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Class 11 Gait Assessment KinesiologyFES Chapter 10 p. 468

Terminology FES pp. 418-9

Manner of walkingRhythmic and alternating movement of the legs along with the trunk and the arms, which results in the propulsion of the body mass.

Gait:An automatic function coordinated by innate (present from birth) and learned reflexes. Unique to every person so can vary greatly Gait

Muscles work together to produce movement but in large portions of the gait cycle, there is little or no muscle action in most of the muscle groups showing the energy efficient nature of walking.

Gait

Gait cycle (GC): The period in which a complete sequence of events takes place & divided into 2 phasesStance phase: heel strike, midstance & toe offSwing phaseThe cyclic pattern of muscles and joints of the body when walkingBegins when one heel strikes the groundEnds when that same leg does heel strike again

Terminology

Double stance or double supportThe point in the gait cycle at which both feet are touching the groundTerminology

Stride: One cycle of the gait cycleConsists of two steps: (1) a left step(2) a right stepStride length ranges from 28-30 inchesStep: Each step makes up 50% of the gait cycleStep length is about 15 inchesTerminology

Cadence: Steps per minuteAverage cadence: 90-120 steps per minute Velocity: Speed of walkingAverage walking speed: about 3.1 miles per hour (mph)

TerminologyForefoot: includes 5 metatarsals & 14 phalangesMidfoot: Includes 5 of 7 tarsal bones (navicular, cuboid, & 3 cuneiforms). The midfoot meets forefoot at the 5 tarsometatarsal (TMT) joints. Hindfoot: includes talus & calcaneus

Terminology Foot Structure

In the foot, a combination of eversion & abduction movements taking place in the tarsal & metatarsal joints Results in lowering medial edge of foot & longitudinal arch

Terminology Pronation p. 344

In the foot, it is movements that raise medial edge of the foot & of longitudinal arch

Terminology Supination p. 344

Over and Under PronationOver-pronation: occurs when there is too much roll on the inside of the foot, which distributes the weight and shock of impact more heavily on the inside of the foot and stretches the soft tissues. Under-pronation: occurs when more weight is absorbed by the outside of the foot

Normal Adult Gait FES p. 417 & p. 418 Walking is an activity in which the person moves his or her body into & out of balance with each step. Children above the age of 7 demonstrate adult gait. Normal gait is smooth, coordinated & rhythmic.

Gait OverviewTwo major abilities essential to walking: Equilibrium - ability to assume an upright posture & maintain balance. Locomotion - ability to initiate & maintain rhythmic stepping. Maintaining stability during locomotion is essential.

Gait OverviewGait is influenced by additional factors such as mass (the weight of a body) & momentum. While walking the body center of mass/gravity is outside of the base of support 80% of the time.

Gait Overview

In humans, gait is primarily determined by the pelvis, upper leg (thigh), lower leg & the foot.The upper body components including the trunk, head, & arms are used in locomotion to provide momentum & counterbalance. The whole arm is used as a counterbalance & for momentum & moves opposite the leg movement. Pattern is linked by the contralateral reflex arc mechanism.Gait OverviewHead Begins Forward Movement: To begin forward movement, we relax the muscles at the back of the neck. The head moves forward which increases its weight. Because of its weight, this movement takes the whole body forward. Our bodies help us move forward, not by requiring increased force, but by using the head to initiate forward movement. Lead all movements with your head is a biomechanically correct statement.

Gait OverviewWhen standing and when walking, our center of gravity (COG) is located in our pelvis at the upper sacral region anterior to S2. Our head is balanced on the top of our spine & the COG for the head is in front of the ear by the cheek. The pivot point for movement of the head is behind the COG, the posterior occipital & cervical muscles exert force to hold up the head.

Center of Gravity (COG)Video sequences of a man walking show the bobbing course of his center of gravity (white circle along red curve).

In the early stance phase, nearly 60% of the body weight is loaded onto the ipsilateral leg. This abrupt impact is absorbed at each of the leg joints.

Shock absorption: The self-selected walking pace of an normal adult is that individuals most efficient way of walking.

Energy conservation: FTM p. 371 Figure 10-9 Efficient gait position

Central Nervous System Role in Gait FES p. 418Coordination of reflexes by the CNS is an essential part of walking.CNS coordinates following actions in walking:Producing appropriate forward propulsion Modulating changes in the center of gravityCoordinating multi-joint trajectoriesAdapting to changing positions and joint positionsCoordinating visual, auditory, vestibular and peripheral afferent information

CNS Role in GaitPeripheral receptors in our joints & muscles detect changes in muscle length & force, joint position, & weight-bearing status of the legs.Righting reflexes involving the eyes & ears, together with tonic neck flexes, maintain an upward, level, & forward head position, while ocular/pelvic reflexes balance the head & pelvis position. Pressure receptors on the soles of the feet relay postural information about weight distribution.

Role of coordinating visual, auditory, vestibular & peripheral informationIf you are standing & begin to walk by lifting your right foot off the floor, signal of the loss of balance begins the reflex process, allowing the right leg and the left arm to swing forward (flexing) & the left leg & right arm to keep the body steady (extending). Flexion & extension of the hip joints cause some rotation of the lumbar spine, & to keep the head facing forward & the eyes level, the lumbar & cervical spine rotate in the opposite direction.

Contralateral Reflex Arcs FES pp. 115-116Reciprocal movements of the arms & legs occur with the right arm flexing at the shoulder joint simultaneously with the flexion at the left hip joint.Normally the shoulder joint starts to flex or extend slightly before the same movement in the elbow joint.

Contralateral Reflex Arcs FES pp. 115-116

The rhythmic alternating movements of the legs which result in the forward movement of the body.

As the body moves forward, one leg provides support while the other leg is brought forward in preparation for its role as the support leg.

The activity that occurs between heel strike of one leg ( reference leg) and the next heel strike of that same leg.

2 Phases of Gait Cycle:Stance Phase- 60%Swing Phase 40%Gait Cycle

Stance PhaseDefinition:Landmarks:When the leg under consideration is in contact with the floorHeel-strike/Initial contact Foot-flat/Loading responseMidstanceHeel-offToe-offStance Phase Landmarks: Heel-Strike or Initial ContactThe moment the persons heel strikes the groundBegins the stance phase & ends the swing phaseHip flexed with knee & ankle in neutral.

The moment that the entire plantar surface of foot is in contact with the ground or when foot is flat on the groundHip flexed with knee & ankle flexed

Stance Phase Landmarks: Foot-flat or Loading response

Midpoint of stance phase & is when the weight of the body is directly over the legWhen the greater trochanter is directly over the middle of the footHip, knee & ankle in neutral (or slightly flexed)When the COG reaches its highest point in the Gait Cycle.

Stance Phase Landmarks: Midstance

The moment the heel leaves the groundHip extended, knee in neutral, and ankle planter flexed.

Stance Phase Landmarks: Heel-off

Stance Phase Landmarks: Toe-offThe moment that the persons toes push off & leave the groundEnds the stance phase & begins the swing phaseHip in neutral with knee flexed & ankle plantar flexedAlso called Pre-swing

Swing PhaseWhen the foot is not in contact with the floorBegins at toe-offEnds at heel-strikeAccompanied by an arm swing

Components:

Acceleration or Early swingMidswingDeceleration or Late swingContralateral arm & leg are moving in the same direction in the sagittal planeAs each shoulder girdle advances, the pelvis & lower limb of the ipsilateral side trail behind

Arm Swing

Hip flexed, knee flexed and ankle plantar flexed

Acceleration or Early swing

Hip flexed, knee flexed and ankle neutral

Midswing

Hip flexed with knee and ankle in neutral

Deceleration (Late swing)

Increasing the walking speed increases the speed of the arm swingWith increased speed, the length of time in stance phase decreasesFES p. 419 In slow walking, the length of time in double stance increases

Gait Variations speed variationsIn running, a higher proportion of the cycle is swing phase because the foot is in contact with the ground for a shorter period. Because of this, there is no double stance phase, and there is a point when neither foot is in contact with the ground (flight phase). As speed increases, stance phase becomes shorter and shorter with an increased tendency for in-toeing.Gait Variations - runningGait variations - running

Gait Variations - AgingFES p. 473 Gluteus maximus & minimus lose their effectiveness & walking loses its easy spring and becomes more labored.Elderly people tend to have decreased muscle bulk, strength, & flexibility, as well as some loss of hearing and vision.The major changes in gait are an overall reduction in velocity & a reduction in step/stride length.

The elderly, when increasing their walking speed, tend to take more steps instead of increasing their stride length. The elderly tend to have more problems in situations that require speed (such as in crossing streets), agility (such as walking on uneven surfaces), or in the dark. There is reduced arm swing, decreased rotation of the pelvis, & a more flat foot approach to both heel strike & push off.

Gait Variations - AgingMuscle Actions in GaitBox 10-2 Kinetic Chain Protocol: Gait (Part 2) FES p. 423 & FTM p. 400

Muscles concentrically contract to create the motion needed during gait cycleMuscles eccentrically contract to decelerate or slow the momentum of the gait cycleMuscles isometrically contract to stabilize & prevent motion of a body part

Muscle Actions in GaitMuscle Actions by Joint Hip Muscles FES pp. 471-473Hip FlexorsIliopsoas, sartorius & rectus femoris.Iliopsoas initiates walking.Some sources include TFL & pectineus2 roles in gait cycle

Hip Flexors 2 roles in gaitFirst RoleSecond RolePrimary role: Concentrically contracts to create forward swing of lower leg during early aspect of swing phaseContract eccentrically to slow extension of thigh that is occurring just before toe-off of stance phaseHamstrings & gluteus maximus2 roles in gait cycle

Hip Muscles - Extensors

Hip Extensors: 2 roles in gaitFirst RoleSecond RoleContract eccentrically:To slow the forward swinging leg at the late aspect of the swing phaseTo slow down the flexion of the thigh occurring during the swing phase

Isometrically contracts forcefully on heel-strike of stance phase: To stabilize pelvis from anteriorly tilting at hip jointTo prevent pelvis & upper body from being thrown forward because of momentum when legs forward motion is stopped by striking the groundHip AbductorsGluteus medius & minimus, TFL & sartoriusTheir action is on pelvis rather than thighMajor function is to contract, creating a depressing force on the pelvis during the stance phase.

Hip AbductorsMajor function is to contract, creating a depressing force of on the pelvis during the stance phaseParticularly active in the first half of the stance phase, from heel-strike to midstance.

Stabilize pelvis & prevent it from falling toward the swing-leg side because when the body is in single-leg support, the center of weight of the body is not balanced over the support limb but over thin air.

Hip AdductorsThigh adductor group2 roles in gait cycle

Hip adductors 2 roles in gaitFirst RoleSecond RoleContract at heel-strikeThis contraction may aid the hip joint extensors stabilization of the pelvis as the force of hitting the ground travels up through the leg.

Contract again just after toe-off which likely aids in the flexion of the hipTFL & anterior fibers of gluteus medius & minimusActive during the stance phaseThe medial rotators perform their reverse action of ipsilateral rotation of the pelvis at the hip joint which pulls the entire pelvis forward & helps advance the swing-leg forward

Hip Medial RotatorsGluteus maximus, posterior fibers of gluteus medius & minimus & the 6 deep lateral rotators of the thighActive during the stance phase

Believed to be important in controlling the hip joint medial rotators actionTheir contralateral rotation of the pelvis controls the ipsilateral rotation of the medial rotator muscles

Hip Lateral RotatorsKnee MusclesFES pp. 473-479Knee ExtensorsQuadriceps femoris group2 roles in gait cycle

Knee extensors 2 roles in gaitContract concentrically at the end of swing phase to extend leg at knee & reach out with the leg in preparation of heel-strikeContract more powerfully during the first half of the stance phase from heel-strike to midstance:

(1st) Eccentrically contract & slow knee flexion that occurs early in stance phase just after heel-strike (2nd) Concentrically contract to extend knee as we approach midstance. When stepping off curb, quads do a eccentric contraction to resist pull of gravity to prevent us from falling.

Hamstrings and gastrocnemius3 roles in gait

Knee Flexors

Contract eccentrically to decelerate knee extension just before heel-strikeContract just after heel-strike which may stabilize the knee in the early stage of the stance phase.Contract during the swing phase to keep the foot from dragging on the ground.

Knee Flexors 3 roles in gaitAnkle MusclesFES pp. 479-481

The movements at the ankle are relatively small but they are essential for shock absorption & progression. Ankle DorsiflexorsAnterior compartment muscles tibialis anterior, extensor digitorum longus, extensor hallucis longus, & peroneus tertius2 roles in gait

Contract eccentrically to slow plantar flexion of the foot during stance phase between heel-strike and foot-flat which allows the foot to be lowered to the ground in a controlled & graceful manner as the body weight transfers over to the stance limb.Contract concentrically during the swing phase to prevent the toes from scrapping on the ground as the swing leg is brought forward.

Ankle Dorsiflexors 2 roles in gaitGastrocnemius & soleus2 roles in gait

Ankle Plantar Flexors

Eccentrically contract during most of the stance phase to decelerate dorsiflexion. Because the foot is fixed to the floor, the force of plantar flexion slows the forward motion of the leg toward the ankle. Without this, the leg would collapse anteriorly at the ankle.Contract concentrically more forcefully at heel-off during the late stage of the stance phase to help push the foot off the floor.Ankle Plantar Flexor 2 rolesSubtalar MusclesAlso called the talocalcaneal joint which is between talus and calcaneus.Tibialis posterior, tibialis anterior, flexor digitorum longus, flexor hallucis longus, & the intrinsic muscles of the foot2 roles in gait

Subtalar Supinators

Contract eccentrically during stance phase from heel-strike to foot-flat to slow pronation of the Subtalar joint. During this phase of the GC, pronation is a passive process caused by the body weight moving over the arch of the foot.Then contract concentrically between foot-flat & toe-off to supinate the foot.

Subtalar Supinators 2 rolesPeroneus longus & brevisActive during the later stance phase, from foot-flat to toe-off.Believed to co-contract along with the supinators to help stabilize the foot & make it more rigid as it readies to push off the ground for propulsion.

Subtalar Pronators

Movements by JointMoves in a side-lying figure eight patternHealthy SI joint provides stability & mobility for the figure 8 movement pattern. If SI joint is not functioning properly, the entire gait is disrupted. A healthy SI joint provides a rocking movement of the pelvis.

Pelvic movements FTM p. 371Figure 10-10 Rocking movements of the SI FTM p. 372

Hip & Knee Movements FTM p. 371Hip movements Knee movements Hips move in a slightly oval patternBegins with medial rotation during leg swing & heel strikeLateral rotation during push-off

Knees move in a flexion and extension pattern opposite each other; The knees never reach full extension that is part of the standing posture

Ankles rotate in an arc around the heel at heel-strike & around a center in the forefoot at push-off. Maximum dorsiflexion is at the end of the stance phaseMaximum plantar flexion is at the end of push-off or toe-off.Ankle is neutral at heel-strike.Ankle movements FTM p. 371Muscle Testing of Gait Patterns FTM pp. 383-4 Proficiency Exercise 10-5 pp. 385-395Efficient movement pattern: If left leg extended for heel strike, right arm is extendedActivation of flexors of both the arm and leg & inhibition of the extensors. Strength imbalances common in this gait pattern. If a muscle contracts too strongly, it overpowers the antagonist group.

Muscle Testing of Gait Patterns If the flexors of the left leg are activated, the flexor & adductor muscles of right arm should activate, facilitate, & coordinate with the flexors & adductors of the left leg. The right arm muscles should test strong & the flexors & adductors of right leg & left arm should test weak & inhibited. Inhibited left hip flexors would indicate right arm flexors inhibited too.Similarly, if the right leg adductors are activated, the left arm adductors should test strong & the abductors of the left leg & right arm should test weak.

Strength testing results should show that: Simple Gait AssessmentFTM pp. 370-372 & 408-9 Proficiency Exercise 10-3 p. 372Figure 3-17 Assessment Recording Form pp. 108-9Finding problems in gait can be the key to identifying the cause of pain in the feet, ankles, legs, knees, hips, back or neck. Gait analysis/assessment can help determine underlying problems such as:Bone deformitiesMovement restrictionsMuscle weaknessNerve dysfunctionSkeletal or joint misalignmentsComplications from spasticity or contractureComplications from arthritisSimple Gait AssessmentOptimal Walking Pattern

Observe client standing (static testing) & walking (dynamic testing). Client is observed in the standing position to evaluate posture as well as bone & soft tissue symmetry. Focus is placed on evaluating the foot & ankle during standing to assess differences in between rear foot & forefoot.

Optimal Walking PatternObserve client walking from front, back & sides while walking barefooted or wearing socks as well as wearing normal walking shoes. The therapist observes the following: Joint range of motionSpeedQuality of gaitSynchrony of all arm & leg jointsOptimal Walking PatternOptimal Walking PatternHead and trunk vertical, shoulders levelArms swing freely opposite leg swingStep length and timing evenEntire body oscillates verticallyEntire body moves rhythmicallyHeel strike: foot at right angle to legKnee extended, not locked

Weight shifts forward in stance phasePush-off: foot strongly plantar flexedDuring leg swing, foot easily clears floorHeel contacts floor firstWeight rolls to the outside of the archArch flattens slightly in response to weight loadWeight shifts to ball of foot

FTM p. 370 Figure 10-8 Toe should point directly forward with each step. A= properB = improperHeel to Toe Foot Placement

How to Assess GaitFTM p. 402 Fig. 10-20Look for areas that move inefficiently.Pain causes tightening & alters normal relaxed flow.Look for compensation & shifting movement patterns.

Class ActivityLets Walk!Generally done in Gait Laboratories where videography is used to record the clients gait and joint movementsPressure/force plates and electromyography provide additional information.Complex Gait Analysis

Abnormal Gait Antalgic gaitTo reduce pain, patients avoid putting weight on the affected sideCharacterized by a decrease in the stance phase on the affected side. A person moves off the affected foot as quickly as possible to avoid pain.The person has a limping gait to avoid pain.

Ataxic or broad-based gaitAn unsteady, uncoordinated walk with a broad base of support and the feet thrown outwardFound in alcohol intoxication, neuro-pathy such as in diabetes, long-term alcoholism, & some stroke victims

Loss of the ability to carry out familiar, purposeful movements in the absence of paralysis or other motor or sensory impairmentTypically the person can stand, but has difficulty initiating gait, is very unsteady, takes small irregular steps, and their feet appear frozen to the floorCan be found in dementia

Apraxic gaitCharacterized by a stooped posture, loss of arm swing, shuffling, small steps, & festinationAn ataxic gait is characterized by imbalance, & usually a broad couching stance in compensation

Parkinsons gait (Parkinsons Disease FES p. 621)

Foot hangs with the toes pointing down, causing the toes to scrape the ground while walkingFound in Guillain-Barre Syndrome (FES p. 131), Multiple Sclerosis (FES p. 617), damage to the peroneal nerve, & herniated lumbar disk. Feet & toes are lifted through hip & knee flexion to excessive heightsUsually secondary to dorsiflexors weakness. The foot will slap at initial contact due to decreased control.

Steppage Gait Foot Drop

Weakness in the gluteus medius & minimus musclesThe individuals opposite hip sags on weight bearing because the hip abductors cannot maintain proper alignment. Has excessive lateral trunk flexion & weight shifting over the stance leg.

Trendelenberg Gait: FES p. 473

Some Causes of Gait AbnormalitiesStructure of footMuscle imbalanceArthritisMortons Toe: second toe is longer than big toeBone spurs, bunions, deformities of big toe & flat feetToo-rigid foot: Foot does not pronate enough or it may stay in pronation past midstanceImpact forces are not absorbed through the gait so the shock is sent up the kinetic chain.Structure of footMortons ToeBone Spur

Peroneus longus & Tibialis anterior: Oppose each other & insert on same 2 bones. Actions balance the transverse arch. If one shortens, changes how the foot walks in the gait pattern. A tight tibialis anterior pulls on medial side of the foot & strains the everters. A tight peroneus longus pulls on lateral side of foot & strains the inverters.Muscle ImbalanceGastrocnemius & soleus:High heels are blamed for contracted gastrocnemius and soleus muscles and perpetual plantar flexion. These women will only be able to walk on their toes & the plantar flexors will not be able to lengthen.These legs muscles have adapted to this repetitive position and, if not stretched, will permanently shorten their fibers.

Muscle ImbalanceA common muscle weakness that causes dysfunction in gait as well as low back pain. When Gluteus medius is weak, a person will show a lurch to the side as he/she attempts to counteract the imbalance caused by the weakness. The lurch can be minimal or extreme, depending on the severity of the weakness.

Muscle Imbalance-Gluteus Medius

Joint pain, limited ROM of a joint, or joint deformity associated with arthritis can cause an abnormal gait.With arthritis people begin to take smaller steps, limp or alter their gait to compensate for painful or damaged joints. Arthritis