Gait Analysis: Case Study 3
Shiree Smith
12/8/15
PTA 103
Shiree Smith
12/8/2015
PTA 103
Gait Analysis
Case Study #3
Multiple Sclerosis (MS) is a degenerative disorder of the central nervous system
in which demyelination of the axon occurs which affects the conduction of nerve
impulses. Signs and symptoms include fatigue, numbness, vision loss, paralysis, and
diminished brain function. The gait cycle of a patient with MS can be affected in a
variety of ways, and the patient may present with muscle weakness, muscle spasticity,
balance problems, sensory deficit and fatigue.
Our patient, a 45 year-old female with MS, has several of these deficits. Namely,
she presents with bilateral muscle weakness in her quadriceps with an MMT of 3+/5.
Consequently, she exhibits an abnormal gait pattern and becomes easily fatigued
during ambulation. She requires frequent breaks to regain energy upon evaluation, and
she is uneducated about energy conservation techniques. In addition, our patient
experiences knee buckling when transferring from sit to stand, and she requires the use
of either both lower extremities or minimal assistance from a therapist when not using
her upper extremities. We will be working with our patient to address these issues and
help her reach the short term goals laid out by her PT.
To address the issues our patient is experiencing during ambulation, we must
identify the muscular deficits she experiences during the gait cycle and identify any
compensatory measures she is utilizing. Our patient experiences muscle weakness in
her quadriceps and has been graded 3+/5 MMT (patient can complete the motion
against gravity with minimal resistance at end range) in both lower extremities. This
muscle weakness will affect numerous phases of the gait cycle, further described using
the Rancho Los Amigos terminology.
To begin the gait cycle, we will analyze the stance phase first. Beginning with
initial contact, our patient will exhibit deficits in knee extension and hip flexion. She may
initially strike the floor with her forefoot rather than her heel due to circumduction of the
hip, which will be discussed later. Also, our patient may flex her trunk to shift her center
of gravity forward and move the line of force anterior to the knee, thereby forcing her
knee into extension.ᵌ By way of reversal of muscle action, she may use her hip
extensors and plantar flexors to pull her knee into extension, while also pressing against
her anterior thigh to assist in pushing her knee into extension. ᵌ
In the loading response phase of normal gait, the knee begins to flex and the
quadriceps eccentrically contract to help control this motion. Our patient will keep her
knee in full extension and her trunk flexed during this phase to maintain stability. During
midstance, the body is being advanced over the stationary foot, and our patient
accomplishes this by continuing flexion of the trunk and extension of the knee.²
In terminal stance, there is minimal quadriceps activation, as ground reactive
forces and the plantar flexors keep the knee in extension. ² Our patient maintains trunk
flexion. In the preswing phase, our patient begins to externally rotate the hip to prepare
for the swing phase of the gait cycle.
During the swing phase, our patient must bring her leg in front of her to prepare it
for the beginning of stance phase again. Due to her bilateral quadriceps weakness, she
is unable to use her rectus femoris muscle to assist in hip flexion helping her to clear the
ground with her foot in initial swing. In addition, she experiences deficits when extending
her knee in terminal swing to prepare for her foot to strike the ground. To compensate,
our patient must externally rotate and circumduct her hip to essentially “shorten” her leg
enough to clear the ground and propel it forward.ᵌ This results in a decreased stride
length, a slower cadence and increased energy expenditure during the gait cycle.
To become more efficient at ambulation and to increase the safety of our patient,
we need to work to improve several aspects of her gait cycle. The PT has listed several
short term goals for our patient, beginning with increasing bilateral quadriceps strength
to a grade of 4/5. By increasing our patient’s quadriceps strength bilaterally, she will
begin to ambulate with a more typical gait pattern and rely less on compensatory
maneuvers. This will help her to conserve her mechanical energy and increase her
cadence.
In addition, by increasing her muscular strength, we will be working towards her
short-term goal of transferring from sit to stand independently. Currently, she does not
have enough bilateral strength in her quadriceps and must rely on the use of both of her
upper extremities to assist in the transfer.
While working to strengthen her musculature, we will need to gait train our
patient using an assistive device to maintain her safety while helping to correct the
deficits she experiences during ambulation. We will also need to practice transfers with
our patient, as this is an area she is also experiencing deficits. All gait training and
transfer training must include the use of a gait belt!
We can begin to gait train our patient using a two-wheeled walker with a fourpoint gait pattern. A four-point gait pattern is initially ideal for our patient whose gait
speed is low, as it requires low energy input from our patient and provides maximum
stability.
Our patient is married with three children under the age of 10. Assuming that her
children are young and full of energy, a walker is the safest assistive device for our
patient to use to ensure she maintains her balance and safety during ambulation in her
home. Because our patient flexes her hip during ambulation as a compensatory tactic, a
two-wheeled walker is advised so that she may partially weight bear on the handles
without the walker rolling forward. It is recommended she use a walker with a seat so
she can rest as frequently as necessary, especially because the PT noted in her
evaluation that she becomes physically exerted during ambulation. It is also advised
that our patient use a walker with a basket to provide her with storage for her
belongings as she ambulates around her home and otherwise. This is a keystone in
helping our patient preserve energy during ambulation.
As our patient progresses towards the short-term goals outlined for her, we will
need to make adjustments to our gait training as necessary. The first change will be to
advance her from a four-point gait pattern to a two-point gait pattern. A two-point gait
pattern still includes the use of a walker, so she will still have the stability and balance
control of her assistive device. However, she will ambulate with a quicker cadence while
maintaining low energy output. Once our patient has demonstrated a greater tolerance
for ambulation without frequent rest breaks, we can change her assistive device to
bilateral quad canes with a two-point gait pattern. She can further be progressed to
bilateral single point canes with a two-point gait pattern, and then a unilateral single
point cane with a modified two-step gait pattern. If at any time our patient feels unsafe
or unstable, she can always revert back to previous assistive devices or gait patterns as
necessary.
As our patient increases the strength of her quadriceps, we can begin to train
her in transferring from sit to stand independently. We can do this by teaching our
patient the basics of the transfer, highlighting the energy preservation along the way, i.e.
scooting to the edge of the seat to move the center of gravity over her feet. She can
practice transferring in the parallel bars with a high-seated chair behind her and a
therapist next to her. As she advances, we can progress her by lowering the height of
the seat behind her and practicing transfers outside of the parallel bars.
Ideally, our patient will be able to ambulate for 20 minutes without taking a rest
stop, will be able to transfer from sit to stand independently, and will be educated on
energy conservation techniques.
References
1.Oandplibrary.org. 13: Normal Gait | O&P Virtual Library. 2015. Available at:
http://www.oandplibrary.org/alp/chap13-01.asp. Accessed December 1, 2015.
2. Moon.ouhsc.edu. MUSCLE ACTIVITY. 2015. Available at:
http://moon.ouhsc.edu/dthompso/gait/kinetics/mmactsum.htm. Accessed December 2,
2015.
3. F. A. Davis Publishing. Clinical Kinesiology and Anatomy, 5Th Ed. + Kinesiology
Flashcards, 3Rd Ed. [Place of publication not identified]: F A Davis; 2011.
4. National Multiple Sclerosis Society. Walking (Gait) Difficulties. 2015. Available at:
http://www.nationalmssociety.org/Symptoms-Diagnosis/MS-Symptoms/Walking-(Gait),Balance-Coordination. Accessed December 2, 2015.