Gait

Question 1

What is Gait

Answer 1

1. A method of human locomotion.
2. A learned feature.
3. Automatic and conscious control – Central Pattern Generators (sit in spinal cord)
4. Involves use of both legs alternately for support and propulsion.
5. Walking ↔ Gait but Gait implies manner or style.
6. Varies according to age: gender: body geometry and pathology

Question 2

State tasks of gait cycle

Answer 2

Three main tasks must be accomplished:

1. Weight acceptance – transfer of weight onto limb that has completed swing and has unstable alignment. Shock absorption & forward progression.
   a. CVA pts particularly struggle with this
2. Single limb support – one limb must support the entire body weight and provide truncal stability.
3. Limb advancement – requires foot clearance as limb swings through to its destination in front of body.

Question 3

State phases of gait cycle

Answer 3

Stance phase - 60% of gait cycle. Considered leg has a period in contact with ground

Swing phase - 40% of cycle. Ave speed
Period when foot is not in contact with the ground.
Initial swing = 60-75%
Mid swing = 75-85%
Terminal swing = 85-100%

Question 4

Explain initial contact (heel strike)

Answer 4

First period of double stance

When foot touches ground; other leg at end of terminal stance

Question 5

Muscle activity in initial contact

Answer 5

Hip flexed – extension initiated =
hamstrings

Knee extended - Quadriceps, hamstrings (eccentric)

Ankle dorsiflexed - Tib ant
Eccentric lowering of foot to floor

Question 6

Explain loading response (flat foot)

Answer 6

Double support ends

Body weight transferred onto stance leg; other leg in pre-swing phase

Question 7

Muscle activity loading response (flat foot)

Answer 7

Hip Ext- concentric hamstrings, glute max; contralateral ABDs stabilise pelvis & trunk

Knee Flex (a cushion effect) - eccentric Quadriceps

Ankle - PF by eccentric of dorsiflexors; eversion (supination) – transfers wt to lateral border of foot

Question 8

Explain mid-stance

Answer 8

First part of single limb support

COM (COG) passes from behind to in front of stance foot

Begins with lifting foot and continues until body weight is over supporting foot: stance leg goes over foot; other leg is in mid-swing

Question 9

Muscle activity of mid-stance

Answer 9

Hip extension - momentum; Abductors of stance limb control contralateral pelvis dropping

Knee restores to slight flex - more ext; not much mvt

Ankle - DF by momentum, controlled eccentrically by PFs

Question 10

Explain terminal stance

Answer 10

Body is propelled forwards and starts to end stance phase

Body weight moves forward beyond foot & leg in trailing position

Stance leg heel rise & continues until other leg heel strike

Question 11

Muscle activity of terminal stance

Answer 11

Hip extension increase by gravity- 0° at heel rise

Abductor power decreases at onset of double support

Heel rise – passive; starting to PF

Question 12

Explain pre-swing

Answer 12

Final stage of stance phase

Second double support interval
Body weight transfer to opposite limb

Begins with other leg initial contact & ends with stance leg toe-off

Question 13

Muscle activity

Answer 13

Ground contact of opposite leg results in:
↑ ankle plantar flexion and toe flexors - concentric PFs and toe flexors
↑ knee flexion- concentric hamstrings
↓ hip extension - momentum

Question 14

Explain initial swing

Answer 14

Begins when swing leg foot is lifted & ends when foot is opposite the stance leg

Question 15

Muscle activity of initial swing

Answer 15

Hip flexion– initial concentric action to propel limb forward, assisted by gravity & momentum.
Knee flexion- hamstrings concentric contraction from pre-swing.
Ankle - concentric dorsiflexion to clear toes from ground

Question 16

Explain terminal swing

Answer 16

Deceleration – final stage of swing

Begins when stance leg tibia vertical & ends when swing leg foot touches floor (heel-strike)

Question 17

Muscle activity terminal swing

Answer 17

Hip flexion- momentum continues, eccentric control slows.
Knee – from flexion to extension by momentum- controlled by eccentric Hamstrings
Ankle dorsiflexion for heel strike - concentric

Question 18

Weight distribution in gait

Answer 18

Initial contact - heel weight acceptance
Loading response and midstance - lateral border of foot first then on to MT heads
Terminal stance - heel off; more weight on MT heads and Hallux
Pre-swing - toe off; weight on toes phalanges

Question 19

UL movements in gait

Answer 19

1. Flexion & Extension of hip – causes rotation at lumbar spine
2. To keep head facing forwards – thoracic & cervical rotation to opposite side.
3. Reciprocal movement of upper and lower limbs:
   a. Right shoulder flexion / Left hip flexion
4. Flexion & Extension at elbow mimics shoulder movement but slight delay

Question 20

Changes in older peoples gait

Answer 20

1. Reduction in overall velocity & stride length.
2. Reduction in agility – uneven surfaces or crowds or darkness.
3. Decreased arm swing, pelvic rotation.
   A flat foot approach to heel-strike and toe-off - smaller heel strike and toe-off so less weight acceptance

Question 21

What causes change in elderly gait

Answer 21

1. Decreased muscle bulk
2. Decreased muscle strength - particularly hamstrings, DF, PF
3. Decreased flexibility and joint range
4. Loss of vision and hearing.

Question 22

Abnormal gait patterns

Answer 22

Ataxic gait - Unsteady, uncoordinated walk with wide base of support, the feet thrown outward.
Damage to Cerebellum due to MS, CVA, TBI commonly

Antalgic gait - A short stance phase on painful side- avoids pain on weight- bearing structures (hip, knee, ankle or foot).

Apraxia gait - Unable to carry out familiar, purposeful movements in the absence of paralysis or other motor or sensory impairment. The process is forgotten.

Trendelenburg gait - The Trendelenburg gait pattern is caused by weakness of the abductor muscles of the lower limb, gluteus medius and gluteus minimus which results in the pelvis dropping to the opposite side.

Hemiplegic gait - Weakness down one side following a CVA. Can be high tone or low tone hemiplegic gait

Parkinson gait - OFF PHASE - Small stride length, small BoS, shuffling and festinating movement pattern. Trouble initiating movement, no trunk movement, loss of arm swing, head flexed and protracted; Struggle in turning. (ON PHASE) - wider BoS, larger stride length, arm swing, head flexed and protracted

High stepping gait - Caused by a drop foot caused by lack of DF

Question 23

Rehabilitation of gait involves assessment of the gait cycle to identify deficits such as

Answer 23

• Deficits can be: muscle weakness, muscle tightness, high tone, low tone, ataxia, sensory deficit, apraxia, pain, initiation problems, speed of movement, quality of movement, efficiency of movement, cardiovascular fitness, joint stiffness, confidence
• All deficits will need addressing but ultimately leading to the re-education of a safe walking pattern promoting an efficient gait pattern where possible

Question 24

How you would address these deficits as part of gait re-education

Answer 24

Muscle weakness/low tone

Progressive strengthening work/ electrical stimulation/splinting/weightbearing

Muscle tightness

Stretches/positioning/splinting/soft tissue work

High tone

Medication/ soft tissue mobs/stretches/splinting /positioning

Ataxia

Coordination and core stability

Sensory deficit

Sensory stimulation,

Apraxia

Repetition and use of external cues

Pain

Hot/cold/tens/jt mobs/soft tissue mobs/medication

Initiation problems

Cueing

Speed of movement

Repetition of movement/progressing speed/treadmill

Quality of movement

Repetition of specific movement/facilitation of movement

Efficiency of movement

Analysis of movement

Cardiovascular fitness

Cardiovascular training on treadmill

Joint stiffness

Joint mobs

Confidence/Anxiety

Repetition and reassurance

Question 25

How to do part practice for gait re-education

Answer 25

1. In standing with table support practice assisted stepping with affected leg – encouraging DF and knee flexion
2. In standing with table support practice stepping with unaffected leg – transferring weight
3. Progress along the table with w/c behind
4. Backward stepping
5. Sideways stepping
6. Onto step

Question 26

How to do whole part practice for gait re-education

Answer 26

1. Treadmill training with or without PBWS provides an opportunity to practice repetitively the components of gait.
2. A harness can be used for individuals with significant functional limitations – provides security & earlier mobility

Question 27

Rationale for treadmill training

Answer 27

1. Gait training may commence early
2. Enables practice of complete gait cycle
3. Task specific practice
4. Improves walking
5. Improves strength & fitness
6. Opportunities for speed & endurance training
7. Workload input and output is measurable
8. Minimises manual handling risk

Question 28

State your rationale for using a walking aid, short or long term?

Answer 28

• Short term - To enable mobility and facilitate increased independence, social interaction, weight-bearing, return to function
• Long term - To reduce risk of falls, to enable continued mobility and independence, for fatigue management (e.g 4 wheeled walker in MS)
• As a last resort think about walking aids as it will take away their own balance reactions thus aim to get off walking aid ASAP

Question 29

What should be considered when issuing walking aids?

Answer 29

1. Compensations
2. Reliance on walking aid
3. Changes to gait cycle
4. Cognition, require carryover to learn how to use
5. Falls risk/ trip hazard if used incorrectly / inappropriately issued

Question 30

What are the types of walking aids

Answer 30

1. Sticks
2. Crutches
3. Frames

Question 31

State types and uses of walking sticks

Answer 31

Types:

1. Wooden/metal sticks
2. Quadripods - stroke pts
3. Tripods - stroke pts
4. Fischer sticks - for hand arthritis

Uses:

1. Only when absolutely necessary
2. First choice of walking aid
3. For high level balance (CVA, MS, TBI, PD)
4. For relief of pain (RA,OA) - fischer
5. Can use two if it helps
6. Can use a high stick or pole to prevent too much leaning - more for balance than WB
7. Always use in the opposite hand to the leg affected - encourage more normal gait pattern
8. Gait patterns:**​
   
   1. Sit to stand
   2. FWB/PWB
   3. 2pt gait/3pt gait/4pt gait (with 2 sticks)
   4. Steps and stairs

Question 32

How to measure for walking sticks

Answer 32

• Often measured in standing with elbows slightly flexed (15-20 degrees), the ulnar styloid to floor. A metal stick may be adjusted or, if using wooden stick, this is ‘cut’ to appropriate size
• In lying with shoes off: the elbow should be in slight flexion (15°-20°), measure from the ulnar styloid to the bottom of the foot, allowing for footwear,
• If you are giving a stick to a neurological patient you might consider a higher stick to prevent them leaning too much on the stick

Question 33

What are the types and uses of crutches

Answer 33

Types:

1. Elbow crutches
2. Fischer crutches
3. Axillary crutches - not used now

Uses:

1. Only when absolutely necessary
2. Second choice of walking aid
3. For high level balance (CVA, MS, TBI)
4. For relief of pain (RA,OA)
5. Post-op THR, TKR, knee arthroscopies, foot surgery
6. Can use one if it helps - always use in the opposite hand to the leg affected
7. Gait patterns
   
   1. ​Sit to stand​
   2. FWB/PWB/NWB
   3. 2pt gait (with 1 EC)/3pt gait/4pt gait (with 2 EC)
   4. Steps and stairs

Question 34

How would you measure for an elbow crutch

Answer 34

• Often measures in standing with elbows slightly flexed (15-20o), the ulnar styloid to floor. Some elbow crutches also have adjustment for forearm length – the cups should be at least 3 fingers width below fold of elbow
• In lying with shoes off: the elbow should be in slight flexion (15°-20°), measure from the ulnar styloid to the bottom of the foot, allowing for footwear

Question 35

What are the types and uses for frames

Answer 35

Types:

1. Zimmer frame
2. Wheeled Zimmer frame
3. Delta frame (PDs)
4. Stroller
5. Pulpit frame
6. Gutter frame

Uses:

1. 3rd choice walking aid
2. Outdoor use - Delta frames (PDs), Strollers
3. Stable - all except delta frame
4. Speed - slowest is ZF/pulpit/gutter frame, medium speed is wheeled zimmer frame, fastest is delta frame and stroller
5. Manouverability - WZF, delta frame and strollers
6. Disadvantages - ZF/pulpit/gutter frame (have to lift it), delta frame (unstable, have to use brakes), stroller (have to use brakes)
7. Pulpit and gutter frames:
   
   • Early mobilisation after: surgery; neurological event eg. TBI; recovering from hospitalisation
   • Usually start with pulpit frame as provides more support
   • Progress to gutter frames, these can be provided for home use
   • Good for people who:
     
     1. can’t lift a frame
     2. need to lean on their arms
     3. have poor trunk
     4. have poor cardiorespiratory function
8. Gait patterns:
   
   1. ​Sit to stand
   2. FWB/PWB/NWB
   3. 2pt gait (NWB)/3pt gait

Question 36

How would you measure for frames

Answer 36

1. If a patient requires a frame to stand or mobilise this will require two people.
2. Ensure that the frame is accessible before the patient stands up and that it is at the approximate height - visual estimation initially, then accurately measured - and adjusted on all four legs.
3. When standing upright with hands on the frame handles, the patient should have 15°-20° of elbow flexion
4. For patients with PD measure higher so they are not flexed over

Question 37

How would you teach stairs/steps

Answer 37

• Sticks/crutches can be used to climb steps/stairs, either by using both or by using a rail and using one stick/crutch and carrying the other in the same hand.
• Steps and kerbs are only possible with a walking frame if the second level is wide enough to accommodate the frame and the patient balanced enough to place it.
• Ascending or descending stairs the aid stays with the affected limb to relieve weight on that limb

PWB:

1. Ascending – lead up with unaffected leg. Crutches/sticks remain with the affected leg and follow with that limb to the same stair or level
2. Descending – lead down with crutches/sticks and the affected leg, unaffected leg then follows to the same stair or level

NWB:

1. Ascending – crutches/sticks stay down taking the weight while the unaffected leg goes to the stair above, standing on the unaffected leg balance is gained and the crutches drawn up to the same level as the affected leg
2. Descending – the crutches/sticks are placed down first, the weight transferred to them via the arms and the unaffected limb is then gently lowered to that stair

Question 38

How would you teach sit to stand/stand to sit

Answer 38

sit to stand, stand to sit with:

1. Zimmer frame
2. Elbow crutches
3. 2 sticks
4. 1 stick

Assume NWB, PWB, FWB as appropriate

Sticks/Crutches:

1. Generally both sticks/crutches are placed in one hand, elbow crutches are disengaged with the elbow and one hand is used to push up from the chair into standing.
2. Sticks/crutches then positioned suitably for walking.
3. The procedure is reversed to sit down, elbow crutches are disengaged first, both are placed in one hand before lowering into sitting, the other hand is used to safely locate the chair.

Frames:

1. For walking frames, push up from chair with both arms or, if difficult to initiate angle of rise to standing, one hand can be placed on the frame (never two, unsafe as frame may tip) the other hand pushes from the chair.
2. Reverse the procedure for sitting, always turning completely for safe sitting! Patients tend to launch themselves at the chair!

Question 39

Explain 2 point gait

Answer 39

• 2 point gait (NWB or FWB)
• FWB usually follows 4 point gait, the opposing arm and leg moving simultaneously as confidence and skill is built by practice.
• NWB - Non-wheeled zimmer frame or crutches used.

Intructions:

1. Affected leg and opposite/both crutch(es)/stick(s) are advanced together, followed by the other leg (with/out oppositr crutch)

Question 40

Explain 3 point gait

Answer 40

3 point gait (PWB) – requires a zimmer frame or 2 crutches/sticks. The amount of PWB can be gradually progressed through to FWB when appropriate

Instructions:

1. Take both crutches/sticks or frame forward followed by taking the affected leg forward, then sharing weight with arms, step-to or step-through with the unaffected leg.
2. In a step-through gait (not with zimmer frame) the affected leg is taken a full step length past the stance leg

Question 41

Explain 4 point gait

Answer 41

• Requires 2 sticks/crutches.
• Very stable as at no time are both feet or walking aids off the ground at the same time. However, this means it is a relatively slow pattern.
• Only appropriate where near FWB is allowed. It is ideal for balance and as a step to re-learning a normal reciprocal gait pattern.

Instructions:

1. Take one crutch/stick forward, followed by the opposite leg.
2. Then take the other crutch/stick forward followed by the alternate leg. The opposing arm and leg movement is as for a normal gait pattern

Question 42

Additional clinical rationales when issuing walking aids for home use?

Answer 42

1. Environment safe? Remove trip hazards (presence of rugs, threshold strips, steps, worn floor coverings, adequate lighting)
2. Stairs – ensure have one for upstairs and downstairs
3. Steps indoors/outdoors – teach technique with walking aid
4. Correct technique when using on stairs (if stick/ elbow crutch)
5. Ensure able to carry other objects as necessary - require kitchen trolley or suggest a backpack
6. Can the aid fit through doorways - access to bathroom and bedroom

Question 43

What are the types and uses of orthoses

Answer 43

Types:

1. Rigid
2. Dynamic and semi-dynamic
3. Foot-up splint

Uses:

1. Orthoses are external devices that support or enhance an impaired limb
2. In neurological rehab orthoses are most frequently used to improve function and to prevent or correct deformity
3. If correctly applied AFO’s have been shown to increase speed and efficiency of gait (Tyson & Rogerson 2009)
4. Disadvantages - May make some activities more difficult e.g. sit – stand & stairs as the orthosis may prevent the lower leg moving over the foot

Question 44

Gait patterns with walking sticks

Answer 44

1. Sit to stand
2. FWB/PWB
3. 2pt gait/3pt gait/4pt gait (with 2 sticks)
4. Steps and stairs

Question 45

Gait patterns for elbow crutches

Answer 45

1. Sit to stand​
2. FWB/PWB/NWB
3. 2pt gait (with 1 EC)/3pt gait/4pt gait (with 2 EC)
4. Steps and stairs

Question 46

Gait patterns for frames

Answer 46

1. ​Sit to stand
2. FWB/PWB/NWB
3. 2pt gait (NWB)/3pt gait

Question 47

List safety checks when issuing walking aids in an hospital/clinic environment:

Answer 47

1. Ferrules - bottom of aids; replace immediately if not worn smoothy or unevenly
2. Handles
3. Check structure of mobility aid - wood = splinters, cracks; adjustable = poppers effective; metal = not bending; elbow crutches = check plastic; brakes working
4. Adjustable equipment – measured correctly for patients height
5. Appropriate footwear
6. Environment – check no trip hazards/ busy environment/ wet floors etc
7. Ensure adequate instructions for use - does the patient understand and remember? Has the patient had clear and concise training with appropriate practice and supervision? Have written instructions been given if necessary?