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Abnormal Gait

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?...

...Probably
very little!