PTA 130 - Fundamentals of Treatment I
GAIT ANALYSIS & GAIT TRAINING
Introduction
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Gait is one of the most basic components of independent function
A common goal of rehabilitation is to restore or improve the ambulatory status of a patient
Purpose of Gait Analysis:
o Assist with understanding the gait characteristics of a particular disorder
o Assist with movement diagnosis
o Determine proper interventions
o Evaluate the effectiveness of treatment
Gait Cycle
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The gait cycle begins when the heel of the reference extremity contacts the supporting surface
and ends when the heel of the same extremity contacts the ground again
The gait cycle is divided into two phases:
o Stance –
 The interval in which the foot is on the ground (60% of the gait cycle)
o Swing –
 The interval in which the foot is not in contact with the ground (40% of the gait
cycle)
Double Support
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Refers to the interval in a gait cycle in which body weight is transferred from one foot to the
other and both right and left feet are in contact with the ground at the same time
Two periods of double support occur within a single gait cycle
Gait Cycle – Stance Phase
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Traditional Terminology
o Heel strike
o Footflat
o Midstance
o Heel-off
o Toe-off
LAREI Terminology
o Initial contact
o Loading response
o Midstance
o Terminal stance
o Preswing
Gait Cycle – Swing Phase
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Traditional Terminology
o Acceleration
o Midswing
o Deceleration
LAREI Terminology
o Initial swing
o Midswing
o Terminal swing
Ankle and Foot: Stance Phase
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Heel strike to foot flat
Foot flat through midstance
Midstance to heel off
Heel off to toe off
Heel Strike to Foot Flat
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Normal Motion:
o 0 -15 degrees PF
Normal Muscle Activity:
o Eccentric contraction of tibialis anterior
Result of Weakness:
o Lack of PF causes the foot to slap the floor
Foot Flat through Midstance
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Normal Motion:
o 15 degrees PF to 10 degrees DF
Normal Muscle Activity:
o Gastroc and soleus muscles act eccentrically
Result of Weakness:
o Excessive DF and uncontrolled tibial advance
Midstance to Heel Off
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Normal Motion:
o 10-15 degrees of dorsiflexion
Normal Muscle Activity:
o Gastroc and soleus contract eccentrically
Result of Weakness:
o Excessive DF and uncontrolled forward motion of tibia
Heel Off to Toe Off
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Normal Motion:
o 15 degrees DF to 20 degrees PF
Normal Muscle Activity:
o Gastroc, soleus, peroneals, and flexor hallicus longus contract to PF the foot
Result of Weakness:
o No roll off. Decreased contralateral step
Ankle and Foot: Swing Phase
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Acceleration to midswing
Midswing to deceleration
Acceleration to Midswing
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Normal Motion:
o Dorsiflexion to neutral
Normal Muscle Action:
o Dorsiflexors are contracting to bring the ankle into neutral
Result of Weakness:
o Foot drop and/or toe dragging
Midswing to Deceleration
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Normal Motion:
o Neutral
Normal Muscle Action:
o Dorsiflexion
Result of Weakness:
o Foot drop and/or toe dragging
What happens at the Knee and the Hip during gait?
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What happens at the knee during the stance phase and swing phase of gait?
What happens at the hip during the stance phase and swing phase of gait?
Gait Terminology
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Stride Length
o The distance between corresponding contact points of the same foot (e.g., distance from
heel strike to heel strike of the same foot)
Step Length
o The distance between corresponding contact points of opposite feet (e.g., distance from
heel strike of one foot to heel strike of the opposite foot)
Stride Width
o The lateral distance between the feet
Sinusoidal Motion
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COG located at S1 - S2
During preferred rate walking the COG approximates a sinusoidal curve from the:
o Sagittal perspective - no greater than a 2” peak-to-valley excursion
o Frontal perspective - no greater than a 2” medial-to-lateral excursion
Increased Energy Expenditure in Gait
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If the COG deviates too far from the norm increased energy is required
o Example: Walking with a stiff-knee (“stiff-knee gait”) while in a brace/cast
During stance phase the patient 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
Rehabilitation of Ambulation
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Requirements for normal gait:
o Normal range of motion
o Normal and balanced muscle strength
o Normal balance
o Stabile structures for weight acceptance
o Normal control of reciprocal gait pattern both in symmetry and muscle activation
sequence
The Control of Gait
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Motor control options:
o ‘Manual’ control theory –
 Thinking about having to take a step each time you want to advance the foot
forward
o ‘Automatic’ control theory –
 An automatic control system that accounts for gait mechanics without having to
think about foot placement and other metrical details
Preferred Rate of Ambulation
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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
Pathological Gait
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Results when a segment is not able to move as it should
Common Causes:
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o Injury
o Weakness, loss of flexibility
o Pain
o Bad habits
As a result, compensations occur elsewhere in the body with resultant effects (stress, weakness,
and further injury)
Abnormal Gait Patterns
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Propulsive
Scissor
Spastic
Steppage
Waddling
Trendelenberg
Antalgic
Leg length discrepancy
Circumduction
Vaulting
Hip Hiking
Quadriceps Gait
Stiff Knee Gait
Abnormal Gait Patterns
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Propulsive Gaito A stooped, rigid posture, with the head and neck bent forward; Balance deficit
Scissor Gaito Characterized by legs flexed slightly at the hips and knees, giving the appearance of
crouching, with the knees and thighs hitting or crossing in a scissor-like movement
Spastic Gaito A stiff, foot-dragging walk caused by one-sided, long-term, muscle contraction
Steppage Gaito Foot drop where the foot hangs in plantarflexion, toes can scrape the ground during
swing phase; Exaggerated hip and knee flexion used to clear toes
Waddling Gait –
o A distinctive duck-like walk; trunk sways side to side; wide base of support
Trendelenburg Gaito Weakness of the hip abductor muscles; pelvis drops on the contralateral side with
compensatory lateral trunk lean over that side
Antalgic Gait Pattern- A protective gait pattern
o Stance time is usually limited on the painful limb resulting in uneven timing and/or
uneven step lengths
o
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The uninvolved limb will demonstrate a shortened step length since it must bear weight
sooner than normal
o Pain promotes a modification of the gait pattern to avoid joint motions, muscle
contraction and weight bearing that sustains or may increase the pain
Functional Leg length discrepancy –
o The pelvis dips downwards on the side of the shortened limb with compensatory lateral
trunk bend
Circumductiono Secondary to hip flexor weakness; adductor muscles act as hip flexors while the hip joint
is extended
Hip hikingo Pelvis lifts on the side of the swinging limb by contraction of spinal muscles and lateral
abdominal wall; may also see posterior trunk lean
Vaultingo Used to increase ground clearance in swing phase by going up on the toes of the stance
phase leg
Stiff knee Gait –
o During stance the patient will vault over the fixed foot (especially during mid-stance) &
COG will be deflected higher than the usual 2” upward vertical displacement
Pathological Gait
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Gluteus Medius Gait – (Trendelenburg Gait)
o Pelvis drops on contra-lateral non-weight bearing side
o Compensation – patient moves trunk laterally over the weak hip
Quadriceps Gait – (weakened Quads)
o An immediate lurch occurs at heel strike forcing the femur backward & the trunk forward
to passively lock the knee
o Compensation – COG moves anterior to the knee with increased forces at the knee joint
& hip extensors
o The knee often buckles during this gait pattern
Hip Abductors
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Normal Strengtho Prevent contra-lateral hip from dipping greater than 5-8 degrees
Stance-side abductor muscle group is active
Loss of abductors:
o Positive Trendelenburg sign
o Weakness of abductors manifests as ‘lurching gait’ (toward stance side)
Analysis of Deficits: Quadriceps – Stance Phase
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Early stance (Heel strike – Foot flat)
o Guides knee into 20 degrees of flexion eccentrically (controls unlocking of the knee)
Late stance (Heel off – Toe off)
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o Controls for knee flexion (~40 degrees at TO)
Early stance weakness/absence
o Inability to absorb energy
o Buckling
o Late stance weakness/absence
o Knee collapse into flexion -premature flexion into early swing
Analysis of Deficits: Paraspinals – Stance Phase
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Early stance (HS - FF) & late stance (HO - TO)
o Prevent forward flexion of trunk acting on pelvis
Early & late stance weakness/absence
o Trunk falls forward
o Loss of head and neck control
Analysis of Deficits: Hip Extensors – Stance Phase
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Early stance (HS)
o Prevent hip flexion (jack-knifing)
Early stance (HS - FF)
o Guide hip into flexion eccentrically
Early stance (HS) weakness/absence
o Hip/trunk collapses into flexion
Early stance (HS - FF)
o Trunk falls forward
Analysis of Deficits: Pre-tibial Group – Stance Phase
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Early stance (HS - FF)
o Lowers forefoot to floor eccentrically
o After forefoot contacts floor- pull tibia forward over foot
o Early stance weakness/absence
o Forefoot slaps to the floor - ‘drop-foot’ gait
o Loss of forward pull of tibia
Analysis of Deficits: Plantar Flexors – Stance Phase
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Late mid-stance
o Concentrically pulls tibia forward
Late stance (HO - TO)
o Provides propulsive thrust during push off
o Early stance weakness/absence
o Loss of forward pull of tibia
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Loss of forward thrust - poor transition to early swing
Analysis of Deficits: Plantar Flexors – Stance Phase
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Late mid-stance
o Concentrically pulls tibia forward
Late stance (HO - TO)
o Provides propulsive thrust during push off
o Early stance weakness/absence
o Loss of forward pull of tibia
o Loss of forward thrust - poor transition to early swing
Analysis of Deficits: Peroneals – Stance Phase
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Late stance (HO - TO)
o Dynamically provide collateral stability to ankle when plantar flexed
o Secondary plantar flexor for forward thrust
Late stance weakness/absence
o Ankle instability causing medial-lateral movement
o Potential for ankle injury - sprains
o Poor transition from late stance to early swing
Analysis of Deficits: Plantar Intrinsics – Stance Phase
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Late stance (HO - TO)
o Provide medial - lateral stability to MTP joints (especially nos. 1 & 2)
o Improves forward propulsion and transition to early swing
Late stance weakness/absence
o Excessive medial - lateral ‘shimmy’ of hindfoot during HO
o Inefficient forward thrust
Analysis of Deficits: Hip Flexors – Swing Phase
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Late stance - early swing (acceleration)
o Forward flexion of femur working with plantar flexors to accelerate LE in early swing
o 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
o Compensate with circumduction at hip
Analysis of Deficits: Dorsiflexors – Swing Phase
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Mid-to-late swing (deceleration)
o Affects ‘toe-up’ concentrically
o Functionally shortens LE during swing through
Mid-to-late swing weakness/absence
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Loss of ‘toe-up’
Compensation
 Increased hip flexion - ‘steppage gait’
 Circumduction at hip
Analysis of Deficits: Hamstrings – Swing Phase
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Late swing (deceleration)
o Decelerates tibial shank
o Provides for smooth transition between late stance and early swing
Late swing weakness/absence
o ‘Impact on terminal extension’ - knee slapped into extension or hyperextension
INTERVENTIONS for Gait Dysfunction
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ROM – for any joint motion restriction
Stretching – for soft tissue restriction or shortened muscle groups
Strengthening for weakened musculature
Gait training to address specific deviations
o May need temporary or permanent AD if deviations are significant
Balance training
HEP Instruction / Patient Education
Modalities – as needed
INTERVENTIONS for Gait Dysfunction
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Orthotics
Heel lift, or shoe build up for leg length discrepancies or foot drop
Appropriate assistive device
Functional activity training
Gait Training Safety Measures
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Gait belt
Proper guarding techniques
Proper lighting
Clear unobstructed path
Proper shoe wear
Adherence to weight bearing status
Use of appropriate device that has been fitted/measured for the patient
Patient’s cognitive status
Gait Training – Rate of speed
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Why could this statement be detrimental to your 83 y.o. patient?
“Mrs. Jones, while you’re walking, I want to go very slow!”
What are some possible implications of this?
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Mr. Jones will be safe - probably won’t fall and break her hip
The path of the COG may be distorted
Energy cost
o Suppose Mrs. Jones has a cardiac condition?
Mr. Jones’ gait may never return to ‘normal’
Is it possible that...
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…going very slow might actually cause Mrs. Jones to lose her balance and fall?
How?
o Mrs. Jones may never reach her pre-injury/disease preferred rate of ambulation and
therefore never trigger a CPG that automates gait
What is a CPG?
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Central Pattern Generator (CPG)
A group of synaptic connections at the spinal cord level which are triggered by an event or
condition (perturbation)
When a threshold is met via a triggering mechanism the CPG appears to be activated and
takes over automatic control of gait metrics (the individual does not have to think about it)
Gait Training Objectives
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Are all patients’ objectives/goals 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…
Mr. Smith, a frail 87 year old male, that lives in a third story walk-up, and has a history of
emphysema and a fractured hip?
It is important to keep the objectives/goals in mind during gait training
Gait Training - ADs
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Various assistive devices are available for use during gait/ambulation activities
o Parallel bars
o Walkers
o Bilateral & unilateral crutches
o Canes (single point, quad)
Remember it is very important to properly guard your patient during gait training while using an
assistive device in the clinic
Assistive Device Progression
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Progression from assistive device to normal gait
Progress from assistive device with large base of support to small base of support
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2 Axillary crutches or 2 Lofstrand crutches  1 Axillary crutch or 1 Lofstrand or 1
Straight cane
Hemi-walker  Straight cane
Walker  Quad Cane
Gait Training & Documentation
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Document any deviations noted during gait training
o Did gait appear vigorous or labored?
o Was gait guarded or restrained – was the patient attempting to gain stability and security?
o Was the toe/floor clearance distance slightly decreased?
o Was there decreased reciprocal arm swing?
o Was there decreased step and/or stride length?
Documentation for Gait Training
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Narrow or wider dynamic base of support?
Increased lateral head movement?
Increased or decreased rotation of pelvis?
Any abnormal or pathological gait patterns noted?
Gait distance / endurance
Any shortness of breath or other physiological reactions
Any episodes of loss of balance?