Clinical Gait Analysis and Postural Stability in a Complex Case

ESSA Elements

• 1.3.1: Illustrate the scope of practice of Accredited Exercise Physiologist (AEP).
• 1.3.2: Employ core principles of case management within the AEP scope.
• 1.3.4: Employ evidence-based practice and professional clinical practice principles.
• 3.3.4: Formulate actions to manage client clinical status before, during, and after assessment and exercise.
• 3.3.5: Choose and apply guidelines and measurement tools/techniques to assess clients’ clinical and functional status.
• 3.3.6: Recognise, interpret, revise, and demonstrate responses to changing risk factors in multi-disciplinary care models.
• 3.3.7: Formulate and demonstrate measurement, evaluation, and reporting of exercise capacity.
• 3.3.8: Explain the principles of body mechanics.
• 3.3.9: Discuss core principles of functional capacity.
• 3.3.10: Formulate and demonstrate measurement, evaluation, and reporting of functional capacity in various settings.
• 11.4.3: Evaluate functional body mechanics and its interrelationship to rehabilitation.
• 11.4.4: Examine the scope of exercise physiology practice in rehabilitation.
• 11.4.5: Compare the roles of AEPs and other health professionals in delivering care to musculoskeletal clientele.
• 11.4.6: Select and employ screening tools to establish client baseline exercise and functional capacity.
• 11.4.7: Consider medications, surgical interventions, clinical and safety risks, and their implications on exercise.
• 11.4.8: Recognise clinical signs and symptoms of adverse musculoskeletal response.

Dynamic Equilibrium

• Determination of body position involves comparing, selecting, and combining senses, leading to the choice and generation of body movement.
• Key senses: Vision, Vestibular, and Somatosensation.

Sensory Components of Balance

• Somatosensory: Skin receptors (60-70%) detect motion of the body with respect to the support surface.
• Proprioceptive: Muscle spindles and Golgi tendon organs detect motion of body segments relative to each other.
• Visual: Eyes (10-20%) detect motion of the body with respect to extrapersonal space.
• Vestibular: Inner ear (10-20%).

Postural Strategies

• Ankle Strategy
• Hip Strategy
• Stepping Strategy

Rules of Balance Training

• Exercise must be safe & challenging.
• Stress multiple planes of motion.
• Incorporate a multisensory approach.
• Progress from static, bilateral & stable surfaces to dynamic, unilateral & unstable surfaces.
• Adequate function in the open chain is critical as a first step in rehabilitation.
• Progress towards sports-specific exercises.
• Functional rehabilitation should occur in the closed kinetic chain.
• Utilize open areas and keep assistive devices within reach.
• Sets and repetitions: 2-3 sets, 15-30 repetitions or 10 reps for 15-30 seconds.

FITT: Type of Balance Exercises

• Static: COG is maintained over a fixed base of support on a stable surface.
• Semi-dynamic:
  • Person maintains COG over a fixed base of support while on a moving surface.
  • Person transfers COG over a fixed base of support to selected ranges while on a stable surface.
• Dynamic: Maintenance of COG over a moving base of support while on a stable surface (involve stepping strategy).
• Functional: Same as dynamic with the inclusion of sports-specific tasks.

Anterior/Posterior Perspective in Gait Analysis

• Observe from anterior/posterior as well as lateral views.
• Look for:
  • Pronation or supination of foot/ankle
  • Knee valgus/varus
  • Pelvic tilt

Gait Kinematics

• Hip: Adequate flexion (ROM ~ 40°) during swing phase for foot clearance and step length.
• Knee: Flexion (ROM ≈ 60-70°) during loading response via eccentric quadriceps contraction.
• Ankle: Dorsiflexion (ROM ≈ 20-30°) in swing for foot clearance.
• Pelvis: Anterior pelvic tilt remains relatively constant ≈ 10° throughout gait cycle; may increase with abdominal mass, age, or aid use.

Gait Retraining

• Exercises/drills: running drills, obstacle crossing, agility ladders, walking between parallel bars with hand support.
• Motor pattern adjustments:
  • Toe-out gait to reduce second KAM peak in OA patients.
  • Medial knee thrust to reduce first KAM peak in OA patients.
  • Rate of loading of the first KAM peak may be more important than the magnitude of the peak.
• Use of assistive devices, barres, harnesses.
• Biofeedback and 3D motion capture biomechanics labs; low-cost Kinect and Wii validated for different tasks.

Cerebral Palsy (CP)

• CP is a physical disability affecting movement and posture.
• Etiology: Results from brain injury before, during, or after birth (most commonly in utero or before 1 month of age).
• Motor type depends on the area(s) of the brain that were deprived of oxygen and injured (Motor cortex (70-80%), Basal ganglia (6%), Cerebellum (6%)).

Biomechanics and CP

• Balance and walking aids: Consider base of support and strength/stability requirements.
• Ankle-Foot Orthoses (AFO’s):
  • Restrict or inhibit excessive motion.
  • Encourage normal gait kinematics.
  • Support ankle joint complex.
  • Facilitate GRF and joint torque.
• Ground Reaction Ankle-Foot Orthosis (GRAFO): Alters the location of the ground reaction force vector.

Clinical Gait Analysis and CP

• Spasticity can cause torsion of lower limb segments as the child grows.
• Clinical gait analysis helps identify affected areas and variables benefiting from interventions.
• Informs surgical decisions, exercise rehabilitation programs, walking aid selection, and AFO design.

CP and EP

• Cardiorespiratory (aerobic vs. anaerobic).
• Muscle strength (endurance vs. power).
• Balance/postural stability.
• Mobility.