PEMERIKSAAN GAIT,

LOCOMOTION, AND BALANCE

 DEFINISI
 Gait (Pola jalan)
– cara seseorang berjalan
– Dikarakteristikkan oleh ritme, irama, langkah, jarak
langkah, dan kecepatan

 Locomotion (pindah tempat)

– Kemampuan untuk bergerak dari satu tempat ke tempat
lain

 Balance (keseimbangan)
– Kemampuan untuk mempertahankan tubuh dalam
keseimbangan dengan gravitasi secara statik dan
dinamik
 TUJUAN PEMERIKSAAN
 Mengetahui adanya gangguan,
keterbatasan, dan ketidakmampuan
berjalan, berpindah, dan keseimbangan
 Menentukan apakah perlu menggunakan
alat bantu, ortotik, prostetik.
 INDIKASI KLINIS

 Penyakit, gangguan, atau kondisi pada sistem :

– Kardiovaskuler, respirasi, muskuloskeletal, neuromuskular
 Impairment
– Sirkulasi (klaudikasio intermitten)
– Integritas dan mobilitas sendi (nyeri gerak hip)
– Fungsi motor (pola gerak abnormal)
– Kinerja otot (penurunan kekuatan dan ketahanan otot)
– ROM (lGS tak normal saat jalan)
 Keterbatasan fungsi dalam kemampuan membentuk aksi,
kerja, dan aktivitas yang meliputi :
– Pemelihaaan diri (ketidakmampuan berpakaian krn
ketidaknormalan keseimbangan duduk)
– Pengelolaan rumah tangga (ketidakmampuan melakukan aktivitas
berkebun krn menurunnya kekuatan otot)
– dsb
 Indikasi ….

 Disability (ketidakmampuan atau

keterbatasan kmampuan untuk membentuk
aksi, tugas, atau aktivitas sesuai dengan
aturan dalam konteks sosial budaya
individu
 Faktor resiko
– Meningkatnya resiko jatuh
 KEbutuhan kesehatan, wellness, dan
kebugaran
 OBSERVASI GAIT
 Berjalan adalah berpindahnya tubuh
dari satu titik, ketitik berikutnya
dengan cara menggunakan kedua tungkai
(bipedal : posisi tubuh selalu tegak
selama proses berlangsung). Pola
repetisi daripada penumpuan berat
badan dari satu tungkai ketungkai yang
lain dengan heel – toe striding adalah
fenomena yang membedakan manusia
dengan hominids yang lebih primitif (
Napier, 1967).
 Walking is a series of gait cycles
– A single gait cycle is known as a STRIDE
 TUJUAN
 untuk mengetahui ketidaknormalan gait
yang disebabkan kelemahan otot,
keterbatasan mobilitas sendi, nyeri,
atau ganggan kontrol motoris akibat lesi
sistem saraf
 Analisa : dengan camera video dan
videotape
Normal Walking Requirements
There are (4) major criteria essential to walking.
– Equilibrium
 the ability to assume an upright posture
and maintain balance.
– Locomotion
 the ability to initiate and maintain rhythmic
stepping
 Walking Requirements Cont’d

– Musculoskeletal Integrity
 normal bone, joint, and muscle
function
– Neurological Control,
 must receive and send messages
telling the body how and when to
move. (visual, vestibular, auditory,
sensorimotor input)
 Siklus berjalan :
 Satu cycle, dimulai dari heel strike,
sampai tungkai yang sama mulai heel
strike berikutnya.
 Interval antara dua steps bisa dihitung
jarak dan waktunya.
A Single Gait Cycle or Stride
Gait Flow Chart
 SIKLUS GAIT NORMAL
Stance phase (40%) Swing Phase (60%)

Racho Konvensinal Racho Konvensional

Initial contact Heel strike Initial swing Acceleration

Loading Foot flat Mid-swing Mid-Swing

response
Mid-stance Mid-stance Terminal Deceleration
swing
Terminal Heel off
stance
Pre swing Toe off
 Komponent Gait Normal :
 1). Weight Acceptance.
 2). Single limb Support.
 3). Limb Advancement.
 Stance.
 Initial Contact.
 Loading Response (LR).
 Mid Stance (MSt).
 Terminal Stance (TSt).
 Swing
 Pre-swing (PSw).
 Initial Swing (Isw)
 Midswing (MSw)
 Terminal Swing (TSw)
 Stride length :
 Adalah jarak antara dua jejak kaki, pada
kaki yang sama.
 Pada orang dewasa pria jaraknya
antara 140 – 156,5 cm.
 Stride duration :

 Adalah waktu yang dibutuhkan untuk

jarak tersebut ( stride length ).
 Step length :
 Adalah jarak antara dua jejak
kaki , baik dari kanan kekiri atau
sebaliknya.
 Jarak rata2nya adalah 68 –
78cm.
 Step duration :
 Adalah waktu yang dibutuhkan
dari heel strike kaki yang satu ke
heel strike kaki yang lain.
 Cadence :
 Adalah jumlah steps permenit.
 Dimana nilai rata2nya adalah 112
– 116 permenit.
 Stance Phase of Gait
 When the foot is
contact with the ground
only
 Propulsion phase
 Stance phase has 5
parts:
– Initial Contact (Heel
Strike) (1)
– Loading Response (Foot
(Missing Loading Response in
Flat) (2) picture)
– Midstance (2)
– Terminal Stance (3)
– Toe Off (Pre-Swing) (4)
 Motions during Stance Phase

 Shoulder flexes
 Pelvis rotates right (transverse plane)
 Spine rotates left
 Hip extends, IRs
 Knee flexes, extends
 Ankle plantarflexes, dorsiflexes, plantarflexes
 Foot pronates, supinates
 Toes flex, extend, flex
 Initial Contact

 Phase 1
 The moment when the
red foot just touches the
floor.
 The heel (calcaneous) is
the first bone of the foot
to touch the ground.
 Meanwhile, the blue leg
is at the end of terminal
stance.
 Static Positions at Initial Contact

 FREEZE FRAME POSITIONS

 Shoulder is extended
 Pelvis is rotated left
 Hip is flexed and externally rotated
 Knee is fully extended
 Ankle is dorsiflexed
 Foot is supinated
 Toes are slightly extended
 Loading Response
 Phase 2
 The double stance period
beginning
 Body weight is transfered
onto the red leg.
 Phase 2 is important for
shock absorption, weight-
bearing, and forward
progression.
 The blue leg is in the pre-
swing phase.
 Static Positions at Loading
Response

 Shoulder is slightly extended

 Pelvis is rotated left
 hip is flexed and slightly externally rotated
 knee is slightly flexed
 ankle is plantarflexing to neutral
 foot is neutral
 Toes are neutral
 Midstance

 Phase 3
 single limb support interval.
 Begins with the lifting of
the blue foot and continues
until body weight is aligned
over the red (supporting)
foot.
 The red leg advances over
the red foot The blue leg is
in its mid-swing phase.
 Static Positions at Midstance

 Shoulder is in neutral
 Pelvis is in neutral rotation
 Hip is in neutral
 Knee is fully extended
 Ankle is relatively neutral
 Foot is pronated
 Toes are neutral
 Terminal Stance

 Phase 4
 Begins when the red
heel rises and continues
until the heel of the
blue foot hits the
ground.
 Body weight progresses
beyond the red foot
 Static Positions at Terminal Stance

 Shoulder is slightly flexed

 Pelvis is rotated left
 Hip is extended and internally rotated
 Knee is fully extended
 Ankle is dorsiflexed
 Foot is slightly supinated
 Toes are neutral
 Toe-Off

 Phase 5
 The second double stance
interval in the gait cycle.
 Begins with the initial
contact of the blue foot
and ends with red toe-off.
 Transfer of body weight
from ipsilateral to
opposite limb takes place.
 Static Positions at Toe-Off

 Shoulder is flexed
 Pelvis is rotated right
 Hip is fully extended and internally rotated
 Knee is fully extended
 Ankle is plantarflexed
 Foot is fully supinated
 Toes are fully extended
 Stance Phase Characteristics

 During a single stride, there are 2 periods of

double limb support (both feet on ground):
– Loading response (right) & Toe Off (left)
– Loading response (left) & Toe Off (right)
Gait Progression
 Swing Phase

 When foot is NOT contacting the ground,

it is swinging!
 Limb advancement phase
 3 parts of swing phase:
 Initial swing
 Midswing
 Terminal swing
 Motions during Swing Phase

 Shoulder extends
 Spine rotates right
 Pelvis rotates left (passive)
 Hip flexes, ERs
 Knee flexes, then extends
 Ankle dorsiflexes
 Foot supination (inversion)
 Toes extend
 Initial Swing

 Phase 6
 Begins when the red foot is
lifted from the floor and
ends when the red swinging
foot is opposite the blue
stance foot.
 It is during this phase that a
footdrop gait is most
apparent.
 The blue leg is in mid-stance.
 Static Positions at Initial Swing

 Shoulder is flexed
 Spine is rotated left
 Pelvis is rotated right
 hip is slightly extended and internally rotated
 Knee is slightly flexed
 Ankle is fully plantarflexed
 Foot is supinated
 Toes are slightly flexed
 Midswing

 Phase 7
 Starts at the end of the
initial swing and continues
until the red swinging limb
is in front of the body
 Advancement of the red
leg
 The blue leg is in late mid-
stance.
 Static Positions at Midswing

 Shoulder is neutral
 Spine is neutral
 Pelvis is neutral
 Hip is neutral
 Knee is flexed 60-90°
 Ankle is plantarflexed to neutral
 Foot is neutral
 Toes are slightly extended
 Terminal Swing

 Phase 8
 Begins at the end of
midswing and ends when
the foot touches the
floor.
 Limb advancement is
completed at the end of
this phase.
 Static Positions at Terminal Swing

 Shoulder is extended
 Spine is rotated right
 Pelvis is rotated left
 Hip is flexed and externally rotated
 Knee is fully extended
 Ankle is fully dorsiflexed
 Foot is neutral
 Toes are slightly extended
 Gait Pathologies
 Deviations from “normal” gait pattern
 Result from
– Pain
– Injury (ROM restrictions)
– Surgery (ROM restrictions)
– Weakness
– Balance deficits
 Consider all “normal” components of stance
and swing phase of a gait cycle or stride
 Compare right and left sides when observing a
person’s gait pattern
 Antalgic Gait

 Painful leg gait

 Decreased stance time on painful leg
 Increased swing time on painful leg
 Decreased swing time on non-painful leg
 Increased stance time on non-painful leg
 Trendelenburg Gait

 Gluteus medius weakness gait

 Lateral trunk lean towards side of
weakness
 Maintain body’s COG over weak side during
stance phase
 Flexed Knee Gait

 Flexed knees
 Flexed trunk posture
 No arm swing
 No initial contact
 No Toe-off
 No hip extension
 Short step
 Shortened stride
 COG stays within BOS
 Common in elderly with fear of falling
Flexed Gait Posture
Common Gait Posture in Elderly People
 BALANCE
 Balance : komponen dasar aktivitas
 Ditentukan oleh tonus postural :
– mobilitas
– stabilitas
 Kualitas balance tergantung intregitas :
– SSP dan SST
– muskuloskeletal
 Instrumen Pengukur Balance

1 . Sitting Balance Test

– Menilai kemampuan balance posisi duduk
– Prosedur :
– Pasien duduk di tepi bed
– kaki disangga
– kedua tangan dalam pangkuan
– Dorongan : ke belakang, depan dan
samping.
 Penilaian :

4 = dapat bertahan tanpa bantuan

3 = dapat bertahan dengan bantuan
2 = dapat bertahan statis (tanpa
dorongan), perlu bantuan
1 = tidak dapat mempertahankan
Nilai normatif = 4
Kelebihan dan kelemahan : sederhana,
besarnya dorongan tak dapat
distandardisasi.
 2. Step Test

 Waktu stepping satu tungkai 15 detik

 Prosedur : Pasien berdiri tanpa alas kaki
5 cm dari blok yang tingginya 7,5 cm.
Pasien melakukan stepping 1 tungkai 15
detik kemudian tungkai satunya.
 Reliabilitas : Retest ICC > 0,90 (usia
lanjut) dan > 0,88 (pasien stroke)
 •
 Nilai normatif :
Usia 73 th ; step = 17 ; waktu 15 detik
 Kelebihan dan kelemahan :
– cepat, sederhana
– sensitif
– sulit dilakukan bila gangguan balance
berat
 3. Functional Reach Test (FR)

Mengukur jarak jangkauan

 Prosedur : Pasien berdiri di samping tembok
Menjangkau jarak maksimal
Titik ukur : caput metacarpal jari tengah
 Nilai normatif :
 20 - 24 th : L = 42 cm ; P = 37 cm
 41 - 64 th : L = 38 cm ; P = 35 cm
 70 - 87 th : L = 33 cm ; P = 27 cm
 Functional Reach Test

Distance reached (inches)

Score (check one) Risk for falling
10 inches Unlikely to fall
6-10 inches 2 times more likely to fall
1-6 inches 4 times more likely to fall
Unwilling to reach 28 times more likely to
fall
Modified from Duncan PW and other functional reach ; a new clinical measure of balance, J Gerontol
45(6):M192-197,1990
 4. BERG BALANCE
Terdiri atas 14 kriteria, dimana masing-masing point mempunyai skor 0
– 4 (Jumlah total : 56)
– Aspek yang dinilai :
 Sitting to standing ___________
 Standing unsupported ___________
 Sitting unsupported ___________
 standing to sitting ___________
 Transfers ___________
 Standing with eyes closed ___________
 Standing with feet together ___________
 Reaching forward with outstretched arm ___________
 Retrieving object from floor ___________
 Turning to look behind ___________
 Turning 360 degrees ___________
 Placing alternate foot on stool ___________
 Standing with one foot in front ___________
 Standing on one foot ___________

 Total Score max 56

• Nilai normatif = 56
Interrater ICC = 0, 98

 Validitas :
– Concurrent dengan instrumen lain.
 5. Timed up and Go Test

 Mengukur kecepatan berjalan dari duduk pp

 Prosedur :
– Pasien duduk bersandar di kursi (45 cm)
– Berjalan 3 m, balik, duduk lagi
– Kecepatan : maksimal, tetapi enak.
– Hitung waktunya.
• Reliabilitas :
Interrater ICC = 0, 99
Retest ICC = 0, 99
 Validitas :
– Concurrent dengan instrumen lain
( Berg, BI )
 Kelemahan :
– kurang sensitif
 Nilai normatif :
– Usia 75 th = 85 detik
 TIMED UP AND GO TEST
(berapa waktu yang dicapai dari duduk berdiri jalan 3
meter kemudian berputar kembali duduk kekursi semula)
 TIMED UP AND GO TEST
(berapa waktu yang dicapai dari duduk berdiri jalan 3 meter kemudian
berputar kembali duduk kekursi semula)

Tgl: Tgl: Tgl: Tgl: Tgl: Tgl: Tgl:

PEME-
RIKSA
AN

Waktu

Ket
 Modified Get-Up and Go Test
Task Score

1 = normal
2 = slightly abnormal
3 = mildly abnormal
4 = moderately abnormal
5 = severely abnormal

1. Rising from Chair

2. Walking 10 feet
3. Turning around
4. Sitting down in chair
Summed score
TOTAL SCORE (summed score divided by four)
 6. Pastor’s Test (Marsden’s Test)

Mengukur kemampuan mempertahankan

balance terhadap gangguan eksternal
 Prosedur : Pasien berdiri, mata terbuka
– Berikan dorongan mendadak ke belakang
 Penilaian :
0 = tetap tegak, tanpa melangkah
1 = tegak kembali ; satu langkah ke belakang
(tanpa bantuan)
 Penilaian :
0 = tetap tegak, tanpa melangkah
1 = tegak kembali ; satu langkah ke belakang (tanpa
bantuan)
2 = tegak kembali ; 2 langkah / lebih ke belakang
(tanpa bantuan)
3 = tegak kembali ; beberapa langkah ke belakang
dengan bantuan
4 = jatuh ke belakang tanpa mencoba melangkah

Reliabilitas : Retest tinggi

Validitas : Kemampuan diskriminasi
Kelemahan : Dorongan tidak dapat distandardisasi
Nilai normatif : 0 - 1.
 7. Falls diary

 Mencatat :
– kejadian jatuh
– lingkungan kejadian jatuh
– konsekuensi jatuh
 Prosedur :
– Pasien mengisi kalender :
v= tidak jatuh
x= jatuh
Bila jatuh, mengisi lembar uraian:

 Tempat jatuh
 Sedang apa ?
 Bangun sendiri ?
 Perlu bantuan medis ?
 Arah jatuh
 Pingsan ?
 Terpeleset ?
 Perubahan aktivitas ?
8. Tinnetti balance and gait test