1. PTA 130 Fundamentals of Treatment I
GAIT ANALYSIS & GAIT TRAINING

2. Lesson Objectives Identify phases of the gait cycle
Differentiate between stride and step length
Introduce common pathological gait patterns
Define terms used to describe normal gait
Identify joint specific gait abnormalities in lower extremities

3. Introduction
Gait is one of the most basic components of independent function
A common goal of rehabilitation is to restore or improve the ambulatory status of a patient
Purpose of Gait Analysis:
Assist with understanding the gait characteristics of a particular disorder
Assist with movement diagnosis
Determine proper interventions
Evaluate the effectiveness of treatment

4. Gait Cycle
The gait cycle begins when the heel of the reference extremity contacts the supporting surface and ends when the heel of the same extremity contacts the ground again
The gait cycle is divided into two phases:
Stance –
The interval in which the foot is on the ground (60% of the gait cycle)
Swing –
The interval in which the foot is not in contact with the ground (40% of the gait cycle)

5. Double Support
Refers to the interval in a gait cycle in which body weight is transferred from one foot to the other and both right and left feet are in contact with the ground at the same time
Two periods of double support occur within a single gait cycle

6. Gait Cycle – Stance Phase
Traditional Terminology
Rancho Terminology
Heel strike
Footflat
Midstance
Heel-off
Toe-off
Initial contact
Loading response
Midstance
Terminal stance
Preswing

7. Gait Cycle – Swing Phase
Traditional Terminology
Rancho Terminology
Acceleration
Midswing
Deceleration
Initial swing
Midswing
Terminal swing
Refer to O’Sullivan (pg. 255) for differences between the two terminologies

8. Weight Transmission During Gait

9. Ankle and Foot: Stance Phase
Heel strike to foot flat
Foot flat through midstance
Midstance to heel off
Heel off to toe off

10. Heel Strike to Foot Flat
Normal Motion:
0 -15 degrees PF
Normal Muscle Activity:
Eccentric contraction of tibialis anterior
Result of Weakness:
Lack of PF causes the foot to slap the floor

11. Foot Flat through Midstance
Normal Motion:
15 degrees PF to 10 degrees DF
Normal Muscle Activity:
Gastroc and soleus muscles act eccentrically
Result of Weakness:
Excessive DF and uncontrolled tibial advance

12. Midstance to Heel Off Normal Motion: Normal Muscle Activity:
10-15 degrees of dorsiflexion
Normal Muscle Activity:
Gastroc and soleus contract eccentrically
Result of Weakness:
Excessive DF and uncontrolled forward motion of tibia

13. Heel Off to Toe Off Normal Motion: Normal Muscle Activity:
15 degrees DF to 20 degrees PF
Normal Muscle Activity:
Gastroc, soleus, peroneals, and flexor hallicus longus contract to PF the foot
Result of Weakness:
No roll off. Decreased contralateral step

14. Ankle and Foot: Swing Phase
Acceleration to midswing
Midswing to deceleration

15. Acceleration to Midswing
Normal Motion:
Dorsiflexion to neutral
Normal Muscle Action:
Dorsiflexors are contracting to bring the ankle into neutral
Result of Weakness:
Foot drop and/or toe dragging

16. Midswing to Deceleration
Normal Motion:
Neutral
Normal Muscle Action:
Dorsiflexion
Result of Weakness:
Foot drop and/or toe dragging

17. What happens at the Knee and the Hip during gait?
What happens at the knee during the stance phase and swing phase of gait?
Tables 10.4 and 10.5
Page 323 in O’Sullivan
What happens at the hip during the stance phase and swing phase of gait?
Tables 10.6 and 10.7
Page 324 in O’Sullivan

18. Gait Terminology Stride Length Step Length Stride Width
The distance between corresponding contact points of the same foot (e.g., distance from heel strike to heel strike of the same foot)
Step Length
The distance between corresponding contact points of opposite feet (e.g., distance from heel strike of one foot to heel strike of the opposite foot)
Stride Width
The lateral distance between the feet

19. Stride Length, Step Length, and Stride Width

20. Gait Cycle
(continued)

21. Gait Cycle

22. Sinusoidal Motion COG located at S1 - S2
During preferred rate walking the COG approximates a sinusoidal curve from the:
Sagittal perspective - no greater than a 2” peak-to-valley excursion
Frontal perspective - no greater than a 2” medial-to-lateral excursion

23. Sinusoidal Motion

24. Increased Energy Expenditure in Gait
If the COG deviates too far from the norm increased energy is required
Example: Walking with a stiff-knee (“stiff-knee gait”) while in a brace/cast
During stance phase the patient will vault over the fixed foot (especially during mid-stance)
COG will be deflected higher than the usual 2” upward vertical displacement with increased energy cost

25. Rehabilitation of Ambulation
Requirements for normal gait:
Normal range of motion
Normal and balanced muscle strength
Normal balance
Stabile structures for weight acceptance
Normal control of reciprocal gait pattern both in symmetry and muscle activation sequence
Houglum LR -

26. The Control of Gait Motor control options: ‘Manual’ control theory –
Thinking about having to take a step each time you want to advance the foot forward
‘Automatic’ control theory –
An automatic control system that accounts for gait mechanics without having to think about foot placement and other metrical details

27. Preferred Rate of Ambulation
Free or comfortable walking speed
Self-selected pace
Rate at which the normal individual is most energy efficient
Range: ~ mph (cadence of ~ steps per minute)
Will vary from individual-to-individual

28. Pathological Gait
Results when a segment is not able to move as it should
Common Causes:
Injury
Weakness, loss of flexibility
Pain
Bad habits
As a result, compensations occur elsewhere in the body with resultant effects (stress, weakness, and further injury)
Houglum LR -

29. Abnormal Gait Patterns
Propulsive
Scissors
Spastic
Steppage
Waddling
Trendelenberg
Antalgic
Leg length discrepancy
Circumduction
Vaulting
Hip Hiking
Quadriceps Gait
Stiff Knee Gait

30. Abnormal Gait Patterns
Propulsive Gait-
A stooped, rigid posture, with the head and neck bent forward; Balance deficit
Scissors Gait-
Characterized by legs flexed slightly at the hips and knees, giving the appearance of crouching, with the knees and thighs hitting or crossing in a scissor-like movement
Spastic Gait-
A stiff, foot-dragging walk caused by one-sided, long-term, muscle contraction

31. Abnormal Gait Patterns
Steppage Gait-
Foot drop where the foot hangs in plantarflexion, toes can scrape the ground during swing phase; Exaggerated hip and knee flexion used to clear toes
Waddling Gait –
A distinctive duck-like walk; trunk sways side to side; wide base of support
Trendelenburg Gait-
Weakness of the hip abductor muscles; pelvis drops on the contralateral side with compensatory lateral trunk lean over that side
Variable sources- Whittle, pg 103

32. Abnormal Gait Patterns
Antalgic Gait Pattern- A protective gait pattern
Stance time is usually limited on the painful limb resulting in uneven timing and/or uneven step lengths
The uninvolved limb will demonstrate a shortened step length since it must bear weight sooner than normal
Pain promotes a modification of the gait pattern to avoid joint motions, muscle contraction and weight bearing that sustains or may increase the pain
O’Sullivan, PTA Exam study guide (bullets 1 and 2) pg

33. Abnormal Gait Patterns
Functional Leg length discrepancy –
The pelvis dips downwards on the side of the shortened limb with compensatory lateral trunk bend
Circumduction-
Secondary to hip flexor weakness; adductor muscles act as hip flexors while the hip joint is extended
Hip hiking-
Pelvis lifts on the side of the swinging limb by contraction of spinal muscles and lateral abdominal wall; may also see posterior trunk lean
Essentials of Kinesiology Ch.12 p. 348 onwards

34. Abnormal Gait Patterns
Vaulting-
Used to increase ground clearance in swing phase by going up on the toes of the stance phase leg
Stiff knee Gait –
During stance the patient will vault over the fixed foot (especially during mid-stance) & COG will be deflected higher than the usual 2” upward vertical displacement
Essentials of Kinesiology Ch.12 p. 348 onwards

35. Pathological Gait Gluteus Medius Gait – (Trendelenburg Gait)
Pelvis drops on contra-lateral non-weight bearing side
Compensation – patient moves trunk laterally over the weak hip
Quadriceps Gait – (weakened Quads)
An immediate lurch occurs at heel strike forcing the femur backward & the trunk forward to passively lock the knee
Compensation – COG moves anterior to the knee with increased forces at the knee joint & hip extensors
The knee often buckles during this gait pattern

36. Hip Abductors Normal Strength-
Prevent contra-lateral hip from dipping greater than 5-8 degrees
Stance-side abductor muscle group is active
Loss of abductors:
Positive Trendelenburg sign
Weakness of abductors manifests as ‘lurching gait’ (toward stance side)

38. Analysis of Deficits: Quadriceps – Stance Phase
Early stance (Heel strike – Foot flat)
Guides knee into 20 degrees of flexion eccentrically (controls unlocking of the knee)
Late stance (Heel off – Toe off)
Controls for knee flexion (~40 degrees at TO)
Early stance weakness/absence
Inability to absorb energy
Buckling
Late stance weakness/absence
Knee collapse into flexion -premature flexion into early swing

39. Analysis of Deficits: Paraspinals – Stance Phase
Early stance (HS - FF) & late stance (HO - TO)
Prevent forward flexion of trunk acting on pelvis
Early & late stance weakness/absence
Trunk falls forward
Loss of head and neck control

40. Analysis of Deficits: Hip Extensors – Stance Phase
Early stance (HS)
Prevent hip flexion (jack-knifing)
Early stance (HS - FF)
Guide hip into flexion eccentrically
Early stance (HS) weakness/absence
Hip/trunk collapses into flexion
Early stance (HS - FF)
Trunk falls forward

41. Analysis of Deficits: Pre-tibial Group – Stance Phase
Early stance (HS - FF)
Lowers forefoot to floor eccentrically
After forefoot contacts floor- pull tibia forward over foot
Early stance weakness/absence
Forefoot slaps to the floor - ‘drop-foot’ gait
Loss of forward pull of tibia

42. Analysis of Deficits: Plantar Flexors – Stance Phase
Late mid-stance
Concentrically pulls tibia forward
Late stance (HO - TO)
Provides propulsive thrust during push off
Early stance weakness/absence
Loss of forward pull of tibia
Loss of forward thrust - poor transition to early swing

43. Analysis of Deficits: Plantar Flexors – Stance Phase
Late mid-stance
Concentrically pulls tibia forward
Late stance (HO - TO)
Provides propulsive thrust during push off
Early stance weakness/absence
Loss of forward pull of tibia
Loss of forward thrust - poor transition to early swing

44. Analysis of Deficits: Peroneals – Stance Phase
Late stance (HO - TO)
Dynamically provide collateral stability to ankle when plantar flexed
Secondary plantar flexor for forward thrust
Late stance weakness/absence
Ankle instability causing medial-lateral movement
Potential for ankle injury - sprains
Poor transition from late stance to early swing

45. Analysis of Deficits: Plantar Intrinsics – Stance Phase
Late stance (HO - TO)
Provide medial - lateral stability to MTP joints (especially nos. 1 & 2)
Improves forward propulsion and transition to early swing
Late stance weakness/absence
Excessive medial - lateral ‘shimmy’ of hindfoot during HO
Inefficient forward thrust

46. Analysis of Deficits: Hip Flexors – Swing Phase
Late stance - early swing (acceleration)
Forward flexion of femur working with plantar flexors to accelerate LE in early swing
Functionally shortens LE (with eccentric action of quadriceps and dorsiflexors) to prevent ‘toe-drag’
Late stance - early swing weakness/absence of forward acceleration after TO
Toe may not clear the floor during swing through
Compensate with circumduction at hip

47. Analysis of Deficits: Dorsiflexors – Swing Phase
Mid-to-late swing (deceleration)
Affects ‘toe-up’ concentrically
Functionally shortens LE during swing through
Mid-to-late swing weakness/absence
Loss of ‘toe-up’
Compensation
Increased hip flexion - ‘steppage gait’
Circumduction at hip

48. Analysis of Deficits: Hamstrings – Swing Phase
Late swing (deceleration)
Decelerates tibial shank
Provides for smooth transition between late stance and early swing
Late swing weakness/absence
‘Impact on terminal extension’ - knee slapped into extension or hyperextension

49. INTERVENTIONS for Gait Dysfunction
ROM – for any joint motion restriction
Stretching – for soft tissue restriction or shortened muscle groups
Strengthening for weakened musculature
Gait training to address specific deviations
May need temporary or permanent AD if deviations are significant
Balance training
HEP Instruction / Patient Education
Modalities – as needed LR

50. INTERVENTIONS for Gait Dysfunction
Orthotics
Heel lift, or shoe build up for leg length discrepancies or foot drop
Appropriate assistive device
Functional activity training

51. Gait Training Safety Measures
Gait belt
Proper guarding techniques
Proper lighting
Clear unobstructed path
Proper shoe wear
Adherence to weight bearing status
Use of appropriate device that has been fitted/measured for the patient
Patient’s cognitive status

52. Gait Training – Rate of speed
Why could this statement be detrimental to your 83 y.o. patient?
Mrs. Jones, while you’re walking, I want to go…” “...very slow!”

53. What are some possible implications of this?
Mr. Jones will be safe - probably won’t fall and break her hip
The path of the COG may be distorted
Energy cost
Suppose Mrs. Jones has a cardiac condition?
Mr. Jones’ gait may never return to ‘normal’
Central pattern generator CPG - a group of synaptic connections probably at the spinal cord level which are triggered by an event or condition
When a threshold is met via a triggering mechanism the CPG appears to be activated and takes over automatic control of gait metrics - i.e., you don’t have to think about it

54. Is it possible that...
…going very slow might actually cause Mrs. Jones to lose her balance and fall?
How?
Mrs. Jones may never reach her pre-injury/disease preferred rate of ambulation and therefore never trigger a CPG that automates gait
What is a CPG?

55. Central Pattern Generator (CPG)
A group of synaptic connections at the spinal cord level which are triggered by an event or condition (perturbation)
When a threshold is met via a triggering mechanism the CPG appears to be activated and takes over automatic control of gait metrics (the individual does not have to think about it)

56. Gait Training Objectives
Are all patients’ objectives/goals the same?
Are your objectives for Ms. Walksalot, a 39 year old healthy female who broke her ankle two weeks ago in an intensive tennis match, the same as…
Mr. Livesinathirdstorywalkup, a frail 87 year old male, with emphysema and a fractured hip?
It is important to keep the objectives/goals in mind during gait training

57. Gait Training - ADs
Various assistive devices are available for use during gait/ambulation activities
Parallel bars
Walkers
Bilateral & unilateral crutches
Canes (single point, quad)
Remember it is very important to properly guard your patient during gait training while using an assistive device in the clinic

58. Assistive Device Progression
Progression from assistive device to normal gait
Progress from assistive device with large base of support to small base of support
2 Axillary crutches or 2 Lofstrand crutches  1 Axillary crutch or 1 Lofstrand or 1 Straight cane
Hemi-walker  Straight cane
Walker  Quad Cane

59. Gait Training & Documentation
Document any deviations noted during gait training
Did gait appear vigorous or labored?
Was gait guarded or restrained – was the patient attempting to gain stability and security?
Was the toe/floor clearance distance slightly decreased?
Was there decreased reciprocal arm swing?
Was there decreased step and/or stride length?

60. Documentation for Gait Training
Narrow or wider dynamic base of support?
Increased lateral head movement?
Increased or decreased rotation of pelvis?
Any abnormal or pathological gait patterns noted?
Gait distance / endurance
Any shortness of breath or other physiological reactions
Any episodes of loss of balance?

61. Questions?