GAIT: GAIT BY Dr. AMRIT KAUR (PT) Lecturer, N.D.M.V.P college of physiotherapy nashik GAIT: GAIT Normal Gait Series of rhythmical , alternating movements of the trunk & limbs which result in the forward progression of the center of gravity One gait cycle period of time from one heel strike to the next heel strike of the same limb GAIT CYCLE: GAIT CYCLE The gait cycle consist of 2 phases for each foot Stance (60 percent of the cycle ) Begins when the heel of one leg strikes the ground and ends when the toe of the same leg lifts off. Swing (40 percent) Swing phase represents the period between a toe off on one foot ad heel contact on the same foot. PowerPoint Presentation: Time Frame : A. Stance vs. Swing: Stance phase = 60% of gait cycle Swing phase = 40% B. Single vs. Double support: Single support= 40% of gait cycle Double support= 20% Gait Cycle - Subdivisions : Gait Cycle - Subdivisions A. Stance phase: Heel contact: ‘Initial contact’. Foot-flat: ‘Loading response’, initial contact of forefoot on ground. Midstance: greater trochanter in alignment w. vertical bisector of foot Heel-off: ‘Terminal stance’ Toe-off: ‘Pre-swing’ Gait Cycle - Subdivisions : Gait Cycle - Subdivisions B. Swing phase: Acceleration : ‘Initial swing’ Midswing : swinging limb overtakes the limb in stance Deceleration : ‘Terminal swing’ DISTANCE AND TIME VARIABLES: DISTANCE AND TIME VARIABLES Temporal variables Stance time Single limb support time Double limb support time Swing time Stride and step time Cadence speed Distance variables Stride length Step length Width of walking PowerPoint Presentation: Step length Distance between corresponding successive points of heel contact of the opposite feet Stride length Stride length is determined by measuring the linear distance from point of heel strike of one lower extremity to next heel strike of same extremity. Width of base of support Side-to-side distance between the line of the two feet Degree of toe out It is the angle formed by each foot’s line of progression and a line intersecting the centre of the heel and second toe. KINEMATICS AND KINETICS OF GAIT: KINEMATICS AND KINETICS OF GAIT Path of Center of Gravity midway between the hips Few cm in front of S2 Least energy consumption if CG travels in straight line Path of Center of Gravity: Path of Center of Gravity Path of Center of Gravity: Path of Center of Gravity HEEL STRIKE TO FOOT FLAT: HEEL STRIKE TO FOOT FLAT Heel strike to forefoot loading Foot pronates at subtalar joint Only time (stance phase) normal pronation occurs This absorbs shock & adapts foot to uneven surfaces Ground reaction forces peak Leg is internally rotating Ends with metatarsal heads contacting ground Sagittal plane analysis: Sagittal plane analysis Joint Motion GRF Mome-nt Muscle Contraction Hip Flexion 30-25 Anterior flexion G.Maximus Hamstring Add.magnus, Isometric to ecentric knee Flexion 0-15 Anterior To Posterior Extensi-on to flexion quadriceps Concentric to ecentric ankle Plantar-Flexion 0-15 Posterior PF Tibialis anterior Ex. digitorum longus Ex.hallucis longus ecentric Frontal plane analysis: Frontal plane analysis JOINT MOTION Pelvis Forwardly rotated position Hip Medial rotation of femur on pelvis knee Valgus thrust with increasing valgus Medial rotation of tibia Ankle Increase pronation Thorax posterior position at leading ipsilateral side Shoulder Shoulder is slightly behind the hip at ipsilateral extremity side FOOT FLAT TO MIDSTANCE: FOOT FLAT TO MIDSTANCE FOOT FLAT TO MIDSTANCE (SAGITTAL PLANE): FOOT FLAT TO MIDSTANCE (SAGITTAL PLANE) Joint Motion GRF Moment Muscle Contraction Hip Extension 25-0 Flexion-0 Anterior to posterior Flexion to extensi-on G.maximus Concentric to no activity Knee Extension 15-5 15-5 flexion Posterior to anterior Flexion to extensi-on Quadriceps Concentric to no activity Ankle 15 of PF to 5-10 of DF Posterior to anterior PF to DF Soleus, gastronem-ius, PF Eccentric Frontal plane analysis: Frontal plane analysis Joint Motion Pelvis Ipsilateral side rotating backward to reach neutral at midstance ,lateral tilting towards the swinging extremity . Hip Medial rotation of femur on the pelvis continue to neutral position at midstance. adduction moment continue throughout single support. Knee There is reduction in valgus thrust and the tibia begins to rotate laterally. Ankle The foot begins to move in the direction of supination from its pronated position at the end of loading response. The foot reaches a neutral position at midstance . Frontal plane analysis: Frontal plane analysis Ankle The foot begins to move in the direction of supination from its pronated position at the end of loading response. The foot reaches a neutral position at midstance. Thorax Ipsilateral side moving forward to neutral. shoulder Moving forward MIDSTANCE TO HEEL OFF : MIDSTANCE TO HEEL OFF MIDSTANCE TO HEEL OFF (sagittal plane analysis): MIDSTANCE TO HEEL OFF (sagittal plane analysis) Joint Motion GRF Moment Muscle Contract-ion Hip Extension 0 to hyperextension of 10-20 Posterior Extension Hip flexors Eccentric Knee Extension 5 degree of flexion to 0 degree Posterior to anterior Flexion to extension No activity PowerPoint Presentation: Ankle PF:5 degree of DF to 0 degree. Anterior DF Soleus PF Eccentric to concentric. Toes Extension: o-30 degree of hyperextens-ion. Flexor hallicus longus and brevis Abductor digiti quinti, interossei, lumbricals MIDSTANCE TO HEEL OFF (frontal plane analysis): MIDSTANCE TO HEEL OFF (frontal plane analysis) Joint Motion Pelvis Pelvis moving posteriorly form neutral position Hip Lateral rotation of femur and adduction Knee Lateral rotation of tibia Ankle –foot Supination of subtalar joint increases Thorax Ipsilateral side moving forward Shoulder Ipsilateral shoulder moving forward. HEEL OFF TO TOE OFF: HEEL OFF TO TOE OFF HEEL OFF TO TOE OFF (sagittal plane analysis): HEEL OFF TO TOE OFF (sagittal plane analysis) Joint Motion GRF Moment Muscle Contraction Hip Flexion :20 degree of hyperextensi-on to 0 degree. Posterior Extension to neutral iliopsoas Adductor magnus Adductor longues concentric Knee Flexion :o-30degree of flexion Posterior Flexion Quadriceps Ecentric to no activity PowerPoint Presentation: Ankle PF :0-20 degree of PF Anterior DF Gastronemius. soleus, peroneus brevis, peronius longus. Concentric to no activity Toes (MTP) Extension: 50- 60 of hyperextension. Flexor hallucis longus Adductor hallicus Abductor digiti minimi Flexion digitorum brevis and hallicus brevis, inrossei, lumbricals Close chain resonse to increasing PF at the ankle. HEEL OFF TO TOE OFF (frontal plane analysis): HEEL OFF TO TOE OFF (frontal plane analysis) Joint Motion pelvis Contralateral side moving forward unless contralateral heel touches the ground. Hip Abduction occur, lateral rotation of femur Knee Inconsistent lateral rotation tibia Foot / ankle Weight is shifted to toes and at toe off only the first toe is in contact., supination of subtalar joint. Thorax Translation on the ipsilaterior side. Shoulder Moving forward. DETERMINANTS OF GAIT : DETERMINANTS OF GAIT Six optimizations used to minimize excursion of CG in vertical & horizontal planes Reduce significantly energy consumption of ambulation The six determinants are Lateral pelvis tilt Knee flexion Knee, ankle and foot interactions Forward and backward rotation of pelvis Physiological valgus of knee DETERMINANTS OF GAIT: DETERMINANTS OF GAIT 1) Pelvic rotation : Forward rotation of the pelvis in the horizontal plane approx. 8o on the swing-phase side Reduces the angle of hip flexion & extension Enables a slightly longer step-length w/o further lowering of CG PowerPoint Presentation: (2) Pelvic tilt : 5 degree dip of the swinging side (i.e. hip adduction) In standing, this dip is a positive Trendelenberg sign Reduces the height of the apex of the curve of CG PowerPoint Presentation: ( 3) Knee flexion in stance phase : Approx. 20o dip Shortens the leg in the middle of stance phase Reduces the height of the apex of the curve of CG PowerPoint Presentation: (4) Ankle mechanism : Lengthens the leg at heel contact Smoothens the curve of CG Reduces the lowering of CG PowerPoint Presentation: (5) Foot mechanism : Lengthens the leg at toe-off as ankle moves from dorsiflexion to plantarflexion Smoothens the curve of CG Reduces the lowering of CG PowerPoint Presentation: Physiological valgus of knee Reduces the base of support, so only little lateral motion of pelvis is necessary. FACTORS AFFECTING GAIT: FACTORS AFFECTING GAIT Age Gender Assistive devices Disease states Muscle weakness or paralysis Asymmetries of the lower extremities Injuries and malalignments GAIT EXAMINATION : GAIT EXAMINATION Take a history Couch examination Static examination Allow patient time to relax Reasonable length walkway - gait pattern changes before & after turn Various systematic ways Look for the obvious! COUCH EXAMINATION : COUCH EXAMINATION Observe deformities & lesions Check ROM’s Check muscle tightness/strength Neurological & vascular assessment STATIC EXAMINATION : STATIC EXAMINATION Feet non-weight bearing (hanging) with weight bearing Standing from front Shoulders, hips, knees, feet From behind Shoulders, hips, calcaneus GENERAL POINTS : GENERAL POINTS Is the gait fast or slow? Is it smooth? Does the patient appear relaxed & comfortable or pained? Is it noisy? FEET : FEET FEET : Is the 1st MPJ functioning properly? Are the toes bearing weight? When is the heel lifting? Is toe off through the hallux? Does the swing phase appear normal? Are the feet too close or is the base of gait wide? FEET LEGS : LEGS Are the knees pointing forwards? Is there genu valgum or varum? Is there tibial varum present? Do they appear internally or externally rotated? Knees from the side – are they fully extending? HIPS & BODY : HIPS & BODY HEAD & SHOULDERS : HEAD & SHOULDERS Are the shoulders level? Do the arms swing equally? Does the head & neck appear normal? Gait: Major points of observation. : Gait: Major points of observation. 1.Cadence a. Symmetrical b. Rhythmic 2.Pain a. Where b. When 3.Stride Even/uneven 4.Shoulders Dipping. Elevated, depressed, protracted, retracted 5.Trunk a. Fixed deviation b. Lurch 6.Pelvic a. Anterior or posterior tilt b. Hike c. Level 7.Knee a. Flexion, extension b. Stability 8.Ankle a. Dorsiflexion b. Eversion, inversion 9.Foot a. Heelstrike 10.Base a. Stable/variable b. Wide/narrow COMMON GAIT ABNORMALITIES : COMMON GAIT ABNORMALITIES Antalgic Gait Gait pattern in which stance phase on affected side is shortened Corresponding increase in stance on unaffected side Common causes: OA, Fx, tendinitis Lateral Trunk bending/ Trendelenberg gait: Lateral Trunk bending/ Trendelenberg gait Usually unilateral Bilateral = waddling gait Common causes: A. Painful hip B. Hip abductor weakness C. Leg-length discrepancy D. Abnormal hip joint Functional Leg-Length Discrepancy : Functional Leg-Length Discrepancy Swing leg: longer than stance leg 4 common compensations: A. Circumduction B. Hip hiking C. Steppage D. Vaulting Increased Walking Base : Increased Walking Base Normal walking base: 5-10 cm Common causes: Deformities Abducted hip Valgus knee Instability Cerebellar ataxia Proprioception deficits Inadequate Dorsiflexion Control/foot drop gait : Inadequate Dorsiflexion Control/foot drop gait In stance phase (Heel contact – Foot flat): Foot slap In swing phase (mid-swing): Toe drag Causes: Weak Tibialis Ant. Spastic plantarflexors Excessive knee extension : Excessive knee extension Loss of normal knee flexion during stance phase Knee may go into hyperextension Genu recurvatum : hyperextension deformity of knee Common causes: Quadriceps weakness (mid-stance) Quadriceps spasticity (mid-stance) Knee flexor weakness (end-stance) Others pathological gaits: Others pathological gaits Arthrogenic gait ( stiff hip or knee) Contracture gait Gluteus maximus gait Planter flexor gait Scissors gait Neurological gait: Neurological gait Ataxic gait Parkinsons gait Hemiplegic gait Spectic diplegic Myopatic gait Hyperkinetic gait RUNNING GAIT: RUNNING GAIT Require greater balance, muscle strength, ROM than normal walking. Difference b/w running and walking Reduced BOS Absence of double support More coordination and strength needed Muscle must generate higher energy bout to raise HAT higher than in normal walking. Divided into flight and support phase. STAIR GAIT: STAIR GAIT Ascending and descending stairs is a basic body movement required for ADL Stair gait involved stance and swing phase kinematics : kinematics SWING PHASE(36%) Foot clearance Foot placement STANCE PHASE(64%) Weight acceptance Pull up Forward continuance SIMILARITIES & DIFFERNCES BETWEEN LEVEL GROUND GAIT AND STAIR GATE : SIMILARITIES & DIFFERNCES BETWEEN LEVEL GROUND GAIT AND STAIR GATE Similarities to Walking Double support periods Ground reaction forces have double peak Cadence similar Support moment is similar (always positive with two peaks) Differences with Walking: Differences with Walking More hip and knee flexion Greater Rom needed Peak forces slightly higher Centre of pressure is concentrated under metatarsals, rarely near heel Step height and tread vary from stairway to stairway Railings may be present PowerPoint Presentation: ……….. THANK YOU ….