Quiz 3: Gait Flashcards
Gait -fundamental to -requires -constraints type of activity -what domains used to look at it (4)
- fundamental human locomotion
- requires correct sequencing of multiple forces
- multiple temporal and spatial constraints
- can be looked at across various domains:
1. pathology: muscles that impair walking
2. impairment: muscles, nervous system
3. functional limitation: DF strength, PF spasticity
4. disability: how do I get to work, how do I shop
Gait Evaluation
- what does examination of gait reveal?
- how can it be used
- what does the deviation suggest
- examine of gait reveals the effects of impairments on functional activities
- gait can be highly diagnostic
- the deviation suggests the intervention, how the impairment affects gait
Basic Gait Review
- what is normal
- what is deviation from normal-what is happening vs what should be happening
- deviation may represent the nervous systems best attempt to solve problems (ie walk with foot drop so compensate with circumduction)
Basic Gait Phases
stance
swing
Stance:
HS–>loading–>heel off (push off)
swing:
early–>middle–>late
What gait segments do we look at?
ankle, knee, hip, pelvis, trunk, scapula, armswing, head
Kinematics
Kinematics: description of movement (without respect to force)
- angular displacement
- velocity
- distance
- stride width
- stride length
- step length
Kinetics
forces producing movement
-force plates
What do we look at in a gait evaluation? (2)
look at each phase and each segment and note deviations from normal
do findings of impairments (range, strength, spasticity, sensation) explain gait findings?
Ankle/Foot: Critical Gait Components
- Heel Strike
- Smoot transition from heel strike to foot flat
- heel off to toe off (push off)
What deviations can occur at the foot/ankle?
Foot slap –> foot drop –> foot drag
Foot Slap
-what is it
- cause (3)
- UMN vs LMN
it is audible: can be seen and heard
unsmooth transition from HS–>FF–>TO
- ankle plantarflexion contracture
- plantarflexion spactisity/tightening/shortened gastroc or achilles
- dorsiflexion weakness (cannot control lifting the toes concentrically or eccentrically thus get the slap)
(stroke, incomplete SCI, MS)
UMN: spasticity of plantar flexors
LMN: flaccidity of the dorsiflexorss: not lift toes and foot slaps
Foot Drop
- what is it
- Cause (2)
foot does not dorsiflex and comes up during gait
- can be limited in active or passive dorsiflexion
- can have a contracture in plantarflexion past neutral
Foot drag
foot drags because cannot dorsiflex
foot drag is worse than foot slap because in foot slap get heel strike but in foot drag the foot does not clear and more likely to trip
Risk of Foot slap/Drop/drag
- falls risk
- worse on uneven terrain
- gait deviation may not present when walking in a clinic on even ground
- may not present on shorter tests (we need to be provocative, ie 6th minute in the 6MWT)
Foot Drag Compensations (6)
- circumduction
- contralateral vaulting
- hip hiking
- contralateral trunk lean
- hip ER
- trunk extension
circumduction compensation
foot drag compensation: swing foot out to side
contralateral vaulting compensation
foot drag compensation: up on tip toes (hypertrophy) to clear the other foot
hip hiking compensation
foot drag compensation: ipsilateral quadratus lumborum to clear that foot
contralateral trunk lean compensation
foot drag compensation: lean to the other side to use passive tension to clear the foot
hip ER compensation
foot drag compensation: look like ER of involved leg to use adductors but trying to bring foot forward and it pivots on the floor and then swing it
trunk extension compensation
foot drag compensation: to bring the foot forward
Tx for foot drag: (5)
- stretch plantarflexors
- strengthen dorsiflexors
- task specificity
- medication (baclofenn, tizanidine,)
- bracing/splinting, night splints , AFO
tell patient to pay attention to gait
*ashworth scale will not always show it bc not provocative
AFO: pros and cons
it is a last resort for foot drag because it locks the foot in place so it blocks motion, causes muscle weakness and worse contractures
Gait Deviations: Knee
- critical components at the knee (2)
- deviations (2)
- knee flexion during heel off: if not, will drag the foot even if good DF
- smooth transition of knee flexion to extension during stance
Deviations:
- absent or inadequate knee flexion at heel off
- extension thrust
absent or inadequate knee flexion at heel off
-cause (2)
tx (3)
cause:
1. quadriceps spastisity (co-contraction)
2. hamstring weakness
tx:
1. medical
2. learn to activate hamstrings without activating quads (prone, bend knee)
3. stretch quads and strengthen hamstrings
extension thrust at the knee
- cause
- tx
cause:
1. plantarflexion spasticity/contracture (knee snaps back when travel through(–this is NOT genu recurvatum, knee hyperextension past physiological neutral but can cause genu recurvatum)
–cannot get dorsiflexion once the weight is over the knee and the force moment snaps the knee back
tx: stretch the plantarflexors
Gait Deviations at the Hip Critical components (5)
- flexion during swing
- extension during stance (hip extension force for push off from back leg)
- neutral adduction and abduction during stance
- ER during swing
- IR during stance
Gait Deviations at Hip (5)
- inadequate flexion during swing
- Trandelenburg
- Scissoring Gait
- Gluteus Maximus Lurch
- Inadequate Hip Extension
Trandelenberg
- what is it
- cause
- compensation
- treatment
- cause: stance phase weakness of hip abductors resulting in closed chain adduction (need abductor to hold neutral)
- –weakness of gluteus medius/TFL
- -less frequently: spasticity of adductors
compensate with ipsilateral trunk lean
- treatment: strengthen gluteus medius
- –open chain: SLR
- –closed chain: stand at the parallel bars go in and out of trandelenburg eccentrically
- –closed chain: resist side step at the hip
scissoring gait
- what is it
- -cause
- -treatment
often occur with weakness of abductors: trandelenberg
–in swing phase do more hip adduction during flexion so leg crosses over midline
- –cause:
1. spasticity of adductors
2. weakness of abductors
tx:
1. stretch adductors
2. strengthen abductors
gluteus maximus lurch
- what is it
- cause
- compensation
- tx
–inadequate mid to late stance hip extension (trunk extension to drive hip extension)
- cause: 1. hip extensor weakness 2. hip flexor contracture (psoas, sitting)
- compensation: trunk extension
- tx: 1. walk behind them and support their trunk
2. strengthen gluteus maximus
3. resist walking forward at ASIS
Inadequate hip extension
- what is it
- cause
- compensation
- tx
do not fully extend hip during gait, looks like they are sitting when they walk
- hip extension in gait is the most critical determinant of stability to prevent falls
- tx: resist walking with gait belt over ASIS to stimulate, get a powerful push off with every step (often not weak but do because more stable)
in gait critical determinants of stability to prevent falls are:
- most important: strength of push off (hip extension)
- heel strike
- medial – lateral stability
Unilateral Pelvic Retraction
- what is it
- cause
- compensation
- tx
retraction of hemi pelvis
cause: 1. weakness or atrophy in trunk extensors
2. weakness or atrophy in hip protractors
usually part of a larger hemiplegic pattern
(common in stroke, especially cortical shock)
tx: because it is depressed and retracted: anterior elevate pelvis, forward and anterior (because it is depressed and retracted)
excessive trunk flexion
-cause
cause:
1. trunk extension weakness
2. contracture of hips/ abdominal muscles
diminished or absent trunk rotation
cause:
* **parkinsons disease
- contracture of trunk flexors
- spinal stenosis
- lumbar compression fractures
What are 2 gait deviations at the trunk?
- excessive trunk flexion
2. diminished or absent trunk rotation
what is a gait deviation at scapula?
scapular protraction
scapular protraction
- cause (3)
- tx (2)
cause:
- unilateral: hemiplegia
- bilateral: postural fault, poor posture
- bilateral parkinson gait
tx:
- stretch protractors of the scapula (pec)
- strengthen retraction of scapula (rhomboid)
gait deviations of the arms: (2)
- absent or diminished armswing
2. unilateral excessive armswing
absent or diminished armswing
-cause
cause:
- unilateral: hemiplesia (called flail arm/flail shoulder) [can also be antalgic]
- bilateral: Parkinsons (usually unilateral to bilateral)
unilateral excessive armswing
-cause
cause:
- hemiballismus (it is like a pendulum)
- loss of ability to terminate movement at a specific point
head gait deviation (1)
gait deviation of forward head
deviation forward head
- -why is this an issue
- -when does this happen
- -what commonly causes
–COG is in front of them, increases falls risk and requires constant firing at the toe flexors and gastroc,
–patient thinks he needs to look at the floor to not fall.
this is common in parkinsons disease and in cases where patients are scared of tripping
–common in prolonged positioning
Name 5 specific gait syndromes
- parkinsonian gait
- cerebellar gait
- hemiplegic gait
- multiple sclerosis
- tabes dorsalis
Parkinsonian Gait
8 components
- cervical hyperextension (to get face off floor)
- absent armswing (arms close to body)
- flexed trunk
- absent trunk rotation
- shuffling (bilateral, toe first, initial contact)
- festination
- tremor
- freezing
festination
leads to falls, start to walk and then steps get shorter and shorter and faster and faster: tell the patient to look up to break the cycle (common in parkinsons)
freezing:
in parkinsons
doorway or threshold is a visual stimulus to stop them
tell the patient to look at a distant object
(goad and halter: being pushed and pulled in equal and opposite directions
–they are trying to move so dont tell them to try harder
cerebellar gait
–2 components
wide based: wide BOS for balance
ataxic: uncoordinated gait
hemiplegic gait: (6)
- unilateral pelvic retraction (pelvis)
- foot drag (ankle/foot)
- possible extension thrusts (knee)
- possible tredelenberg (hip)
- unequal step lengths
- diminished stance time on the involved leg
Multiple Sclerosis gait
anything is possible but worsens over time due to fatigue
therefore we need tests to be fatiguing
pattern: a slow down over time (ie 6mwt – slow down more at the 6th minute)
Tabes Dorsalis
“stamping gait” (syphalis)
stamping feet to increase sensory feedback due to dorsal column damage
loss of proprioception, slam foot with each step for feedback from the damaged dorsal column information
steppage gait
ankle plantarflexion contraction
–a compensation for foot drop by flexing the hip more
hip gait deviations: (5)
- inadequate flexion during swing
- trandelenberg
- scissoring gait
- gluteus maximus lurch
- inadequate hip extension
gait deviations: knee (2)
- absent or inadequate knee flexion at heel off
2. extension thrust
gait deviations at ankle: (4)
foot slap
foot drop
foot drag
steppage gait
Inadequate flexion at hip during swing
Hip flexor weakness
Hamstring tightness
extend trunk and use passive tension of anterior structures (hip flexors and abs) swing phase to bring the leg forward
tx: strengthen hip flexors
tx: stretch hamstrings
note: lack of hip flexion is cocomitted with foot drop so need to correct this to help with that as well
hip hiking
caused by any impairment that limits the ability of the LE to functionally shorten
ie weak hip flexors
compensation: contralateral pelvis elevates during swing phase to clear the advancing leg –Quadratus Lumborum
weak gluteus maximus
weak hip extensors
compensation: backwards lean of the trunk during early stance phase to shift the line of gravity behind the hip to reduce the demands of the hip extensors
weak hip abductors
- contralateral pelvic drop because unable to stabilize pelvis with the weak gluteus medius
- trunk leans over ipsilateral side in stance phase
=trendelenburg
genu recurvatum
paralysis of the quadriceps, plantarflexor contracture, or hamstring weakness causes this ultimately where there is hyperextension of knee (see during stance phase)
hamstring weakness
hamstring is unable to slow down the swing and so the knee will snap into extension
weak quadriceps
patient leans forward at the hip to bring the COG forward so the line of force will fall anterior to the knee and force it into extension (need quad contraction normally to prevent the knee from buckling when the line of force falls behind the knee when going into stance)
weak dorsiflexors
foot flat equinnus gait foot slap foot drop steppage gait
weak gastroc/soleus
no heel rise at push off, causes a short step length on the good side
hip or knee flexor contracture
knee or hip is in flexion causing the a crouched gait (lumbar lordosis and reduced stride length)
hip circumduction
caused by any impairment that reduces ability of the LE to shorten in swing and instead does a circular arc to clear the advancing leg
vaulting
for any impairment that doesn’t allow LE to shorten in swing – rise up on tip toes of stance foot to clear the advancing limb
hemiplegic gait
depends on severity and spasticity
- no Reciprical armswing
- extension synnergy in LE: hipp adduction, IR, ankle platnarflexion and inversion
- step length is longer on involved side and shorter on good side
ataxic gait
cerebellar dysfunction
-gait lacks coordination causing jerky and uneven movements, poor balance, walk with a wide BOS, movements appear exaggerated and pts have a hard time walking in a straight line
parkinsonian gait
LE and trunk flexion, elbows partially flexed without armswing, short stride length, shuffling gait with flat feet and weight forward on toes, festinating (feet try to keep up with forward leaning trunk) (starts slow and increases in speed with difficulty stopping)
scissor gait
hip adductor spasticity
most seen during swing
BOS is narrow
trunk may lean over stance leg while other leg trys to swing
antalgic gait
when LE is painful, stance phase is shortened
–a shortened (often abducted) stand phase on the involved side causes a rapid and shortened step on the good side
