Gait and Mobility

Mobility & Gait

  • Focused on understanding and analyzing functional mobility (the ability to move independently and safely from one place to another) and ambulation terminology (terms related to walking).

Key Terminology

  • Functional Mobility: Refers to a person's ability to move in their environment to perform daily activities. This includes bed mobility, transfers, wheelchair locomotion, and ambulation.

  • Gait: The manner or style of walking.

  • Cadence: The frequency of steps

  • Step Length: The distance traveled by one foot

  • Stride Length: The distance covered during one complete gait cycle

  • Step Width: The linear distance between the midpoints of the heels of the two feet during successive steps

Functional Mobility Types

  • Bed mobility:

  • Transfers: Moving from one surface to another, such as from bed to a chair, or chair to toilet.

  • Wheelchair mobility: The ability to propel and maneuver a manual or powered wheelchair for functional tasks and locomotion.

  • Ambulation: The act of walking, encompassing all aspects of gait.

Ambulation Purposes

  • To get somewhere

  • As an integral part of Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs).

  • For exercise

  • For leisure and social participation.

  • To maintain productivity

  • To foster independence and autonomy in self-care and community living.

Key Concepts in Gait

  • Base of Support (BOS): The area beneath an object or person, including every point of contact the object or person makes with the supporting surface. A wider BOS generally provides more stability, while a narrower BOS (e.g., tandem stance) challenges balance.

  • Centre of Gravity (COG): The theoretical point where the entire weight of the body is concentrated and equally distributed.

Gait Cycle

  • A repetitive sequence of lower extremity movements that occurs from the point of initial contact of one limb to the next initial contact of the same limb, serving to propel the body forward.

  • Phases: The gait cycle is divided into two main phases:

    • Stance Phase (approx. 60% of the gait cycle): Occurs when the foot is in contact with the ground, primarily supporting the body's weight.

    • Initial Contact (Heel Strike): The moment the heel first touches the ground.

    • Loading Response (Foot Flat): From initial contact until all parts of the foot are on the ground and full weight is borne.

    • Midstance: The point at which the body's centre of gravity is directly over the supporting foot.

    • Terminal Stance (Heel Off): The heel lifts off the ground, and weight is transferred to the forefoot.

    • Pre-Swing (Toe Off): The toes push off the ground, initiating the swing phase.

    • Swing Phase (approx. 40% of the gait cycle): Occurs when the foot is not in contact with the ground and is moving forward.

    • Initial Swing: The foot lifts from the ground and begins to accelerate forward.

    • Mid-Swing: The leg passes directly beneath the body, with the tibia vertical.

    • Terminal Swing: The leg decelerates as it extends forward to prepare for initial contact.

Developmental Gait

  • A predictable sequence of motor skill acquisition leading to independent ambulation:

    • Rolling: Typically begins around 4−64-6 months.

    • Creeping

    • Crawling: Occurs around 6-8 months, involving belly crawling or hands-and-knees movement.

    • sitting without support: 6-8 months

    • stepping

    • pulling into standing

    • Cruising: Pulling to stand and walking while holding onto furniture, around

    • Walking (Independent Ambulation): Usually achieved between 11−1511-15 months. This early toddler gait is characterized by:

    • A wide base of support for stability.

    • High cadence (short, quick steps).

    • Short step length.

    • Flexed hips and knees.

    • Lack of arm swing.

    • High guard position of arms (held up for balance).

  • Gait patterns mature over time, with increased stability, longer step length, reduced cadence, and reciprocal arm swing typically developing by 3−73-7 years of age.

Pathological Gait Causes

  • Medications:

  • Pain:

  • Weakness:

  • Impaired Balance:

  • Other causes: Spasticity, joint range of motion limitations, proprioceptive deficits, and fatigue.

  • Effects: Can include excessive trunk sway, altered weight-bearing distribution, decreased gait speed, and increased energy expenditure.

Specific Pathological Gaits

  • Antalgic Gait (painful gait): A compensatory gait pattern characterized by a shortened stance phase on the affected, painful limb to minimize the duration of weight-bearing and discomfort (rushing one side). Caused by pelvis, hip, knee, ankle, or foot

  • Ataxic Gait: An uncoordinated, broad-based gait with irregular steps, often described as staggering. It results from cerebellar dysfunction, affecting the coordination of movement and balance.

  • Choreiform: hyperkinetic (excessive movements), but balance is not affected so counterbalance is performed

  • Diplegic gait: bilateral lower extremities more common and upper extremities. flexion at hips and knees in internal rotation. Tight adductors and walking on toes. Swinging gait on both sides. often must go through circumduction. No arm swing

  • **Hemiplegic Gait: Observed in individuals with hemiplegia (e.g., after a CVA). The affected lower extremity is extended and internally rotated, and the foot is often in plantarflexion and inversion. To advance the limb, the leg performs circumduction (a circular motion) due to difficulty with hip and knee flexion and ankle dorsiflexion.

  • myopathic gait: waddling: sway from side to side with hip drop on each step. Caused by weakness of hip girdle like congenital hip dysplasia, muscular dystrophies, spinal muscular atrophy.

  • nauropathic: characterized by foot drop, leading to high-stepping gait or slapping of the foot on the ground. This condition results from inability to dorsiflex (CVA, TBI, trauma)

  • Parkinsonian Gait: Also known as hypokinetic-rigid gait. Characterized by:

    • Short, shuffling steps (festination when steps become progressively faster and shorter, potentially leading to a fall).

    • Decreased or absent reciprocal arm swing.

    • A stooped posture (forward trunk flexion).

    • Difficulty initiating or stopping movement (freezing of gait).

  • Scissoring Gait: A common gait pattern in individuals with spastic cerebral palsy. Characterized by adduction and internal rotation of the hips, causing the knees to cross or nearly cross each other during the swing phase, mimicking the action of scissors.

  • Trendelenburg Gait: Occurs due to weakness of the hip abductor muscles (gluteus medius and minimus) on the stance leg. When the affected leg is in stance, the pelvis drops on the opposite (swing) side.

Outcome Measures

  • Timed Up & Go (TUG): A quick, simple measure of functional mobility and fall risk. It assesses the time a person takes to stand up from a chair, walk 3 meters, turn around, walk back, and sit down. Scores >12 seconds generally indicate a higher fall risk.

  • 6 Minute Walk Test (6MWT): Measures functional exercise capacity and endurance. The individual walks as far as possible in 6 minutes, typically used for cardiopulmonary and functional endurance assessments.

  • 10 Metre Walk Test (10MWT): Measures gait speed, a strong indicator of functional status, fall risk, and frailty. Usual walking speed is measured over a 10-meter distance; a speed of <0.8 ext{ m/s} is often associated with increased fall risk and poor functional outcomes.

  • Berg Balance Scale (BBS): A 1414-item scale assessing static and dynamic balance, commonly used to predict fall risk in older adults. Maximum score is 5656.

  • Dynamic Gait Index (DGI): Assesses balance during various walking tasks, including changes in speed, head turns, pivots, and stepping over obstacles.

Treatment Considerations

  • Footwear:

  • Environment:

  • Gait Aids:

  • Weight-Bearing Status:

    • NWB (Non-Weight Bearing): No weight is placed on the limb.

    • TDWB/TTWB (Touch-Down Weight Bearing/Toe-Touch Weight Bearing): Light contact with the ground for balance, no significant weight.

    • PWB (Partial Weight Bearing): A prescribed percentage of body weight, often 25−50%25-50\%.

    • WBAT (Weight Bearing As Tolerated): Patient determines the amount of weight based on pain and tolerance.

    • FWB (Full Weight Bearing): No restrictions, full weight on the limb.

Level of Assistance: The amount of help required for a task:

  • Independent: No physical or verbal assistance.

  • Supervision/Stand-by Assist: Verbal cues or close presence for safety, no physical contact.

  • Contact Guard Assist (CGA): Hands on patient, but no physical lifting/support provided unless equilibrium is lost.

  • ½ person assist

level of independence:

  • independent

  • modified independence

  • supervision/SBA

  • contact guard

  • Minimal Assist (Min A): Patient performs 75%75\% or more of the task.

  • Moderate Assist (Mod A): Patient performs 50−74%50-74\% of the task.

  • Maximal Assist (Max A): Patient performs 25- 50%50\% of the task.

  • Dependent: Patient requires total physical assistance.

OT Lens Observations

  • Context Assessment: Evaluating the specific environments and tasks where ambulation is required (e.g., home, community, work) to tailor interventions.

  • Coordination of Occupations with Mobility Goals: Integrating mobility interventions into meaningful daily activities (e.g., walking to the kitchen to prepare a meal, ambulating in the garden for leisure).

  • Education on Energy Conservation: Teaching strategies to minimize fatigue during ambulation, such as pacing, modifying tasks, and using assistive devices effectively.

  • Fall Prevention Options: Providing education on home modifications, balance exercises, appropriate footwear, and strategies to prevent falls, including community resources and fear of falling management.