Gait analysis

WALKING: depends upon the repeated performance by the lower limbs of a sequence of motions which advance the body along a desired line of progression while also maintaining a stable weight bearing posture. The effectiveness of walking will depend upon free joint mobility and muscle action. Each sequence of limb action is called a gait cycle which involves a period of weight bearing (stance) and a period of self advancement i.e. swing. Approximately 60% of time is spend in stance & 40% in swing. The reciprocal action of the limbs is timed to trade their weight bearing responsibility during a period of double stance

Gait parameter definition Base of Support is the distance between parallel lines intersecting the midpoint of each heel print Line of Progression is a line located approximately at the center point between both feet along the walkers path of progression Foot Angle is the angle formed by the intersection of the line of progression and a second line, which is drawn through the midpoint of the heel and the space between the second and third tarsal Step Length =Distance between corresponding successive points of heel contact of the opposite feet Rt step length = Lt step length (in normal gait)

Stride Length =Distance between successive points of heel contact of the same foot Double the step length (in normal gait)

Cadence =Number of steps per unit time Normal: 100 115 steps/min

Velocity = Distance covered by the body in unit time Usually measured in m/s Instantaneous velocity varies during the gait cycle Average velocity (m/min) = step length (m) x cadence (steps/min)

Comfortable Walking Speed (CWS) =Least energy consumption per unit distance Average= 80 m/min (~ 5 km/h , ~ 3 mph)

Three are three components or functional elements of walking: Progression Standing Stability Energy Conservation Progression: There are two main progressional forces:

1)The primary one is the forward fall of body weight as the ankle dorsiflexes beyond neutral and accelerates with heel rise. 2)The second generated by the contra lateral swinging limb starts with onset of single limb support The action is particularly important before the body is aligned for a forward fall. The momentum generated by these two actions is preserved at the onset of the next stance phase by floor contact with the heel. As the foot drops towards the floor the pretibial muscles draw the tibia forward,& quadriceps tie the femur to the leg so that the thigh also advances. Thus throughout the stance the heel, forefoot and the ankle serve as a rocker which advance the body over the supporting foot. Standing Stability: Balance is challenged by two factors 1)body is top heavy & walking continuously alters the segment alignment. During walking the body is divided into two functional units: Passenger(head ,neck, trunk),Locomotor unit (limbs joint by intervening pelvis). Weight bearing stability is maximum when its 3 components are vertically aligned. The skeletal architecture is designed for mobility Energy Conservation: efficiency is energy expenditure per task performed. for walking it is oxygen used per meter travelled Oxygen is consumed as the muscles contract during walking. so the energy can be conserved by reducing the amount of oxygen consumed i.e. by reducing muscle activity The muscle activity can be reduced by 1) substituting momentum in place of muscle action whenever possible, displacement of body from the line of progression is minimized . Optimum use of momentum occurs during the persons natural gait velocity which requires a least energy expenditure per meter travelled Both slower and faster pace increase energy cost Minimization of body displacement from the line of progression is accomplished by coordinating the pelvic, knee and ankle motion to keep the relative limb length relatively constant during stance. At the onset of double stance body height is the lowest as the limbs are diagonal. The highest position is in middle of the single stance when the limb is vertical

To reduce these extremes normal gait cycle involves 3 pelvic motions: lateral drop, transverse rotation and anterior tilt Optimum use of momentum occurs during the persons natural gait velocity which requires a least energy expenditure per meter travelled Both slower and faster pace increase energy cost Minimization of body displacement from the line of progression is accomplished by coordinating the pelvic, knee and ankle motion to keep the relative limb length relatively constant during stance. At the onset of double stance body height is the lowest as the limbs are diagonal. The highest position is in middle of the single stance when the limb is vertical To reduce these extremes normal gait cycle involves 3 pelvic motions: lateral drop, transverse rotation and anterior tilt

Joint Motion
The interplay of progression ,standing stability and energy conservation result in complex and continually changing relationship between the various limb segments as the body advances over the supporting foot and the toe is lifted to clear the ground. Each joint performs a repetitive pattern of motion There are three joints involved in walking: 1. Ankle 2. Knee 3. Hip

The ankle joint is formed where the foot and the leg meet. The ankle is a synovial hinge joint that connects the distal ends of the tibia and fibula in the lower limb with the proximal end of the talus bone in the foot. The bones of the ankle, called tarsal bones, consist of the talus, calcaneus (heel), navicular, cuboid, medial or internal cuneiform, middle cuneiform, and lateral or external cuneiform The ankle joint is bound by the strong deltoid ligament and three lateral ligaments: the anterior talofibular ligament, the posterior talofibular ligament, and the calcaneofibular ligament

MOTION AT ANKLE The ankle joint permits planter flexion ,dorsiflexion ,inversion eversion (foot) Two periods of planter flexion and dorsiflexion are experienced in each gait cycle. At onset of stance ankle has 90 degree position(neutral) As heel is loaded foot drops into 10 degrees of PF Then action is reversed and reaches 1o degrees of dorsiflexion. The PF is resumed reaching 20 degrees by the end of stance(double stance) With toe-off foot is raised to neutral dorsiflexion and is maintained in this position throughout the swing phase

The knee is essentially made up of four bones. The femur, which is the large bone in your thigh, attaches by ligaments and a capsule to your tibia. Just below and next to the tibia is the fibula, which runs parallel to the tibia. The patella, or what we call the knee cap, rides on the knee joint as the knee bends. When the knee moves, it does not just bend and straighten, or, as it is medically termed, flex and extend. There is also a slight rotational component in this motion. The knee muscles which go across the knee joint are the quadriceps and the hamstrings. The quadriceps muscles are on the front of the knee, and the hamstrings are on the back of the knee. The ligaments are equally important in the knee joint because they hold the joint together. the bones support the knee and provide the rigid structure of the joint, the muscles move the joint, and the ligaments stabilize the joint.

MOTON AT KNEE Two phases of flexion and extension Beginning in full extension(flexed 5 degrees). It rapidly flexes to 15 degrees. Then it progressively begins to extend . Within onset of double stance it again begins to flex. The action continues in swing till it reaches 60 degrees before extension is resumed

The hip joint is the joint between the femur and acetabulum of the pelvis and its primary function is to support the weight of the body in both static (e.g. standing) and dynamic (e.g. walking or running) postures. The hip joint is reinforced by five ligaments, of which four are extracapsular and one intracapsular The hip muscles act on three mutually perpendicular main axes, all of which pass through the center of the femoral head, resulting in 3 movements: Flexion and extension around a transverse axis (left-right); lateral rotation and medial rotation around a longitudinal axis (along the thigh); and abduction and adduction around a sagittal axis (forward-backward) and circumduction

MOTION AT HIP Only a single arc of hip extension and flexion occurs fro each gait cycle. As the foot strikes the ground the hip is in 30 of flexion. Throughout the stance there is progressive extension into 10 of hyperextension. Then flexion begins in terminal double stance and continues in most of the swing. When the 30 posture is reached it is maintained until stance resumed

To allow progression while maintaining weight bearing stability the limb performs the distinct stance that define the phases of stance. The stance phase is further divided into five stages

1. Initial contact 2. Loading response 3. Mid Stance 4. Terminal Stance 5. Pre swing 6. Of primary concern is the way the foot strikes the floor 7. Heel will strike the floor at an angle of 25 8. The ankle is in neutral position(PF 3) 9. Knee is extended between o to 5 of flexion 10. Hip is flexed 30 11. The body weight vector passes through the heel which is anterior to both knee and hip. 12. Three torques are generated: ankle PF, Knee extension, hip flexion 13. Of primary concern is the way the foot strikes the floor 14. Heel will strike the floor at an angle of 25 15. The ankle is in neutral position(PF 3) 16. Knee is extended between o to 5 of flexion 17. Hip is flexed 30 18. The body weight vector passes through the heel which is anterior to both knee and hip. 19. Three torques are generated: ankle PF, Knee extension, hip flexion

Of primary concern is the way the foot strikes the floor Heel will strike the floor at an angle of 25 The ankle is in neutral position(PF 3) Knee is extended between o to 5 of flexion Hip is flexed 30 The body weight vector passes through the heel which is anterior to both knee and hip. Three torques are generated: ankle PF, Knee extension, hip flexion Control of both knee and ankle is critical to have a normal heel strike

The ankle motion is dependent on the free joint mobility and the pretibial muscles Knee extension is accomplished by the quadriceps action Hip does not influence mode of floor contact but determines the angle between foot and floor.

Acceptance of body weight in such a manner that assures limb stability and still perform progression is the goal of this stage. The action at the ankle precedes and contributes to the knee action. Ankle: After floor contact by the heel the foot drops into 10 of PF in a controlled manner. The action is initiated when the body weight is applied at the foot of the dome of the talus and the floor contact is still at the tip of calcenous.An unstable lever will result from difference in length between these two points. Strong action by the pretibial muscles retards the terminal arc of ankle planter flexion so forefoot contact is gradual .thus heel strike is heard but no foot slap

Knee: flexion of knee is to 15 is initiated by heel rocker action. As the pretibial muscles contract to restrain ankle PF it also draws tibia forward this is rapid action and it advances the knee much faster than the thigh and trunk can follow. As result the body weight shifts posterior to the knee and a flexion torque is induced. Two types of muscle actions result increased quadriceps activity to restrain rate of knee flexion No hamstring muscles are needed for knee hyperextension. Hip: little change in the body position occurs during the loading response.

Advancement of body and limb over a stationary foot is the functional objective of this gait phase As the other foot is lifted from ground a period of single limb support begins, maximum stability is gained by having the foot stationary and in total contact with the floor As the body weight advances the base of the weight vector moves from heel to forefoot Ankle: At onset of single stance ankle is slightly PF by 5

From this position there is gradual dorsiflexion, the basic arc is from -5 to 5 with 10 of DF being attained just as the heel rises to initiate terminal stance. Thus an ankle rocker action is created for body progression so that the tibia can advance beyond neutral position and body wt moves over the forefoot As the body vector moves anterior to the ankle a DF movement is created which would accelerate of limb advancement if it were not controlled by soleus and gastroenemus Knee: knee flexion introduced during response increases to 18 just as single limb support is initiated Motion of knee then reverses to progressive extension which depends on tibia being restrained by soleus so that femur can advance relatively faster In the middle of mid-stance body wt vector moves anterior to the joint center so the need for active muscular control is terminated. Quadriceps action is maximum at the onset of mid stance ,it then progressively declines as knee extends over vertical tibia Once the vector becomes anterior to the knee axis ,extension stability is provided passively and the quadriceps relaxes. Hip :Progressive decline of hip flexion and entry in to extension allow trunk to remain erect while limb becomes more vertical Lifting the opposite limb removes support from that side of the body .The unsupported pelvis falls creating hip adduction in the stance limb. This is rapidly limited to 4 degrees and reduced by active abduction Hip abductor muscle activity is intense throughout the mid stance while extensors are quiet.

Primary objective of TS is forward fall to generate a propulsive force. Heel rise signifies on state of second phase of single stance. Now forefoot serves as the rocker with the body falling forward of its area of support . This creates a primary propulsive force for walking Ankle: At onset of heel rise the ankle drops in to maximum dorsiflexion (10) occurring in stance Motion then reverses to 5 of PF by end of single limb support Stability is accomplished by the triceps surae With heel rise body vector is concentrated at the forefoot The distance between the vector and ankle joint generates a maximum dorsiflexion torque Both soleus and gastrocnemius respond vigorously to maintain ankle in neutral position and ceases as the weight is transferred to the other foot.

Knee: maximum extension of knee between o to -5

At the end of the terminal stance the knee begins to flex .Body weight is rapidly falling towards the other limb There is no quadriceps action for knee extension Stability is gained from the body vector being anterior to the knee axis Hip: Passive extension of the hip jt continues as the body wt advances over the supporting foot and the trunk remains erect by the end of stance there is 120 of hyperextension There is no hip extensor activity during terminal stance As the body wt begins to fall forward the other limb the hip abductors terminate their action ,for passive abduction is induced.

Preparation of the limb for swing is the purpose of action that occur during the preswing phase. Floor contact by the other foot initiates this interval of terminal double support Rapid transfer of body wt to the limb allows the desired action to follow. The critical area of response is the knee

Ankle: there is rapid ankle PF to a 20 position Knee: There is rapid passive flexion to 45 which occurs because the body wt is rolled so far forward of the forefoot rocker that the tibia is no longer stable. Hip: flexion of hip jt is initiated with recovery from hyperextension to neutral that occurs during this phase.

Lifting the foot from the ground and limb advancement followed by preparation for stance are the objectives of three phases of swing

Recovery of the trailing position is the task that is accomplished This involves two critical actions flexion of both hip and the knee. Ankle : DF of the ankle is initiated but only half of the 20 PF present at toe off is recovered at this time Thus toe clearance is not dependent on the ankle dorsiflexion during initial phase of the swing. The muscles contract quickly to lift the foot. Knee: the flexion increases to 60 No dominant flexion force Hip: from the neutral position at toe-off the hip rapidly flexes to 20

As the limb advancement continues the changes in the tibial alignment make foot control critical for floor clearance Hip: maximum flexion to 30 is reached by iliacus action Knee: relaxation of the flexor muscles allows the knee to extend passively ,which accelerates advancement of leg and foot By the end of mid swing knee flexion equals that of hip flexion Ankle: Dorsiflexion to neutral is accomplished and maintained.

Advancement is terminated and the leg is prepared for stance. Knee extension is the critical event. Ankle: continued neutral dorsiflexion is the basic posture, but the foot may drop in to slight PF (3 to 5) at the end of the phase. Knee: The extension of the knee to neutral continues(0 t 5).The quadriceps provide the necessary extensor force Hip: The 30 of flexion attained in flexion is maintained .For this purpose iliacus continues to support limb weight while hamstrings prevent further motion.

 (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

(2) Pelvic tilt: 5o 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

Ankle and foot: 1)Inappropriate initial contact Low heel strike Flat foot contact Forefoot contact 2)Excessive planter flexion 3)Excessive dorsiflexion 4)Varus(inversion) 5)Valgus (eversion)

Knee: Inadequate extension Limited flexion, no flexion Hyperextension Varus Valgus Hip: Inadequate flexion Inadequate extension Adduction-abduction

Initial contact : loss of normal heel strike can occur because of three reasons1)A low heel strike, results due to loss of ankle dorsiflexion to the neutral, floor contact is made by the heel so that the foot is nearly parallel to the ground 2)Flat foot contact can occur when the knee is flexed even though the ankle is at neutral 3)Forefoot contact often called as toe strike will indicate combined ankle planter flexion and knee flexion

Loading response: Attempting to bear weight on a flexed knee in the presence of weak quadriceps leads to a total limb collapse Midstance: Excessive ankle planter flexion prevents the body from moving forward Terminal Stance: Inadequate ankle PF is the critical problem, thus there is excessive ankle dorsiflexion Heel rise is lost and body advancement usually provided by the forefoot is lacking

Preswing: loss of passive knee flexion Initial swing : Inability to flex the hip deprives the patient of limb advancement Mid Swing: Excessive ankle planter flexion causes toe drag Terminal swing: Inability to extend the knee fully leaves the limb in an undesirable position for stance

During walking major displacement of various body segments occur. these are synchronized to reduce the work involved in walking The hip,knee,ankle describe complicated motions during a complete gait cycle Characterization of these motions provides specific information regarding abnormalities in gait E.g. A reduced single limb support could be due to no of phenomenon: hip or knee pain, decreased hip or knee motion, weak musculature etc

Motion analysis can help to find the abnormality, but the motion occurs to fast to be discerned by a human eye Thus measurement using recording instruments is necessary to permit observation at a lower speed

One of the simplest pieces of gait instrumentation is the picture video A picture video helps to measure a persons gait prior to applying any instrumentation, that might alter gait pattern It provides a visual documentation of what happened during instrumented test and is the only way of resolving differences when the recorded footswitches or motion data do not correspond to clinicians visual image of a subject A basic video system consist of a VCR,one or two video cameras ,a character generator ,a video mixer and a TV monitor The video mixer combines images from 2 cameras so that the lateral and anterior /posterior view can be observed simultaneously The character generator enables to overlay text(e.g. name and date)on the video image The clinician can use it as a stand-alone device or with another system

Temporal gait measurements help to find the timings of critical events in gait measurement Cadence, gait cycle duration, stance and swing times, single limb support ,initial & terminal double limb support can be measured By making the measurements over a definite walking distance the persons velocity and stride length can be defined ,which can reveal a great deal about the persons ability to walk E.g. If a person gets weaker has painful joints or feels unstable ,velocity will decrease and the person will spend less time in single limb support on the affected side Footswitches are a convenient and inexpensive way of obtaining temporal gait measurement

There are 2 basic types of foot switches: 1)Compression closing footswitches 2)Force sensitive resistor switches(FSR)

Compression closing switches consist of sandwich of thin pieces of brass shim stock separated by a compressible (non conducting) foam rubber insole

In contact areas conductive rubber cylinders are inserted into holes in the insole When pressure is applied the insole compresses and the conductive rubber cylinder contact the pieces of brass on each side of the insole ,closing an electrical circuit The sandwich is held together with duct tape and is typically about 4 mm thick

The FSR switches consist of 2 thin layers of flexible plastic with printed circuits on the inner surfaces separated by a thin layer of double sided adhesive

 Holes in the adhesive create contact areas As pressure is applied carbon on one surface contact a metal pattern on the other surface creating a resistive electrical circuit As more pressure is applied the resistance drops The associated circuitry triggers at a predefined resistance value indicating a switch closure

Footswitches have typical contact areas in the 1st and the 5rd metatarsal, heel and great toe areas In most footswitch systems, a pair of light beams is positioned along the line of walking progression. The light beams are arranged at a known distance from one another. As the walking subject passes each beam, a signal is received in the recording device. Thus, data about distance travelled and time are acquired. Footswitch and light beam signals can be transmitted and recorded in 3 different ways. The simplest method is to connect the switches to recording devices by cable. Cables can be made lightweight and flexible. They are relatively simple, reliable and expensive. subject must drag the cable along the walkway or some provision must be made for movement of the cable with the subject.

Gait mats are relatively new systems that provide temporal and spatial measurements

These mats consist of a long strip of walking surface such as a carpet into which is embedded an array of switches running across and along the length of the mat As the person walks along the mat the switches close under the feet due to foot pressure enabling the computer to calculate the timing of each switch closure and thus the floor/foot contact pattern Since the geometry of the mat is known the special parameters of gait can be calculated Besides step length measurements advantages of these system are elimination of gait encumbering attachments ,low cost and portability

Gaitrite: This is a portable instrumented carpet that can be used in either a laboratory or field setting. The walkway is 4m long x 0.6m wide x 6mm high and contains 13,824 sensors. Up to fortyone basic gait measures such as walking speed and step length are immediately available upon the completion of a walk across the mat. Assessment using this system takes about half an hour. The Gait Scan is a noninvasive method whereby a computerized pressure mat is utilized to record pressures on the bottom of the foot as a patient walks over the mat. Pressure distribution is directly related to the overall posture and stability of the foot. It is this data that the doctor then analyzes to precisely determine abnormalities and develop an appropriate treatment regimen for the patient.

Goniometers
These are the instruments used to measure different joint angles

They are available in various sizes 6 inch,8 inch ,12 inch and are also used to measure 180 and 360 angles The 180 and 360 are used to measure range of motion of finger and wrist & ROM of large joints respectively

Biplane Goniometer :

Hand held, transparent goinometer standardizes the clinical assessment of ankle dorsiflexion.

Structure allows examiner to control entire forefoot, subtalar joint and ankle joint, preventing unacceptable pronation during measurement. Extensible goniometers: these goniometers are extensible

Electronic goniometers: these are electromechanical devices that span a joint to be measured with attachments to proximal and distal limb segments

These devices provide an output voltage proportional to the angular changes between the two attachment surfaces They move on assumption that the attachment surfaces move with midline of the limb segment onto which they are attached and thereby measure actual angular change of joint The 2 major advantages of these device are low cost and ease of use

A force plate is a device that measures the ground reaction forces exerted by a subject as they step on it during gait. they consist of a Top plate & a bottom plate separated by Force transducers at each corner Any force exerted on the top surface is transmitted through force transducers

The force plates are of 2 Types: 1. Piezoelectric: Utilize quartz transducers that produce an electric charge when stressed. No power supply needed 2. Strain Gauge: Utilize strain gauges in specially machined aluminum transducer bodies referred to as load cells to measure stress

The forces can be applied in three directions Fx,Fy,Fz and can be measured by using a force plate

One or more video cameras can be used in a video system in order to track the bright markers that are placed on the subject along specific locations. Passive Marker Systemsolid shapes with retroreflective tape

Active Marker Systeminfrared (IR) light-emitting diodes (LEDs). The system keeps track of the horizontal and vertical coordinates of each marker from each camera In Three Dimensional (3D) System 2 or more video cameras are used,Computer software program calculates 3D coordinates for each marker using the 2D data obtained from the cameras. In Two Dimensional (2D) System a single video camera is used, assuming all of the motion is occurring on a single plane perpendicular to camera axis.It is Not recommended for use in gait analysis.

Active marker systems have LED markers that are pulsed sequentially ,so the system knows the identification of each marker These systems require more equipment to be placed on the user- battery back, pulsing circutry,markers,cables attached to and carried by the userFor a long duration heat generated by the LEDs can be a problem These markers are used in CODA system which uses a specially designed camera with a array of photodiodes When the LED flashes the signal is detected by the sensor array The data is transmitted to the computer which calculates the 3D coordinates

Passive Marker system: these use light weight reflective markers without the need of electrical cable or batteries on the user IR LEDs send out pulses of IR radiation that are reflected back into the lenses from the marker As the subject walks the markers are detected and later a computer software is used to calculate 3D data

Vicon 3-D Motion Analysis System (6 240Hz cameras) for quantitative analysis of human motion. 3-D models are generated to calculate joint range of motion as well at the translation of a subject through the cameras capture field. This data may be used in collaboration with force plate data to calculate variables such as joint moments, power, and work. The eight camera Vicon System seen below allows for sophisticated measurement of gait parameters and joint angles.

Cerebral palsy (CP) is an encompassing a group of non-progressive non-contagious motor conditions that cause physical disability in human development, chiefly in the various areas of body movement. These affect the gait cycle and the various joint angles

In Parkinson's disease the person has a stooped posture Head forward Hips and knees bent Walking on the front of feet