete task with no one present and no cueing

Functional mobility: modified independent

patient can safely complete the task with no one present with the use of an AD or with increased time to complete

Functional mobility: supervision

1. Requires someone to be arms reach’s reach as a precaution

2. low probability of needing assistance

3. may require cueing

Functional mobility: contact guard

1. Therapist is positioned in proximity to the patient, with hands contacting patient for safety due to a high probability of the person needing assistance,

2. May provide verbal/tactile cues.

Functional mobility: minimal assistance

1. Patient is able to perform the majority of the tasks without assistance (>75%)

2. The therapist can assist with up to 25% of the tasks

Functional mobility: moderate assistance

1. Patient can perform part of the task w/o assistance (50-74%)

2. therapist assist with up to 50% of the task

Functional mobility: maximal assistance

1. Patient performs 25-49% of the tasks without assistance

2. Therapist performs 51-75% of the task

3. May require more than 1 staff member to ensure safety

Functional mobility: dependent assistance

1. Patient is unable to assist with any part of the activity

2. Therapist performs 100% of the task

3. May require more than 1 staff member to ensure safety

What do you do if someone can’t walk independently?

1. Manual contacts; guarding positions: pelvis, anterolateral shoulder vs. thoracic wall

2. gait belt (applied before rising)

3. 2nd person assist

The MUST of guarding

1. Do not cross your feet

2. side step

3. maintain a wide BOS

4. keep pace with patient

guarding position

on the affected/weak side, lateral & slightly posterior to the patient

Weight-bearing precautions: full weight bearing (FWB/WBAT)

1. No restrictions on the amount of weight a person can bear through their limb.

2. Pain and activity tolerance provide guidance

Weight-bearing precautions: partial weight-bearing (PWB)

1. specfied or facility will have a standard to clarify

2. Can be 10%, 25%, 50% etc. (percent of persons BW)

Weight-bearing precautions: toe touch weight bearing (TTWB)

1. Generally less than 10% of body weight

2. allow toes to rest on the floor (rest of load is through other LE and UE’s)

Weight-bearing precautions: non weight bearing (NWB)

1. No weight or foot contact with the ground during transfers or gait is permitted.

2. Can rest foot on a footrest or on the floor/bed when at rest

assisted devices that aid in gait

1. cane

2. crutches

3. walkers

The average weight limit for these devices is _____

250-300 lbs

Cane types:

1. Standard cane

2. aluminum offset cane

3. quad cane

4. hemi-cane

Canes:

1. Widen the BOS to improve balance

2. are NOT appropriate for individuals with WB limitations/restrictions

3. held on the unaffected side (allowing reciprocal arm swing

Weight-bearing restrictions require what type of AD?

crutches or walkers (stable, bilateral)

canes are held on the

unaffected side (the good side)

cane gait pattern:

1. Segmented: cane, involved, uninvolved, repeated

2. Reciprocal: cane + involved extremity advanced together, then the uninvolved limb advanced

bilateral cane gait pattern is the same as using

crutches

bilateral cane gait pattern:

1. 2-point: leg cane, leg cane

2. 4-point: cane leg, cane leg

crutches:

1. used for increased balance support or to offload a LE with WB restriction

2. increase BOW & lateral stability

crutches are more difficult to coordinate than a

walker

Crutch height:

1. Loftstrand: 6 inches, 20-30 deg flexed elbow, cuff at mid-forearm

2. Axillary pad should be 2 inches inferior to the axilla, elbow flexed 20-30 degrees

3. Supine: approximately patient height minus 16 inches.

_____ can be used for all types of gait patterns

crutches

crutch gait pattern: 3 point pattern

1. 3 points of support on the floor (2 crutches + 1 LE)

2. Used for NWB status or PWB (modified 3-point gait

3. Swing-to or swing-through motion

4. crutches move with the effected LE

crutch gait pattern: 2 point pattern

1. resembles the normal gait

2. opposite arm & leg move together (LUE/RLE advance, then RUE/LLE advance)

crutch gait pattern: 4 point pattern

1. Slow but stable gait patterns: one crutch advances, then the contralateral LE; the other crutch advances than other LE advances.

Walkers

1. Allow improved balance & LE WBing reduction as needed

2. offer the greatest combination of BOS, anterior and lateral stability

Offer the greatest combination of BOS, anterior and lateral stability

walkers

no rocking

when using standard walker, all 4 points on ground

Walker gait pattern: FWB (traditional walker gait)

Walker then involved LE, uninvolved LE advances beyond 1st LE, repeat

Walker gait pattern: PWB

walker, involved LE, then with pressure through arms, uninvolved LE advanced, repeat (similar to modified. 3-point gait)

Walker gait pattern: NWB

Walker, weight through UE, NWB limb off of the floor, and anterior to the body or flexed behind, then advance the uninvolved limb, repeat

PWB walker gait is similar to the

modified 3-point gait

NWB walker gait is similar to the

3-point gait

Gait in elevation: curb/single step (no rail): WB

1. ascend forward → walker 1st, uninvolved leg then involved leg

2. With crutches, do uninvolved, involved, crutches.