Assessment and Management of Gait

Essential Components of Walking

• Propulsion: Generation, maintenance, and termination of a basic locomotor cycle using patterned activation and coordination of legs and trunk to propel the body in a specified direction.
• Postural Control: Maintenance of dynamic stability through appropriate postural orientation of body segments relative to each other and environmental conditions to overcome gravity and respond to expected and unexpected perturbations.
• Adaptation: Modulation of the locomotive pattern to achieve goals in real-world environments with varying terrain or obstacles.
• Human walking is a skilled behavior, not just the generation of basic locomotor patterns.

Key Aspects of Gait

• Patterned activation with coordination to propel the body.
• Dynamic stability relies on appropriate postural orientation intersegmentally and in relation to the environment.
• Ability to adapt to expected or unexpected changes in postural stability in real-time.
• Walking is a skilled adaptive process and not uniform under all circumstances, therefore not a one size fits all skill.

Systematic Observational Gait Analysis

• Analysis is typically completed through systematic observation and measurement within the phases of gait in a clinical setting.
• Employ a planned approach to observe each component. Because gait is complex and uses the whole body, observing haphazardly and jumping from one thing to another is not very helpful in ensuring that all components and all joints are reviewed.
• Consider using a distal-to-proximal or proximal-to-distal approach.
• Ask, "What is the person doing or not doing that is the same or different to normal gait?"

Phases of Gait

• Gait is divided into stance phase and swing phase for each leg.

Stance Phase

• Initial Contact (Heel Strike): The moment the foot initially touches the ground.
• Loading Response: Tibia and center of mass shift anteriorly, weight commences to be placed onto the stance leg.
• Mid Stance: Stance leg is around vertical.
• Terminal Stance: Stance leg is posterior to the center of mass, pelvis, and trunk once the pelvis and trunk have moved past the grounded foot.
• Preswing (Push Off/Toe Off): Stance leg is just about to leave the ground.

Swing Phase

• Initial Swing: Foot just leaves the ground and is posterior to the center of mass, normally posterior to the pelvis and trunk.
• Mid Swing: Leg passes the opposite stance leg.
• Terminal Swing: Leg moves anterior to the center of mass or pelvis and trunk and is about to make initial contact.

Observational Considerations

• Observe both sides of the body, regardless of affected/unaffected sides.
• Note deficits on the left versus the right side and document specifically which limb is being observed.
• Observe the trunk, head, neck, and arms.
• Observe from both sagittal and coronal views.
• Take note of step length, stride length, base of support and stride width, cadence, and velocity.

Common Neurological Gait Deviations

• Walking dysfunction is common in people with neurological impairments.
• Deviations may be due to the lesion itself or adaptations from secondary musculoskeletal or cardiorespiratory consequences relating to disuse and inactivity.

Specific Deviations

• Flat Foot at Initial Contact: Lack of heel strike, landing with a flat foot or toe contact, impacting the biomechanics of forward momentum of the tibia, pelvis, and trunk.
• Foot Drop: Lack of dorsiflexion due to muscle weakness, resulting in a floppy foot that falls into plantar flexion.
• Center of Mass Shift: Shifting center of mass over the unaffected stance limb which can cause longer term problems. Some patients may demonstrate pusher syndrome or lateral potion, preferencing their center of mass over their affected side, affecting balance and safety.
• Poor Knee Control in Stance:
  • Hyperextension to control the risk of flexion and collapsing.
  • Knees can give way.
  • Walking in a crouched position with excessive knee flexion.
• Decreased Hip Extension in Mid and Terminal Stance: Impacts propulsion, step/stride length, and gait speed.
• Reduced Push Off: Relates to reduced calf strength. Some patients may also not have ankle range to even reach neutral plantar flexion/dorsiflexion, which also can impact their push off.
• Toe Catching/Reduced Toe Clearance: Safety risk for tripping or falls, often due to lack of dorsiflexion; adjust for small surface variations (normal clearance is approximately 1 cm).
• Increased Double Support Phase: To assist in maintaining balance.
• Reduced Swing Velocity: Due to lacking momentum, limb is lifted and placed; especially in people who lack speed with their gait.
• Reduced Trunk Control:
  • More flexed with a stooped posture.
  • Propelling trunk backward to swing leg through or gain hip extension on the stance leg.
  • Decreased trunk rotation, affecting arm swing.
• Toe Clawing/Gripping: Due to stability or spasticity.
• Wider Base of Support: For balance reasons.
• Reduced/Narrowed Base of Support: With spastic gait patterns.

Secondary Compensatory Strategies

• Vaulting: Propelling up onto tiptoes on the unaffected side while hitching the affected side hip, in order to create length and space to bring their affected leg through in swing without having to flex it as much.
• Hip Circumduction: Swinging the affected leg from the hip out sideways and forward to compensate for a lack of length.
• High Stepping Gait: Overlifting the affected leg to clear the foot, common in patients with foot drop or sensory ataxia.
• Sliding/Shuffling: Sliding the foot forward to avoid lifting it and to maintain balance.
• Scissoring Gait: Legs cross over towards the midline with a smaller base of support, often associated with adductor spasticity.
• Reduced Speed/Cadence: Overall consequence of gait deviations.
• Reduced Stride/Step Length: Overall consequence of gait deviations.
• Step-to Gait: Very slow and asymmetrical, but may be necessary initially.
• Fixating Vision: Compensating for balance issues, risking inability to notice environment.
• Reliance on Upper Limb Support: Impacts arm swing and trunk rotation.
• Reduced Obstacle Negotiation: Impaired ability to adapt to varying environments.

Gait Speed

• Important for determining functional competence in the community.
• Predicts functional outcomes and discharge destinations.
• Slow walking speed is associated with poor health outcomes, disability, and increased fall risk.
• Slow walking results in high total energy costs of walking.
• Gait speed correlates with:
  • Strength of lower limb muscles.
  • Magnitude of push-off power.
  • Hip extension angle at the end of stance (smaller angle = slower speed).
  • Increased time spent in double support phase.
  • Reduced hip abduction power.
• Biomechanical disadvantages (gait aids, AFOs), increased cognitive processing, reduced cardiovascular fitness, fear of falling, and safety concerns can slow gait speed.
• Addressing walking speed in therapy can improve clinical outcomes.

Normative Values

• Gait speed decreases with age.
• Community-dwelling gait speed is approximately 0.9 meters per second.
• Falls, hospital admission, and adverse events are risks for gait speeds less than 0.7 meters per second.

Impact of Gait Speed

• Preferred walking speed indicates general health and functional ability.
• Loss of speed and independence in gait impacts personal independence, need for care, and quality of life.
• Slow walking is associated with frailty, death risk, hospitalization, falls, functional impairments, dependence, and household ambulation only. Mid-range speeds indicate limited community ambulation with likely cognitive decline. Faster walkers are less likely to be in hospital, have adverse events, and are more independent in ADLs and community ambulation.
• Community ambulation is approximately 0.8 meters per second and household walking only is around 0.4 meters per second.

Systematic Gait Assessment Template

• Includes sagittal and coronal plane observations for both right and left sides.
• Breaks down stance and swing phases for assessment.
• Considers initial contact, loading response, mid-stance, terminal stance, pre-swing/toe-off, initial swing, mid-swing, and terminal swing.
• Space for additional comments on assistance levels, use of aids/orthoses, environment, surface, distance, base of support, general movement descriptors (jerky, slow, asymmetrical), and temporal features (step/stride length, stance time, double/single leg support, velocity, cadence).
• Start with one leg, then the other, and work distal to proximal or proximal to distal.
• View from front, back, and side and expose the limb area.
• Document findings.

Gait Presentations in Neurological Conditions

• Different conditions have typical presentations.

Specific Conditions

• Stroke: Hemiplegic gait with unilateral presentation.
• Parkinson's: Stooped posture, shuffling with small step length, festination, and freezing of gait.
• Multiple Sclerosis: Bilateral adduction of thighs (spasticity) and foot drop (weakness).
• Spinal Cord Injury and Brain Injury: Spasticity more common, all four limbs may be affected.
• Spastic Gait: Specific pattern related to the condition.
• Ataxia: Specific pattern related to the condition.

Process of Gait Assessment and Clinical Reasoning

1. Observation.
2. Hypothesis and testing, with impairments.
3. Use impairment testing to determine contributing factors.

• Is the person moving as normal? If not, what is different?
• Employ a systematic approach.

Clinical Reasoning Considerations

• What should the joint/muscles normally be doing?
• What compensations is the patient making?
• What contributes to the impairments? (e.g., reduced ROM, changes in tone, sensory deficits, coordination/motor control deficits, visual problems, habit).
• Consider pain, cardiorespiratory conditions, comorbidities (e.g., amputation, ankle fusion, leg length discrepancy).

Clinical template

• Use of a rollator frame, right leg circumduction in swing, reduced right knee and hip flexion in swing, increased plantar flexion in swing, and increased right knee hyperextension in stance.
  From there, we need to move across to the right hand column and for each item consider what the contributing impairment factors are, noting that at the point of completing a matrix that the objective assessment is completed, and so we are not making a guess or assumptions but actually noting the contributing impairments such as balance or strength, range of movement, proprioception, coordination or motor control or other, and noting we need to be specific again in our documentation here about which limb, whether we're talking about swing or stance phase, and listing anything like specific degrees of movement, range of movement restrictions, or manual muscle testing outcomes.

Other Gait Measurements

• Gait Lab: Video-based assessment with multiple cameras and 3D body markers, force plates.
• Sensory Mats: Spatiotemporal measures.
• Basic Video Recording: Review and track patients, software for measuring angles.
• Treadmill-Based Options: Integration of virtual games for rehabilitation.
  *Clinically observational gait assessment is what is most often used. Realistically, on a daily basis, every time you see the patient, although we don't complete this as formally as a tool every time, we are constantly completing observational gait assessments.
  *There are a range of tools separate to the University of Adelaide template, and your online learning includes some webinars from Mission Gait to further help you understand observational gait analysis.
• A range of outcome measures for assessing gait that look at gait speed, endurance, overall capacity, or safety rather than gait quality.

Outcome Measures

• Ten Meter Walk Test: It is important to note for this test that there are variations, and this is whether the middle section is 10 meters or six meters or another distance with a leading usually of two meters for and also at the end another two meters for deceleration.
• Six Minute Walk Test
• Timed Up and Go
• Dynamic Gait Index
• Rivermead Mobility Index
• High Level Assessment Tool
• Functional Ambulation Category

Treatment Options for Gait

• Varied depending on the individual.
• Factors: cognition, behavior, medical stability, precautions, comorbidities, and severity.

Immobile Patients

• Focus on impairment-related aspects (ROM, strength).
• Bed mobility, sitting balance, and trunk control are prerequisites.
• Functional task-specific practice (standing balance, weight shift, knee control).
• Start with weight shift left or right or perhaps forward and back to again work on trunk control, but also consider their hip and knee control for these. To do this they move their center of mass and notice this movement and then bring their mass back towards midline.
• Knee control exercises (squats, mini-squats, or simply unlocking the knee or both knees and straightening them again).
• Tandem stance to load legs.
• Unaffected leg on a step to force weight-bearing on the affected leg.
• Repeated sit-to-stands.
• Aids and supports as needed (rails, plinth, AFO, brace, splint, bandage or strap).
• Robotic-assisted gait training.
• Cardiovascular fitness considerations.

More Mobile Patients

• Focus on gait quality, efficiency, endurance, independence, and safety.
• Functional task specific practice is commonly broken down into what is called part practice or full gait practice.
  *Paractice includes:
  *standing balance, weight shift, knee control in stance, push off knee and hip flexion for swing along with dorsiflexion, and things like heel strike, and seeing which component the patient is getting stuck with and coming up with an activity for practicing that part of the gait cycle.
  *Full practice means completing the actual task of walking, which may still include things like robotic assisted gait therapy or progressing on towards treadmill training plus or minus body weight support.
• Range of movement, strength, coordination, higher-level balance, and cardiovascular fitness exercises.
• Part practice versus full gait practice.
• Overground training, body weight support, safety harnesses, and gantries.
• Focus on speed, endurance, and cardiovascular fitness.
• Obstacle negotiation, outdoor areas (slopes, surfaces).
• Vocation-related treatments.

Gait Deviations

Swing Phase

• Foot Drop: Inability to dorsiflex the ankle due to a weak anterior tibialis. Compensations include a high steppage gait, circumduction, vaulting, and hip hiking.

Stance Phase

• Foot Slap: Heel strike but lack of eccentric control in foot flat, indicating a weak anterior tibialis.
• Weak Quad: Results in leaning forward to slam the knee back into extension.
• Weak Glute Max: Results in leaning back on the Y ligament.
• Trendelenburg Gait:
  • Uncompensated: Contralateral dropping of the pelvis on the stance leg.
  • Compensated: Leaning to the weak side on the stance leg.