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. diseaseoriented 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 mid-stance) 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 over-ride 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) weakness/absence

Hip/trunk collapses into flexion

Early stance (HS - FF)

Guide hip into flexion eccentrically

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) Early stance weakness/absence Guides knee into 200
of flexion eccentrically (controls unlocking of the knee) Inability to absorb energy Buckling

Late stance (HR - TO)

Controls for knee flexion (~400 at TO)

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 - drop-foot gait Loss of forward pull of tibia

Plantar Flexors - Stance

Analysis of Deficits Plantar Flexors - Stance

Late mid-stance
Concentrically pulls tibia forward

Early stance weakness/absence

Loss of forward pull of tibia Loss of forward thrust - poor transition to early swing

Late stance (HR - TO)

Provides propulsive thrust during push off

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) Late stance weakness/absence Dynamically provide
collateral stability to ankle when plantar flexed Secondary plantar flexor for forward thrust Ankle instability causing medial-lateral 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 weakness/absence Provide medial lateral stability to MTP joints (especially nos. 1 & 2) - cancels second degree of freedom Improves forward propulsion and transition to early swing Excessive medial lateral shimmy of hindfoot during HR Inefficient forward thrust

Paraspinals -Stance

Analysis of Deficits Paraspinals - Stance

Early stance (HS - FF) Early & late stance & late stance (HR weakness/absence TO) Trunk falls forward
Prevent forward flexion of trunk acting on pelvis 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-to-swing 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 midstance 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 rate-dependent 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!