Department of Physical Therapy NEW YORK UNIVERSITY
Historical Perspective Tendency to classify gait according to disease or injury state
Hemiplegic gait Parkinsonian gait Spastic gait Quadra- or paraplegic gait Amputee gait, etc.
Rationale A specific disease or injury state manifested as a discrete and clinically describable problem with the mechanics of gait
Our Starting Point
Well take a deficit-oriented vs. disease- oriented approach to abnormal gait analysis Example: How might a spastic hamstring on one side, secondary to hemiplegia caused by a CVA, affect gait mechanics?
Answer A spastic hamstring may limit step or stride excursion and/or pelvic transverse rotation
Preferred Rate of Ambulation Free or comfortable walking speed Self-selected pace Rate at which the normal individual is most energy efficient Range: ~2.5 - 4.0 mph (cadence of ~75 - 120 steps per minute) Will vary from individual-to-individual
Walking Rates - Historical
Perspective Historically walking rates classified as: Slow: ~75 - 90 steps per minute Medium: ~90 - 105 steps per minute Fast: ~105 - 120 steps per minute
Energy Cost vs. Rate
Summary & Interpretation
Oxygen expenditure is least while walking at a rate somewhere between ~85 to 110 steps per minute irrespective of stride (or step) length Individuals tend to gravitate toward a self-selected pace which is most energy efficient for that individual
Enter - The Idea of a
Preferred Rate A preferred rate of ambulation is a self-selected walking pace that an individual assumes that is most energy efficient
Clinical Implication Since there is apparently a ratedependent issue that drives gait efficiency the PT should understand that going slower than and faster than the preferred rate will lead to inefficiency and potential stress on the cardiovascular and motor control systems
Why is Gait More Efficient
at Preferred Rate? What is the relationship between energy efficiency and a preferred rate of ambulation?
The Center of Gravity
(COG) COG located at S1 - S2 During preferred rate walking the COG approximates a sinusoidal curve from the: Sagittal perspective - no greater than a 2 peak-to-valley excursion Frontal perspective - no greater than a 2 medial-to-lateral excursion
Path of the COG
Distortion of the Path of
the COG A distorted path of the COG will require mechanical and motor control compensations that will: Disrupt normal timing of events Over-ride normal gait control Change from automatic to manual control strategies
Lead to over-correction of gait mechanics
The Result Increased energy expenditure
A Simple Example Walking with a stiff-knee (stiff-knee gait) with a cylinder cast During stance the HAT will vault over the fixed foot (especially during midstance) COG will be deflected higher than the usual 2 upward vertical displacement with increased energy cost
Who Walks with a Stiff
Knee? Transient knee injury patient (e.g., surgical repair of a ligament Hemiplegic with loss of knee control The AK amputee with a locked-knee prosthesis The BK amputee with poor knee control Should we consider each case the SAME?
The Control of Gait
Motor control options: Manual control theory - thinking about having to take a step each time you want to advance the foot forward Automatic control theory - an automatic control system that accounts for gait mechanics without having to think about foot placement and other metrical details
Which one is it?
Think about this...
An Everyday Occurrence Youre walking along 23rd Street, heading west toward your bus stop Youre thinking about what was discussed in Kinesiology class today Youre also thinking that there is a lot a traffic and its going to take you forever to get home tonight...
Questions Are you thinking about foot placement? Are you thinking about how long each step should be? Are you thinking about trunk and pelvic rotation in the transverse plane and maintaining reciprocal arm-swing? Are you thinking about...
Answer Probably NOT! Why? Your gait control is on automatic pilot When do you have to think about gait control? When theres a perturbation
Central Pattern Generator
(CPG) CPG - a group of synaptic connections probably at the spinal cord level which are triggered by an event or condition When a threshold is met via a triggering mechanism the CPG appears to be activated and takes over automatic control of gait metrics - i.e., you dont have to think about it
Evidence Spinalized (cord transected) cats suspended over a treadmill will walk with an alternating, striding quadripedal gait Human quadriplegics have also walked this way
CPG and Supraspinal
Influence Gait perturbations Example: Someone walks across your path from the side that you didnt see Theres a need to take immediate corrective action to avoid a collision
Supraspinal centers appear to override the CPG and switch to a manual
control strategy
What Triggers a CPG?
There seems to be a close relationship between activating a CPG for gait control and preferred rate of ambulation In other words, there is a ratedependent relationship between normal gait mechanics and its control mechanism
So... It appears we maintain the path of the COG within very tight limits and therefore expend the least amount of energy by assuming a preferred rate which in turn leads to an activation of a CPG
Think About This...
Whats one of the most common things heard during gait training in a PT clinic?
Mr. Jones, while youre
walking, I want to go
...very slow!
What are some possible
implications of this? Mr. Jones will be safe - probably wont fall and break his hip (good news). Mr. Jones wont sue you (good news). The path of the COG may be distorted (bad news). Energy cost may increase (bad news) Suppose Mr. Jones has a cardiac condition?
What are some possible
implications of this? Mr. Jones may never reach his preinjury/disease preferred rate of ambulation and therefore never trigger a CPG that automates gait (bad news). Mr. Jones gait may never look normal (bad news).
Is it possible that... going very slow might actually cause Mr. Jones to lose his balance and fall? Why?
Factors That Lead to the
Initiation of Gait Assume right LE will advance first: Weight shift to left LE (unloads right hip) Left hip moves into (hyper-) extension and precedes right hip flexion Right side of pelvis rotates medially preceding right hip flexion COG moves over right foot after its advanced
Factors That Lead to the
Initiation of Gait Successful completion of these events probably leads to a triggering of a CPG as preferred rate is attained
Gait Training Scenario
Mrs. Flanagan is standing in the parallel bars with her physical therapist, Dudley Doright, getting ready to take a left step to start walking. We hear the PT say, Now, Mrs. Flanagan, I want you to put your left foot forward and take a step
What wrong with this
picture? Where is the patients COG relative to her base-of-support? What is probably the size of the left step (step length) relative to the right? What impact will this likely have on her forward velocity? What are the chances of attaining her pre-injury/disease preferred rate?
Deficit-Oriented Gait Analysis Questions: Do diseases/injuries specifically manifest as a stereotypical gait pattern? or Does the disease/injury lead to a deterioration of control parameters which cause gait deficits?
Response If you believe the latterit shouldnt matter what the patients problem is If you understand the consequence of the disease or injury (loss of motor control, weakness, damaged supportive structures, loss of a part of or an entire limb, etc.)...
you should be able to anticipate or
predict what impact a deficit has on gait irrespective of their state of injury or disease.
Hip Extensors - Stance
Analysis of Deficits Hip Extensors - Stance Early stance (@ HS) Prevent hip flexion (jack-knifing)
Early stance (HS FF)
Guide hip into flexion eccentrically
Early stance (@ HS) weakness/absence Hip/trunk collapses into flexion
Early stance (HS FF)
Trunk falls forward
Hip Abductors - Stance
Hip Abductors Prevent contra-lateral hip from dipping greater than 5 - 80 Stance-side abductors active Loss of abductors: Static analysis - + Trendelenburg sign Dynamic analysis - weakness o f abductors manifests as lurching gait (toward stanceside)
Analysis of Deficits Abductors - Stance Early stance COG shifts away from stance side LE Increases moment arm of COG relative to stance side hip Stance side abductors generate counterrotational torque to prevent contra-lateral from dropping > 5-80
Early stance weakness/absence Contra-lateral hip drops > 5-80 Compensation is to lean (lurch) over stance-side LE
Quadriceps - Stance
Analysis of Deficits Quadriceps - Stance Early stance (HS FF) Guides knee into 200 of flexion eccentrically (controls unlocking of the knee)
Late stance (HR TO)
Controls for knee flexion (~400 at TO)
Early stance weakness/absence Inability to absorb energy Buckling
Late stance weakness/absence Knee collapse into flexion -premature flexion into early swing - rubber knee
Pre-Tibial Group - Stance
Analysis of Deficits Pre-tibial Group - Stance Early stance (HS FF)
Early stance weakness/absence
Lowers forefoot to floor eccentrically After forefoot contacts floor- pull tibia forward over foot
Forefoot slaps to the floor - dropfoot gait Loss of forward pull of tibia
Plantar Flexors - Stance
Analysis of Deficits Plantar Flexors - Stance Late mid-stance Concentrically pulls tibia forward
Late stance (HR TO)
Provides propulsive thrust during push off
Early stance weakness/absence Loss of forward pull of tibia Loss of forward thrust - poor transition to early swing
Ankle Stability - Late
Stance Ankle less stable and subject to injury (e.g., sprains) in plantar flexion vs.dorsiflexion Posterior trochlea in mortise Collateral ligaments swing out of collateral position
Position of ankle during push-off (late
stance) = plantar flexed
Analysis of Deficits Peroneals - Stance Late stance (HR TO) Dynamically provide collateral stability to ankle when plantar flexed Secondary plantar flexor for forward thrust
Late stance weakness/absence Ankle instability causing mediallateral movement Potential for ankle injury - sprains Poor transition from late stance to early swing
Analysis of Deficits Plantar Intrinsics - Stance Late stance (HR - TO) Late stance Provide medial lateral stability to MTP joints (especially nos. 1 & 2) - cancels second degree of freedom Improves forward propulsion and transition to early swing
weakness/absence Excessive medial lateral shimmy of hindfoot during HR Inefficient forward thrust
Paraspinals -Stance
Analysis of Deficits Paraspinals - Stance Early stance (HS FF) & late stance (HR - TO) Prevent forward flexion of trunk acting on pelvis
Early & late stance
weakness/absence Trunk falls forward Loss of head and neck control
Analysis of Deficits Hip Flexors - Swing Late stance - early swing (acceleration) Forward flexion of femur working with plantar flexors to accelerate LE in early swing Functionally shortens LE (with eccentric action of quadriceps and dorsiflexors) to prevent toe-drag
Late stance - early
swing weakness/absence of forward acceleration after TO Toe may not clear the floor during swing through Compensate with circumduction at hip
Dorsiflexors - Swing
Analysis of Deficits Dorsiflexors - Swing Mid-to-late swing (deceleration) Affects toe-up concentrically Functionally shortens LE during swing through
Mid-to-late swing weakness/absence Loss of toe-up Compensation Increased hip flexion - steppage gait Circumduction at hip
Hamstrings - Swing
Analysis of Deficits Hamstrings - Swing Late swing (deceleration) Decelerates tibial shank Provides for smooth transition between late stance and early swing
Late swing weakness/absence Impact on terminal extension - knee slapped into extension or hyperextension
Gait in the Elderly Men Murray, Kory & Clarkson
Gait did not appear vigorous or labored Gait pattern did not resemble that of patients with CNS damage Gait was guarded and restrained attempt to maximal stability and security
Gait in the Elderly Men Murray, Kory & Clarkson
Gait resembled someone walking on a slippery surface decreased step & stride legnth wider dynamic BOS increased lateral head movement decreased rotation of pelvis
Gait in the Elderly Men Murray, Kory & Clarkson
toe/floor clearance distance slightly decreased lower stance-toswing ratio decreased reciprocal arm swing more from elbow than shoulder
Spasticity and its Impact
on Gait Spasticity - resistance to passive stretch Results from CNS (UMN) injury/disease Increased source of uncontrolled/poorly controlled tension Probably due to loss of inhibiting action of the CNS While tension production may be significant the time-rate-of-tension development may be delayed
Spasticity & Gait
Spastic response may be caused by: Unexpected quick stretch of muscles Foot contact with floor Supraspinal overlay
Effects: Restrict joint excursion Delay transition from one gait phase to the next
Spasticity & Gait
Dubo et al. showed that EMG activity of spastic muscles increased during mid-stance i.e., there was a loss of phasic control of muscles
Spasticity & Gait
Examples Quadcriceps May prevent knee from unlocking during interim between HS and FF Knee maintained in extension leading to a vaulting over stance limb or circumduction of hip Disrupts (timing) transition to mid- and late stance May prevent LE bending during swing phase
Spasticity & Gait
Examples Plantar flexors Increase in spastic tone may limit forward rotation of tibia between MS and PO May locate ground reaction force well behind knee causing significant flexion moment during late MS and knee buckling tendency
Ankle may be locked up during PO
decreasing propulsive thrust forward inefficient transition from TO to early swing
Spasticity & Gait
Examples Hamstrings May limit forward swing of LE decreasing step length May prevent knee from reaching a terminally extended position just prior to HS
Gait Training - Questions
If gait is controlled by a ratedependent chain of synaptic connections at the spinal cord level (i.e., a CPG), is it possible for a PT to effect (physiological) changes in the gait control system?
Gait Training - Questions
If gait is initiated (and sustained) as described previously (e.g., unloading of hip, pelvis rotates medially, COG loads over stance foot, etc.), how do we train patients to start walking?
Gait Training - Questions
What impact will assistive devices have on gait performance?
Parallel bars Walkers Bilateral & unilateral crutches and canes PTs using contact guarding from the side or behind
Gait Training - Questions
If the rhythmic, symmetrical alternating characteristics of gait are triggered when a patient assumes their preferred rate, will gait symmetry and a normal appearing gait be possible if the patient walks substantially slower than her preferred rate?
Gait Training - Questions
Are all patients objectives concerning walking the same? Are your objectives for Ms. Walksalot, a 39 year old healthy female who broke her ankle two weeks ago in an intensive tennis match, the same as for Mr. Livesinathirdstorywalkup, a frail 87 year old male, with emphysema and a fractured, pinned hip?
Gait Training - Questions
Whats the best thing a PT can say to their patient while gait training?...
