Assessment and Management of Gait

Essential Components of Walking

• Gavin Williams in Lenin describes the essential components of walking as:
  • Propulsion: Moving the body in a specified direction.
  • Postural Control: Maintaining dynamic stability through appropriate postural orientation of body segments relative to each other and the environment to overcome gravity and respond to expected and unexpected disturbances.
  • Adaptation: Modulating the locomotive pattern to achieve goals in real-world environments, such as varying terrain or obstacles. This highlights the understanding of human walking as a skilled behavior rather than a basic locomotor pattern.

Key Aspects of Gait

• Patterned activation with coordination to propel the body.
• Dynamic stability relying on appropriate postural orientation and intersegmentally relative to body parts and the environment.
• Ability to adapt to expected or unexpected changes in postural stability in real time.
• Gait is a skilled adaptive process, not uniform under all circumstances; it's not a one-size-fits-all skill.

Systematic Observational Gait Analysis

• Completed through systematic observation and measurement of aspects within the phases of gait in a clinical setting.
• Observe components in a planned way, working distal to proximal or proximal to distal on the body.
• Ask: What is the person doing/not doing that is the same or different from normal gait?

Phases of Gait

• Gait is divided into stance and swing phases for each leg.
  • Stance Phase:
    • Initial Contact (Heel Strike)
    • Loading Response (Tibia and center of mass shift anteriorly)
    • Mid Stance (Stance leg is around vertical).
    • Terminal Stance (Stance leg is posterior to the center of mass).
    • Preswing (Toe-off) - Leg is about to leave the ground.
  • Swing Phase:
    • Initial Swing (Leg just leaves the ground).
    • Mid Swing (Leg passes opposite stance leg).
    • Terminal Swing (Leg moves anterior to the center of mass and is about to make initial contact).

Observational Considerations

• Observe both sides of the body, regardless if the person has an affected and unaffected side.
• Note deficits on the left versus the right side, documenting specifics.
• Take note of the trunk, head, neck, and arms.
• Observe from sagittal and coronal views.
• Note step length, stride length, base of support, stride width, cadence, and velocity.

Common Neurological Gait Deviations

• Walking dysfunction is common in people with neurological impairments due to the lesion itself and adaptations from secondary musculoskeletal or cardiorespiratory consequences.
  • Flat Foot at Initial Contact:
    • Lack of heel strike, landing with a flat foot or toe contact.
    • Impacts forward momentum of tibia, pelvis, and trunk.
  • Foot Drop:
    • Lack of dorsiflexion due to muscle weakness.
    • Foot is floppy and falls into plantar flexion.
  • Center of Mass Shift:
    • Shift over to the unaffected stance limb.
    • Pusher Syndrome: Preference for putting the center of mass over the affected side.
  • Poor Knee Control in Stance:
    • Hyperextension to control risk of flexion and collapsing.
    • Lack of control (co-activation of quads and hamstrings).
    • Knees giving way or walking in a crouched position.
  • Decreased Hip Extension:
    • Reduced hip extension in mid and terminal stance.
    • Impacts propulsion, step and stride length, and speed of gait.
  • Reduced Push Off:
    • Reduced calf strength.
    • Lack of ankle range to reach neutral plantar flexion dorsiflexion.
  • Toe Catching:
    • Reduced toe clearance due to lack of dorsiflexion.
    • Safety risk for tripping or falls.
  • Increased Double Support Phase:
    • More time with both feet on the ground to assist in maintaining balance.
  • Reduced Swing Velocity:
    • Lacking momentum, limb is lifted and placed.
  • Reduced Trunk Control:
    • Flexed trunk 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.
  • Toes Clawing:
    • Gripping with toes.
  • Wider Base of Support:
    • Commonly presented for balance reasons.
    • Spastic gait can reduce or narrow base of support.

Secondary Compensatory Strategies

• Vaulting: Propelling up onto the unaffected side foot to create length and space to bring the affected leg through in swing--plantar flexion on the unaffected side to help clear the affected leg.
• Hip Circumduction: Swinging the affected leg from the hip out into sideways circumduction due to lack of flexion at the hip or knee or dorsiflexion at the ankle
• High Stepping Gait: Overlifting affected leg to clear the foot, common in patients with foot drop or sensory ataxia.
• Sliding or Shuffling: Sliding the foot forward to maintain balance without lifting it.
• Scissoring Gait: Legs cross over in towards the midline adduct as they come forward with a smaller base of support as a result of reduced or narrowed base of support along with strength, coordination, or motor control problems.

Consequences of Gait Deviations

• Reduced speed or cadence.
• Reduced stride and step length.
• Reliance on a step-to gait.
• Altered stance and swing ratios, presenting as limping.
• Fixing vision on something to compensate for balance issues.
• Reliance on upper limb support.
• Reduced obstacle negotiation ability.

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 risk of falling.
• Slow walking results in high total energy costs of walking.
• Gait speed correlates with strength of lower limb muscles, magnitude of push-off power, and hip extension angle.
• Speed also correlates with increased time spent in double support phase and reduced hip abduction power.
• Biomechanical disadvantages include using gait aids or AFOs that limit dorsiflexion.
• Neurological conditions can make walking less automatic and require more cognitive processing.
• Cardiovascular fitness, fear of falling, balance issues, and a need to adapt to different environments can slow someone down.

Gait Speed Normative Values

• Age-related normative values for gait speed (velocity in meters per second) - data from Holman, Bouchette, Bohannon
• Low gait speeds (below 0.7 m/s) are a risk for falls, admission to hospital, or adverse events.
• Community dwelling gait speed is around 0.9 m/s, allowing someone to cross roads safely.

Impact of Gait Speed Loss

• Loss of speed and independence in gait has a significant impact on personal independence and freedoms, the need for care and assistance, and quality of life.
• Slow walking speeds are associated with frailty, increased risk of death, hospitalization and falls, functional impairments, and severe walking disability.
• Mid-range walking speeds demonstrate limited community ambulation with likely cognitive decline.
• Faster walkers are less likely to be in hospital, have adverse events, and are independent in ADLs.
• Study indicates community ambulation occurs around 0.8 \frac{m}{s} and household walking only at 0.4 \frac{m}{s}.

Systematic Gait Assessment Template

• The template includes sagittal plane observation as well as coronal plane observations with right and left sides assessed for both planes.
• Stance and swing phases are broken up in the table.
• Comments at the top consider the different phases of gait.
• Note what is happening at initial contact, loading response, mid stance, terminal stance, pre swing or toe off, as well as initial swing, mid swing, and terminal swing in the swing phase.
• Space for additional comments around the level of assistance, use of aids or orthoses.
• Note the environment, surface and distance, the person's base of support, general descriptors of movement, and temporal facial features.
• Start with one leg and then the other, working distal to proximal or proximal to distal.
• View from front and back as well as the side, expose the limb area as best as possible, and document findings.

Typical Gait Presentations in Neurological Conditions

• Different neurological conditions have some typical presentations.
  • Stroke: Hemiplegic gait with unilateral presentation.
  • Parkinson's: Stooped posture, shuffling with small step length, sliding the foot on the floor known as festination, and freezing of gait.
  • Multiple Sclerosis: Varied depending on lesion location and severity, but bilateral adduction of the thighs and foot drop can be common.
  • Spinal Cord Injury and Brain Injury: Can be varied, but spasticity is often more common, all four limbs may be affected.
  • Spastic Gait: Distinct pattern demonstrated in the video; focus on the right leg:
    *Initial contact: heel is not striking the ground
    *Knee has excessive flexed with slight genu valgum
    *Hip is internally rotated
    *During loading response, ankle remains excessively plantar flexed, the knee in a state of gingival gum, and the hip remains internally rotated.
    *Mid stance: ankle is excessively plantar flexed, knee remains flexed, and the hip excessively adducted and internally rotated
    *Terminal stance: Ankle has restricted dorsiflexion, knee is normally flexed and the hip reamins overly abducted and internally rotated
    *Swing phase -- angle remains plantar flexed, creating risk of foot drag due to lack of clearance. Knee and hip flexion are somewhat normal. The hip is still excessively adducted and internally rotated, attributing the scissoring motion.

Process of Gait Assessment and Clinical Reasoning

*   Observation, hypothesis, and testing with impairments.
*   Question: Is the person moving as normal? If not, what is different?
*   Take a systematic approach.
*   Consider:
    *   What would the joint normally do or be moving like?
    *   What would the muscles normally do or be moving like?
    *   What compensations is the patient making to attempt to complete the task?
*   Consider normal biomechanics and kinetics and kinematics compared to what the person is actually doing.

Contributing Impairments

• Reduced range of movement, changes in tone or spasticity, somatosensory deficits, coordination and motor control deficits, visual problems.
• Movement pattern a formed habit.
• Consider other factors such as pain, cardiorespiratory or other comorbidities, amputation, ankle fusion, or leg length discrepancy.

Clinical Reasoning Template

• The person may not be able to walk to the shop unaided, and so the movement strategies may include 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.

Gait Lab Assessment

• Video-based assessment with multiple cameras and 3D body markers.
  • Viacom system is set up at the Flinders Medical Center Rehab Centre.
    *inertial measurement units (IMUs) are like Apple Watch which measure accelerations, angular velocities, and gyroscopes.
• Sensory mats with sensors, such as the GAITRite, look at spatiotemporal measures.
• Basic video recording with software to measure angles.
• Treadmill-based options are emerging.
• Zebra system for gait assessment and training.

Clinical Observational Gait Assessment

• Most often used due to the need for a large space and cost for gait labs.
• A range of tools separate from the University of Adelaide template can be used.
• A range of outcome measures for assessing gait include:
  • 10-Meter Walk Test.
    • Note that there are variations in the middle section (6 meters in Australia)
  • 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 individual factors such as cognition, behavior, medical stability, precautions, comorbidities, and severity.
  • More immobile patients often have significant weakness, so focus on range of movement and strength.
  • Patients need some level of ability with bed mobility, sitting balance, and trunk control before attempting gait activities.

Functional Task Specific Practice

• Achieving standing balance with trunk control is the key part of therapy, including static balance control, response to perturbations, and dynamic control.
• Weight shift left or right or forward and back to work on trunk control.
• Knee control in stance, including squats or mini squats, or unlocking and straightening the knees.
• Tandem stance can load one of the legs or the other.
• Unaffected leg onto a step to force more weight bearing on the affected leg.
• Repeated sit to stands to improve functional strength and knee control.
• Place the affected leg forward plus or minus putting any weight onto it and then return their two feet back in line to progress towards a step two gait before aiming to progress to a step through once they are able.
• Consider aids and supports such as rails or a plinth.
• AFO, brace, or splint to control dorsiflexion.

Therapy for More Mobile Patients

• More focus on gait quality, efficiency, endurance, independence, and safety for more mobile patients by part or full gait practice.
• Break gait down into components like standing balance, weight shift, knee control in stance, push off knee and hip flexion for swing along with dorsiflexion, and things like heel strike.
• 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.
• Integrate obstacle negotiation, outdoor areas with slopes, different surfaces, and vocation-related treatments.