First Abnormal Gait Lecture Flashcards
Why do we perform gait analysis?
- To compare to normal
- Hypotheses for underlying mechanisms for observed dysfunction (i.e.- WHY is the hip dropping? WHY is he circumducting?)
- Classification of disability severity
- Prediction of future status
- Det: need for AD (adaptive/orthotic/prosthetic vs assistive/protective/supportive), effectiveness/fit of the AD)
- Assess effectiveness of intervention
Advantages of observational gait analysis
- Easy to perform in any clinical environment
- Time efficient
- Low cost
- Initial impression can be gleaned
Disadvantages of observational gait analysis
- Tendency to focus eye on gross deviations, not subtle ones
- Depends on experience and individual bias
- Unknown reliability and validity, integrated assessments are qualitative
Which leg do you observe first?
Right
When referring to pelvis/trunk, refer to _____ leg
Stance
Reliability of OGA?
-Low to moderate
How to improve reliability of OGA
- Video tape clients (you can pause or slow down the tape, don’t have to fatigue them by making them repetitively walk)
- Training
- Experience
Scales we use to quantify OGA
Physicians Rating Scale
Edinburgh Visual Gait Analysis
Gait Assessment Rating Score (GARS)
Dynamic Gait Index (DGI)
Physicians Rating Scale:
- Normal Gait Rating
- Categories Observed
Normal Gait: 0
- Crouch
- Knee recurvatum
- Foot contact
- Hindfoot position (at contact/during stance)
- Speed of gait (slow/variable)
- Change (3–don’t know what that means)
Edinburgh Visual Gait Analysis:
- Number of levels/what is normal
- Number of variables, and what categories
-3-5 levels (0 normal, 1 is mild, 2 is mod deviation, etc)
-17 variables– 6 foot, 4 knee, 3 hip, 2 trunk, 2 pelvis)
I.e.- knee in stance:
2 is 30 degrees flexion, 1 is 15-30 degrees, 0 is 0-15 degrees. 1 is 10 degrees recurvatum, 2 is more than 10 degrees recurvatum
Gait Assessment Rating Score
Greater than 18 on long form and greater than 8 on short form (for client’s risk of falls)
DGI
Adds walking with head turns, walking and turning 180 degrees, stepping over/around obstacles, stairs
-4 levels: Normal to impairment (0-3, 3 is normal)
Dual tasking challenge examples
standardized walking and talking tasks (med predictive value and decent specificity if person keeps walking)
- Standardized tests = serial subtraction, recite alphabet, recite items in a category
- walking and remembering test (forward digit span)
Functional Mobility Scale
5 m, 50 m, 500 m 1- WC 2- Indep walker 3- Two crutches 4- One crutch 5- Indep. On level surfaces 6- Indep. On all surfaces/stairs
Functional Ambulation Categories (FAC)
Physically Dependent:
0 = nonfunctional (req help of 2 people)
1= dependent, level 2 (needs help with carrying weight and balance)
2= dependent, level 1 (needs help with one person for balance/coordination)
Physically Independent:
3= dependent on supervision (verbal or standby)
4 = indep on level ground
5 = independent on any surface
What is the average onset of independent walking?
11-15 months old
When does consistent heelstrike arise with absent push off?
24 months old
When does reciprocal arm swing develop?
30-36 months
What decreases after 4-5 months of independent walking? Be specific.
BoS decreases. First abduction, then ER (last component to decrease)
When does temporal phasing begin? What is it?
(Swing to stance phase)
Occurs 3-6 months after the onset of walking
When do we have a mature walking pattern?
5 to 6 years of age
Which gait changes are noted in the elderly?
Mild stiffness (greater proximally i.e. Less rotation at pelvis and trunk)
Decreased arm swing
Decreased speed
Increased Cadence
Decreased step length (decreased swing excursion and increased stance/double support)
Increased stride width (hip and, greater toeing out)
Increased toe-floor clearance
Decreased heel strike
Comfortable Gait Speed in 40s for men and women
Men: 146 cm/sec
Women: 139 cm/sec
Comfortable gait speed for 70 year olds
Men: 133 cm/sec
Women: 137 cm/sec
Max gait speed for those in their 40s
Men: 246 cm/sec
Women: 212 cm/sec
Max gait speed for those in their 70s
Men: 207 cm/sec
Women: 175 cm/sec
Gait speed is associated with….
Muscle strength, especially hip abduction and knee extension
MCID of gait speed in patients with hip fracture?
0.1 m/s
5 pathological mechanisms of gait?
Deformity Muscle Weakness Sensory Loss Pain Impaired Motor Control
Forms of deformity for pathological mechanisms of gait
-Contracture (ankle pf, knee flexion, knee extension, hip flexion)
What is the definition of a contracture?
Structural change within fibrous connective tissues of muscle, ligaments, or joint capsule, following inactivity or scarring
What are common contracture types? Two most common?
Ankle PF and Hip Flex are most common
Others are knee flexion and knee extension
What is the deficit of an ankle-plantarflexion contracture?
Obstructs progression of leg during stance
Inhibits foot clearance
What is the deficit of a knee flexion contracture?
Inhibits advancement of thigh
What is the deficit of a knee extension contracture?
Increases energy expenditure due to compensations to clear floor
What is the deficit of hip flexion contracture?
Increases strain on back and hip extensors
What goes into the muscle weakness category of pathological mechanisms?
- Disuse
- Neurological Impairment
- Strength (when you test 5/5, PF is 18 percent of what you need, knee is 53 percent, and hip is 18 percent)
- Gait deviations (decreased speed and substitutions)
What impairments fall under the pathological mechanism category of sensory loss?
- Proprioceptive impairments
- Light touch, deep pressure
- Gait deviations
What type of gait deviations result from sensory loss?
Decreased speed
Substitute by locking knee
Hitting the floor loudly (poor proprioception)
Visual monitoring of legs/feet
Consequences of pain in gait
- Attempt to reduce compressive and shear forces
- Excessive tissue tension– deformity and weakness
- Deformity: moves into positions of comfort of intra-articular pressure (like how the knee is more comfortable in flexion but you can get a contracture)
- Weakness– secondary to joint selling (causes disuse atrophy)
What are positions of comfort and intra articular pressure for ankle, knee, and hip?
Ankle = 15 degrees PF Knee = 30-45 degrees flexion Hip = 30 degrees flexion
What are consequences of impaired motor control in gait?
- Spasticity
- Decreased selective control
- Primitive locomotor patterns
- Impaired phasing
Spasticity of lower extremity… what happens
Obstruction of yielding quality of eccentric muscle activity during stance
Spasticity of soleus/gastrocnemius results in?
Persistent ankle plantarflexion = loss of ankle rocker
Spasticity of hamstrings results in
Effective terminal swing, resists thigh advancement in stance
Spasticity in hip flexor results in
Restricted progression in mid and terminal stance
Spasticity of quadriceps inhibits…
Pre-swing prep for limb advancement
What impact does impaired phasing have on the gait cycle?
It’s due to control errors and spasticity
- Muscle actions prolonged, curtailed, premature, delayed, continuous, and/or absent
- Results in SUBSTITUTIONS in specific phases.
Arm swing is related to
Speed– faster gait is related to more aggressive arm swing. During slow walking, no arm swing should be seen.
Why does hip circumduction occur? What phase does it occur in?
- Occurs in swing phase
- Occurs because of weak hip, knee, and/or ankle flexor
What is hip hiking a substitution for?
Lack of knee flexion or ankle dorsiflexion. Comp for extensor spasticity of swing leg. Makes sense for leg length discrepancy
Excessive hip flexion in swing phase results in
Foot drop or flexor synergy
What is involved in a flexor synergy?
Hip: Flexion, abduction, external rotation
Knee: flexion
Ankle: Dorsiflexion
Upper extremity: scap retraction, shoulder abduction/ER, elbow flexion, forearm supination, finger and wrist flexion.
What is involved in an extension synergy?
Hip: extension, adduction, internal rotation
Knee: extension
Ankle: Plantarflexion and inversion
Toe: flexion
Upper extremity: scap protraction, shoulder adduction/IR, elbow extension, forearm pronation, wrist/finger flexion
Backwards trunk lean/APT in stance is caused by
Weak glut max on stance leg
Forward trunk lean is a compensation for….
Quad weakness or hip/knee flexion contracture
