Gaits Not Gates

Carla Wilhite, OTR/L Sherril York. Ph.D.

Oklahoma AgrAbility 1

Goals & Objectives

 Describe normal gait phases and components  Practice observational analysis  Determine mechanical consequences of abnormal gait  Suggest justification documentation examples  Present recommendations for improving work performance 2

What is Normal Gait?

 A series of losing and regaining balance resulting in forward motion  Normal pattern assumes variety of forms  Disruptions in sequence of actions result in anatomical or mechanical deviations  Some differences due to body type, gender, pathology, or galactic origin 3

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Gait Cycle

 Cycle extends from time heel contacts ground until same heel contacts ground again  Consists of two phases  Stance  Swing  Consists of periods of single limb support and double limb support 5

Phases of Gait Cycle

  Stance phase –60% of cycle  Initial contact/loading  Midstance  Terminal stance  Preswing Swing phase –40% of cycle  Initial swing  Midswing  Terminal swing 6

Phases of Walking

Taken from Soderberg, G. (1986).

Kinesiology:Application to Pathological Motion

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Phases of Gait Cycle

Taken from Pribut, S. (2004). Gait Biomechanics.

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Weight Shift

 Weight shifts from slightly lateral in the heel at heel strike  Moves forward between 1st and 2nd long bone of foot  Exits through the great toe at toe off Taken from Pribut, S. (2004). Gait Biomechanics.

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Anatomy of a Walk

    Walking is a cyclic movement Head position should remain relatively level Arms and legs move in opposition Pelvis, and shoulders, rotate forward-back and up-down around spine Taken from Classic Walk Tutorial http://www.rubberbug.com/tutorials.htm

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Anatomy of a Walk

 Feet and Legs  Heel strike as weight shifts to forward foot  Double limb support  Arms  Move in opposition to legs Taken from Anatomy of Walking Tutorial http://www.rubberbug.com/walking.htm

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Anatomy of a Walk

 Feet and Legs  Weight is transferred to forward foot, knee flexes to absorb shock  Toe-off of back foot occurs  Single limb support  Arms  Move in reciprocal motion to legs Taken from Anatomy of Walking Tutorial http://www.rubberbug.com/walking.htm

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Anatomy of a Walk

 Feet and Legs  Forward knee extends and lifts body  Weight on foot rolls from outside to inside  Back leg begins swing forward  Arms  Move in reciprocal motion to legs Taken from Anatomy of Walking Tutorial http://www.rubberbug.com/walking.htm

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Anatomy of a Walk

  Feet and Legs  Free leg has now moved forward in prep. for heel strike  Weighted leg is beginning propulsion to toe-off Arms  Arms move like pendulums in opposition to legs Taken from Anatomy of Walking Tutorial http://www.rubberbug.com/walking.htm

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Anatomy of a Walk

 Feet and Legs  Free leg now is weighted at heel strike  Double limb support  Arms  Opposite to leg movement Taken from Anatomy of Walking Tutorial http://www.rubberbug.com/walking.htm

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Anatomy of a Walk

 With legs apart, the pelvis and shoulders rotate in opposite directions around the spine  As one leg moves past the other, the pelvis and shoulders move vertically in opposite directions  As the legs part, the pelvis and shoulders again rotate in opposition Taken from Anatomy of Walking Tutorial 16 http://www.rubberbug.com/walking.htm

“Normal” Gait Lab

 Gain familiarity with gait sequence  Demonstration of typical gait patterns 17

Normal Gait Sequence

Click on link below to view normal gait Downloaded from McGill Medical Gait Disorders site http://sprojects.mmi.mcgill.ca/gait/normal/movie2.asp

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Gait Deviations

 Common Causes of Gait Deviations:  Pain or discomfort during weight-bearing or movement  Muscle Weakness  Limitations of joint movement  In-coordination of Movement  Changes in bone or soft tissue (including amputations) 19

Gait Deviations

 Pain or Discomfort: Clues  Report of pain and location  May spend less time in weight-bearing phase  Grimacing 20

Gait Deviations

 Muscle Weakness: Clues  Broadened base of support  Shorter steps  Diminished arm swing  Difficulty with balance  Extensive weakness: inability to ambulate 21

Gait Deviations

 Limitation of joint movement: Clues  Arthritis pathology  Surgical procedures (instrumentation)  Disuse of a body part (Can confirm joint limitation through measurement and gait analysis) 22

Gait Deviations

 In-coordination: Clues  Spasticity  Hemiparesis  Hypertonia: Cannot selectively activate muscle: see total flexion or total extension patterns when moving limbs 23

Gait Deviations

 Changes in bone or soft tissue: Clues  Bone shortening after fracture  Congenital malformations  Scar tissue 24

Gait Deviations

 Bottom Line: Anything that is not “normal” gait (i.e. forward progression) is a gait deviation.

 Vs. “Functional” gait 25

Pathology at Specific Joints

 Toes  Extended  Clawed 26

Pathology at specific joints

 Ankle and Foot  Forefoot contact  Foot-flat contact  Foot slap  Inversion/eversion  Drag  No heel off 27

Pathology at Specific Joints

 Knee  Limited flexion  Hyper or hypo extension  Varus/valgus  Wobbling  Extension thrust 28

Pathology at Specific Joints

 Hip  Circumduction (multiple components)  Limits in flexion or extension  Problems with rotation  Problems with adduction or abduction 29

Pathology at Specific Joints

 Pelvis  Hiking  Posterior or anterior tilt  Dropping  Rotation problems  Trunk  Back or forward lean  Lateral lean 30

Pathology at Specific Joints

 Arms  Decreased or absent arm swing  Head and neck  Kyphosis  Head forward posture 31

Lab: Walking Experiences

 Place one foot directly in front of the other  Walk with a wide base of support  Walk with toes pointed out  Walk with toes pointed in  Take a shorter than normal stride  Walk with both arms beside body 32

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Hemiplegia

Click on link below to see Hemiplegic gait Downloaded from McGill Medical Gait Disorders site http://sprojects.mmi.mcgill.ca/gait/hemiplegic/hemimovie.asp

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Drop Foot

Click on link below to see Drop foot gait Downloaded from McGill Medical Gait Disorders site http://sprojects.mmi.mcgill.ca/gait/footdrop/footmove.asp

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Parkinson’s

Click on link below to see Parkinson’s gait Downloaded from McGill Medical Gait Disorders site http://sprojects.mmi.mcgill.ca/gait/parkinson/movie1.asp

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Limp

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Writing your observations

  Describing what you see.

   What’s the functional problem? (Not DX) What’s the impact of the problem?

What’s the recommendation (s)?

Estimate the “costs”  Energy expenditure=fatigue  Orthopaedic costs= mechanical wear and tear  Functional costs= Walking safety/stability/mobility  Refer for professional analysis (PT) 38

Describing what you see

 “ Mr. Jones was observed walking today across a level dirt and gravel surface between his home and workshop. I observed the following difficulties as he was walking” :     Mr. Jones was using a quad cane to ambulate.

He was walking with a wide base of support.

While advancing his right leg while, his right forefoot was striking the ground and he was circumducting his leg.

He has a decreased step length and he walks very slowly. 39

Estimating the Costs…

 “Because Mr. Jones has difficulty in walking from his home to the workshop, he becomes more fatigued (energy cost), he appears to be placing more weight over his left leg to compensate for right sided weakness (wear and tear), and he has problems maintaining his balance while walking to reach his workplace (functional cost).” 40

Referral

 “ Mr. Jones should be referred to a physical therapist for a professional analysis of his gait to determine if…  He is using the appropriate assistive device.

 He needs further remediation/improvement in his gait.

 To improve his balance and mobility for functional activities.

 To determine the need for orthotic devices.

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Recommendations and Justification

 “Mr. Jones may need a powered mobility device to enable him to get to his farm work spaces to:  Prevent physical fatigue.

 Enable him to have increased mobility in getting to his work locations.

 Prevent secondary injury from additional biomechanical stress on his non-affected limb.

 Keep him safer when moving from his home to the worksite.

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Farm gait contexts

 Gait is dynamic. How does it change if:  On uneven terrain?

 Carrying a bucket?

 Walking with a feed sack on one shoulder?

 Slippery surfaces?

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Adaptations

 Personal assistive device  Farm mobility device  Community mobility 44