wk 8 - pathological gait Flashcards
understand classifications and cause of gait pathology
discuss some examples of neurological disorders causing gait disturbance
4 things that must occur for a person to walk and what is the difference between normal and abnormal gait with these 4 things
- Each leg must be able to support body weight
- Balance must be maintained during single limb support
- Swinging leg must be able to advance
- Sufficient power must be generated
In normal gait, these are achieved efficiently and symmetrically
In abnormal gait, these may be achieved through abnormal movements,
increasing energy consumption and potentially requiring walking aids
when describing gait patterns how should you explain it?
descriptive anatomical terminology with refernce to gait cycle events/periods
not described by cause (eg hemiplegic gait) as that can look different in different people
overall observations for gait (8)
- Speed
- Cadence
- Head tilt
- Shoulder tilt
- Base of gait
- Asymmetry
- Irregularity/lack of coordination
- Tremor/involuntary movements
observing abnormal gait can be looked at during 3 gait periods
weight acceptance- includes initial contact and loading response
single limb support- midstance and terminal stance
swing lim advancement -
weight acceptance (IC) what to look out for with abnormal gait and in what plane?
initial contact (sagittal view): striking with the heel is normal, anything else (midfoot, flat foot, forefoot) strike is abnormal
IC (frontal view): excessive calcaneal inversion/eversion (is it just at initial contact or just it correct through midstance?- may be normal if corrects)
IC (transverse): adducted or abducted foot placement (more than 10 degrees)
Could be abnormal hip rotation, abnormal bony torsion at the femur or tibia or deformity of the foot.
weight acceptance (LR) - 3 abnormal things that can occur in sagittal plane
sagittal plane:
foot slap- rapid/uncontrolled plantarflexion after heel strike, often audible (weakness of ankle dorsiflexors
abnormal knee flexion/extension
1. inadequate extension (crouch gait)
-due to knee/hip contracture/spasticity
2. inadequate flexion or hyper extension (stiff knee gait)
-due to knee hyperextension (genu recurvatum)
trunk/hip abnormailities
1. anterior trunk bending - weak knee extensors
2. posterior trunk bending - weak hip extensors
3. abnormal hip flexion -inadequate (shortened stride on one side)
single limb support - ankle, rearfoot and toes in sagittal and frontal plane
sagittal plane:
1. early heel lift or no heel lift (apropulsive gait)
2. peak dorsiflex angle at ankle and first metatarsophalangeal joint - should be 20 degree in ankle and 15-20 in MTPJ
3. excessive clawing of toes / overactivity of long extensor muscles
frontal plane:
1. calcaneus (inversion/eversion) and foot pronation/ supination
single limb support- knee and thigh
knee:
should be full extended
1. indequate extension
2. hyperextension
3. varus/valgus (frontal plane)
thigh:
1. internal/external rotation looking at patella (frontal)
2. femoral anteversion (squinting patalla)
single limb support - pelvis and trunk
- contralateral pelvic drop (trendelenburg sign)-hip abductor weakness, pain, abnormal hip joint, wide base of gait
swing phase - ankle
- failure to dorsiflex the ankle to neutral during swing can impact ground clearance (compensation strategies will occur: steppage, hip hiking, circumduction)
swing phase - 4 compensation strategies for limb length difference
- Circumduction – weak hip
flexors - Hip hiking – pelvis lifted via
contraction of spinal
muscles - Steppage – exaggerated
knee and hip flexion - Vaulting – going up on the
toes of the stance phase leg
what is step length asymmetry due to (3)
weak hip flexors,
limited hip extension on one side, or hyperactive/spastic hamstring muscles
what do walking aids do and what types of are there
Operate by supporting part of the body weight through the arm rather than the
leg
- Cane – increases the base of support, Suitable for minor stability problems
- Crutches – by definition 2 points of attachment/loading. Armpit/hand or forearm/hand
- Walking frames- Most stable walking aid, Usually move frame forwards first, then take a short step with each foot. Rolling walker
classifications of gait pathology based on what? (7)
-body systems approach
-planes of motion
-structure and function
-key components of gait control
-level of pathology
-gait classification scores
-global pathology
classifying gait dysfunction (3)
-High level (e.g. cautious gait, frontal or subcortical dysequilibrium)
* Mid-level (cerebellar ataxic, Parkinsonian, hemiplegic gait)
* Low-level (arthritic or antalgic gait)
sensory disorders (sensory ataxia, vestibular ataxia, visual ataxia) - what are their gait characteristics?
SA- steppage gait
VA- weaving from side to side, may fall to one side
Visual A- tentative, cautious
peripheral motor disorders (arthritic, myopathic/neurpathic) - what are their gait characteristics
A- shortened stance phase on affected side, trendelenburg sign
M- exagerated lumbar lordosis, trendelenburg sign, foot slapping, foot drop, steppage gait
neuromotor disorders (hemiplegia/paresis, paraplegia, parkinsonism, cerebellar ataxia)
H- leg circumduction, loss of arm swing, foot dragging
P- bilateral leg circumduction, scissor gait
Park- small shuffling, absent arm swing, freezing
C- wide base of gait, increased trunk sway, staggering
high level/ cognitive (cautious, frontal related gait disorders) - what characteristics
CG- wide base of gait, shortened stride, decreased velocity
FRGD- same as above + freezing and difficulty initiating gait
upper motor neurone lesions are what
due to damage occurirng anywhere between the cortex and L1 in the spinal cord
what are typical features of UMNL
gait:
circumduction,
foot plantar flexed and inverted,
knee and hip fail to flex,
scissor gait if paraplegia
increased reflexes, muscle tone, muscle spasticity
what is Lower Motor Neurone Lesion
damage of LMN axon (nerve cell bodies within the central horn of spinal cord- they innervate peripheral musculature), L2 and lower is LMN only.
damage to what areas can be UMN or LMN
C1- L1
cerebral palsy what is it
Singe or multiple lesions to the motor centres of the cerebellum before, during or shortly after birth
Brain damage is non-progressive, but clinical
manifestations develop and change as the child grows
Similar patterns seen in other UMN disorders
(stroke, traumatic brain injury, etc)
hemiplegia means what
one side of body is affected, upper and lower limb
diaplegia
both legs affected
monoplegia
one limb affected
how is cerebral palsy classified ?
according to site
quadriplegia
diplegia
hemiplegia
problems with cerebral palsy include
-motor control
-balance
-muscle spasm - overactivity of the stretch reflex is normally inhibited by Upper motor neurones. partial reduction in inhibition leads to exaggerated reflexes. major reduction in UMN inihibition leads to muscle spasm
gait abnormalities in cerebral palsy
-Increased hip adduction and knee flexion secondary to spasticity
or contracture
– Knee: jump gait, crouch gait, stiff knee gait, recurvatum knee
– Foot and ankle: equinus, calcaneus, varus (common with spastic
hemiplegia), valgus (more common in diplegia)
what is the most common neurological deficit and leading cause of gait impairment?
stroke
what is the major effect of having a stroke?
hemiparesis- weakness on one side of the body (lower/upper limb and face)
it occurs contralateral to the side of the stroke lesion and is sometimes accompanied by
1. unilateral sensory loss
2. loss of vision
Spina Bifida what is it?
- Caused by incomplete closure of the neural arches
of the spinal cord
*Motor and sensory deficits, varying in severity with
different forms
*Depends on level of spinal cord affected - need to know dermatomal and myotomal anatomy!
- e.g. low lumbar (L4 and L5) and sacral (S1) level
- Gait deviations will be consistent with patterns ofmuscle weakness
friedriech’s ataxia
Recessive genetic disorder, usually presents between 5-15 years of age
* Degenerative disease which effects Cerebullum and spine
* Causes unco-ordinated movements of trunk, arms, legs
* First symptom is usually gait disturbances
what gait abnormailities occur with friedriech’s ataxia
- Wide base of support
- Poor control of limbs in open chain movements
- Scissoring gait
- Athetoid Movements – slow writhing involuntarty movments
- Poor trunk stability
parkinsonian gait is what ?
Degenerative disease of the dopamine-
producing cells of the basal ganglia
* May be idiopathic or drug-induced
* Strength is relatively preserved
* Rigidity, bradykinesia (slow movement) and
tremor
parkinsonian gait - gait abnormalities
-Postural instability
* Short steps of rapid cadence
* Difficulty with gait initiation (freezing
multiple sclerosis what is it?
Autoimmune attack on oligodendrocytes in
the CNS causing progressive demyelination
and repair
* Over time causes scars or plaques on
nerves
* Commonly affects the cerebellum causing
ataxia, and spinal cord causing spastic
paralysis
duschenne muscular dystrophy, what is it
Only affects boys
* Dx between ages of 1-5 yrs
* By age 12 usually progressed to wheelchair
* Death usually early adulthood due
pulmonary and cardiac complications
duschenne muscular dystrophy - gait characteristics
- Trendelenburg
- Toe walking
- Lumbar lordosis
- Knee instability and recurvatum
- Balance problems
drop foot - what is it
Inability to dorsiflex foot during swing phase
of gait
* Can be caused by:
- Nerve injury (Spinal nerve root or Peroneal
nerve)
- Muscle or nerve disorders (MS, polio, CMT)
- Brain or spinal cord disorders
- Muscle weakness
drop foot gait abnormalities
high steppage gait with foot slap
poliomyelitis what is it?
Virus attacks and destroys anterior
horn cells of the spinal cord, causing
paralysis, flaccidity and atrophy
polio abnormal gait characteristics
-Genu recurvatum
* Foot drop
* Contractures due to imbalance between
agonist/antagonist muscle groups
* Fatigue
* Orthoses and walking aids are often required
Charcot Marie-Tooth (CMT) what is it
-genetic disorder - hereditary
-onset is delayed until second/third decade of life
-distal weakness (stork leg) appearance caused by muscle atrophy
-often pes cavus deformity with clawing of the toes
CMT - abnormal gait characteristics
- increased peak pressures under lateral/mid foot and forefoot
-increased pressure time integrals under the lateral heel and lateral forefoot.
ataxic means what
signs: staggering, unsteady, wide based
cause: cerebellar lesion/ proprioceptive deficit
abductory twist means what
signs: forefoot abduction and heel adduction following heel lift
cause: compensation for prolonged pronation/ hallux limitus
antalgic means what
signs: shortened stance phase, unequal arm swing + other pain avoiding compensations
causes: pain avoidance during weight bearing
anteversion means what
signs: excessive medial rotation of the femoral neck (normal is 20 degrees)
cause: in toeing often compensated by ipsilateral internal pelvic rotation and external hip rotation
apropulsive means what
signs: ineffective leverage during push off
cause: inadequate supination, hallus limitus, elderly
equinus means what
signs: plantarflexed foot, causing tip toe gait with forefoot contact rather than a heel strike
cause: plantarflexor spasticity with or without tendoachillies contracture, congential talipes equinovarus (clubfoot)
drop foot means what
signs: plantarflexion of foot during swing with reduced clearance
cause: dorsiflexor weakness due to peroneal neuropathy, plantarflexor spasisicty or stroke
delayed heel rise means what
signs: delay in transferring weight to forefoot, normal heel rise occurs around 44% of gait cycle
cause: plantar flexor weakness
circumduction means what
signs; trunk and pelvic rotation
cause: compensation for restricted hip/knee flexion
foot slap means what
signs: sudden plantarflexion of foot during loading response
cause: weak dorsiflexors
forefoot abduction means what
signs; forefoot deviation laterally
cause: may compensation for in toeing cause by femoral anteversion
genu recurvatum
signs: knee hyperextension during stance
cause: weak quads, plantarflexion contracture
genu valgum
signs: abduction defomrity of the knee
cause: arthristis, hereditary
genu varum
adduction deformity of the knee (bow legged)
cause: arthritis, hereditary
