GAIT

DR NITI KHURANA

 series of rhythmical alternatingmovements of limb and trunk whichresult in forward progression of theCOG

 Human locomotion, or gait, may be described as a translatory progression of the body as a whole, produced by coordinated, rotatory movements of body segments. Normal Gait =
Series of rhythmical , alternating movements of the trunk & limbs which result in the forward progression of the center of gravity series of controlled falls

Fundamental Purpose Of Walking Gait:

1. Maintenance of support of the hat: that is, preventing collapse of the lower limb 2. Maintenance of upright posture and balance of the body 3. Control of the foot trajectory to achieve safe ground clearance and a gentle heel or toe landing 4. Generation of mechanical energy to maintain the present forward velocity or to increase the forward velocity 5. Absorption of mechanical energy for shock absorption and stability or to decrease the forward velocity of the body

GAIT INITIATION
Gait initiation may be defined as a Stereotyped activity that includes the series or sequence of events that occur from the initiation of movement to the beginning of the gait cycle.

Time interval or sequence of motions occurring between two consecutive initial contacts of the same foot; each cycle lasts for 1-2 seconds

SINGLE STANCE Occurs when only one is on the ground 30% of the gait cycle: single leg stance

DOUBLE STANCE Both limbs are simultaneously incontact with the ground; 20% of thegait cycle; double leg stance % increases to more one slowly walks;it becomes shorter as walking speed increases and disappears in running

WALKING2 periods of double leg support RUNNING- with double float period of time in which neither foot is in contact with the ground

PHASES OF GAIT CYCLE

STANCE PHASE Makes up to 60% of the gait cycleduring normal walking Occurs when the foot is on the groundand bearing weight

 The Los Amigos National rehabilitation Center (RLA) has developed different terminology in which the subdivision have been redefined and named.

STANCE PHASE
HEEL STRIKE
Refers to the instant atwhich the heel of the leading extremity strikes the ground.RLA: initial contact refers to the instant the foot of the leading extremity strikes the ground .

FOOT FLAT
occurs immediately afterheel strike and is the point at whichthe foot fully contacts the ground.RLA: Loading response occursimmediately following initial contactand continues until the contralateralextremity lifts off the ground at theend of the doublesupport phase

MIDSTANCE
It is the point at which thebody weight is directly over the supporting lower extremity. RLA: Midstance begins when the contralateral extremity lifts off the ground and continues to a position in which the body has progressed over and ahead of the supporting extremity.

HEEL OFF
is the point at which theheel of the reference extremity leavesthe ground.RLA: Terminal stance is the period fromthe end of midstance to a point justprior to initial contact of thecontralateral extremity or followingheel off of the reference extremity

TOE OFF
It is the point at which only the toe of the ipsilateral extremity is incontact with the ground.RLA: Preswing encompasses the period from just following heel off to toe off

SWING PHASE
40% of the walking cycle. Occurs when the foot is not bearingweight and is moving forward

ACCELERATION

Begins once the toe of the reference (ipsilateral) extremity leaves the ground.10% of the swing phase .

RLA
Initial swing begins at the samepoint as acceleration continues untilmaximum knee flexion of the reference(ipsilateral ) extremity occurs

MIDSWING
occurs when theipsilateral extremity passes directlybeneath the body.( 80% of the swingphase)RLA- Midswing encompasses the periodimmediately following maximum kneeflexion and continues until the tibia isin a vertical position

DECELARATION
Occurs after the midswing when the tibia passes beyond the perpendicular and the knee is extending in preparation for heelstrike.-10% of the swing phase

RLA
Terminal

swing includes the period from the point at which the tibia is in the vertical position to a point just prior to initial contact

COMPARISON OF TERMINOLOGY
TRADITIONAL Heel strike to Foot Flat Foot flat to Midstance Midstance to Heel off Heel off to Toe off Toe off to Accelaration Accelaration toMidswing Midswing toDeceleration RLA Initial contact Loading response Midstance Terminal stance Preswing Initial swing Midswing Terminal swing

 Traditional terminology refers to points in time RLA terminology- refers to lengths of time

WEIGHT LOADING
Weight acceptance period of the STANCELEG First 10% of the gait cycle A period of double support or double-leg stance

LOAD RESPONSE AND MID STANCE

Consists of the single support or SINGLELEG STANCE

Accounts for the next 40% of the gaitcycle

HEEL OFF TO TOE OFF

Make up the weight-unloading period Accounts for the next 10% of the gaitcycle A period of double support

GAIT TERMINOLOGY Time and distance are two basic parameters of motion, and measurements of these variables provide a basic description of gait.

TIME VARIABLES
TEMPORAL VARIABLES INCLUDE STANCE TIME SINGLE-LIMB AND DOUBLE-SUPPORT TIME SWING TIME STRIDE AND STEP TIME CADENCE SPEED.

DISTANCE VARIABLES
THE DISTANCE VARIABLES INCLUDE STRIDE LENGTH STEP LENGTH AND WIDTH DEGREE OF TOE-OUT

TIME VARIABLES

Stance time
It is the amount of time that elapses during the stance phase of one extremity in a gait cycle.

 Single-support time
It is the amount of time that elapses during the period when only one extremity is on the supporting surface in a gait cycle.

 Double-support time
It is the amount of time spent with both feet on the ground during one gait cycle. The percentage of time spent in double support may be increased in elderly persons and in those with balancedisorders. The percentage of time spent in double support decreases as the speed of walking increases.

STRIDE LENGTH It is linear distance in the plane of progression between successive points of foot-to floor contact of the same foot. 75 cm.

STEP LENGTH
distance b/2successive contact points on opposite feet 37.5cm(15inches) Should be equal for both legs Increased in tall persons Decreased in children Female at old, with age ,fatigue, pain and disease

NORMAL CADENCE
Number of steps per minute. 90-120 steps per minute WALKING SPEED distance covered over a period of time. SLOW 70M./MIN MEDIUM 95/MIN FAST 120M/MIN

 Cadence =number of steps/time

 Step duration
Refers to the amount of time spent during a single step. Measurement usually is expressed as seconds per step. When there is weakness or pain in an extremity, step duration may be decreased on the affected side and increased on the unaffected (stronger) or less painful side

NORMAL PARAMETERS OF GAIT

BASE WIDTH- distance between the two feet 5 to 10 cm (2-4 inches) Wide base- cerebellar or inner ear problems, diabetes or peripheral neuropathy indicating loss of sensation, tight hip abductors

Joint Motion
Another way in which gait may be described is through measuring the trajectories of the lower extremities and the joint angles.

OBSERVATIONAL GAIT ANALYSIS, whereby an observer makes a judgment as to whether a particular joint angle or motion varies from a norm. Observational gait analysis is used to hypothesize causes of deviations and direct treatment objectives. Disadvantage of the observational method of analysis is: That it requires a great deal of training and practice to be able to identify the particular segment of gait in which a particular joint angle deviates from a norm while a person is walking. Videotaping with slow playback can improve this greatly. Another disadvantage of observational gait analysis methods is that they frequently have low reliability, although recent reports have identified some variables and conditions under which reliability is satisfactory

Sagittal Plane Joint Angles

The approximate range of motion (ROM) needed in normal gait and the time of occurrence of the maximum flexion and extension positions for each major joint may be determined by examining the joint angle .

Gait Cycle - Components:

Phases:
(1) Stance Phase: reference limb in contact with the floor (2) Swing Phase: reference limb not in contact with the floor

Gait Cycle - Components:

Support:
(1) Single Support: only one foot in contact with the floor (2) Double Support: both feet in contact with floor

Gait Cycle - Subdivisions:

A. Stance phase:
1. Heel contact: Initial contact 2. Foot-flat: Loading response, initial contact of forefoot w. ground 3. Midstance: greater trochanter in alignment w. vertical bisector of foot 4. Heel-off: Terminal stance 5. Toe-off: Pre-swing

Gait Cycle - Subdivisions:

B. Swing phase:
1. Acceleration: Initial swing 2. Midswing: swinging limb overtakes the limb in stance 3. Deceleration: Terminal swing

Gait Cycle

Path of Center of Gravity

Center of Gravity (CG):
midway between the hips Few cm in front of S2

Least energy consumption if CG travels in straight line

CG

 During ambulation, the body's center of gravity is propelled forward. However it also moves vertically and laterally; we presume a gait pattern to be energy efficient to the extent that it minimizes vertical and lateral displacements.

Displacement of Center of gravity:

During normal pattern of gait within each gait cycle, the center of gravity is displaced: Twice in vertical direction, in sagittal Plane. Twice in lateral direction, in horizontal Plane. That occurs relative to plane of progression.

VERTICAL DISPLACEMENT OF COG

Viewed in the sagittal plane, the vertical displacement of the center of gravity traces a smooth sinusoidal curve. This curve's amplitude in the normal adult male is approximately 5 cm or 2 inches. The center of gravity moves vertically through two full oscillations during each gait cycle, so that the curve has two peaks and two troughs.

1.

Vertical displacement (in sagittal plane)

Movement of the lowest displacement occurs at heel strike and double support. Movement of the highest displacement occurs at mid-stance. Average: 1.8 inch. Pathway: sinusoidal curve.

A. Vertical displacement:
Rhythmic up & down movement Highest point: midstance Lowest point: double support Average displacement: 5cm Path: extremely smooth sinusoidal curve

 The low points or troughs in the sinusoidal pathway occur during the gait cycle's two periods of double limb support (loading response and preswing). The depth of the troughs is limited by:
Pelvic rotation Knee-ankle-foot interactions

The high points or peaks occur at midstance and again at midswing. The height of these peaks is limited by:
Lateral pelvic tilt (drop) Knee flexion in stance

LATERAL DISPLACEMENT OF COG

The center of gravity also oscillates laterally during ambulation. The total lateral displacement traces a sinusoidal curve with an amplitude of approximately 6 centimeters or 2.5 inches. The greatest lateral excursion of the center of gravity occurs at the end of midstance. Thus, only one full lateral oscillation of the center of gravity (to the right and left) occurs during a gait cycle. The amplitude of this lateral excursion is limited by a structural feature in the lower extremities, namely genu valgus.

2. Lateral displacement: ( in horizontal plane)

The displacement occurs over the right then over the left leg during walking. The maximum displacement is at mid-stance Average: one and 3/4 inches. Pathway: sinusoidal curve.

Path of Center of Gravity

B. Lateral displacement:
Rhythmic side-to-side movement Lateral limit: midstance Average displacement: 5cm Path: extremely smooth sinusoidal curve

The combination of displacement:

When the vertical and lateral displacement of center of gravity of body are combined and projected on the coronal plane: They will describe as figure of(8). It occupies approximately "2" inches square. The importance of displacement pattern of center of gravity is helping in translation of body from one point to another tical displacement during walking

Path of Center of Gravity

C. Overall displacement:
Sum of vertical & horizontal displacement Figure 8 movement of CG as seen from AP view
Vertical plane Horizontal plane

 N.B. At the maximum vertical displacement of center of gravty, it still lies slightly below the level of same COG when the subject is standing. that means the person is slightly shorter when he is walking than in standing.

Determinants of Gait :
Six optimizations used to minimize excursion of CG in vertical & horizontal planes Reduce significantly energy consumption of ambulation Classic papers: Sanders, Inman (1953)

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

Determinants of Gait :

(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

Determinants of Gait :

(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

Determinants of Gait :

(4) Ankle mechanism:

Lengthens the leg at heel contact Smoothens the curve of CG Reduces the lowering of CG

Determinants of Gait :

(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

Determinants of Gait :

(6) Lateral displacement of body:

The normally narrow width of the walking base minimizes the lateral displacement of CG Reduced muscular energy consumption due to reduced lateral acceleration & deceleration

Saunders Determinants of Gait

The determinants were supposed to represent adjustments made by the pelvis, hips, knees, and ankles that help to keep movement of the bodys center of mass to a minimum. Determinants was first described by Saunders and coworkers in 1953.

 Determinant is a various movement occurs in the body including pelvis, knee and ankle to maintain center of gravity of the body in a horizontal plane and ensure the smoothing pathway of gait.

"6" Determinants of gait: Major determinants: 1) Pelvic rotation. 2) Pelvic tilting. 3) Knee flexion in stance phase. 4) & 5) Foot and knee mechanism. 6) lateral displacement of the body.

Minor determinants: 1. Neck movement. 2. Swinging of arms

PELVIC ROTATION
In normal pattern of walking: The pelvis rotates alternatively to right and to left in relation to the line of progression in transverse plane about the vertical axis. The average magnitude of this rotation is approximately four degrees (4o ) on either side of the central axis. The total equal "8" degrees. Associated hip movement: Internal and external rotation during stance phase. Function: Pelvic rotation during normal gait decreases the vertical displacement of COG 3/8 inches

 LATERAL PELVIC SHIFT (PELVIC LIST)

Side to side movement of the pelvis during walking.- 5cm(2inches)- increases if the feet are farther apart. Causes relative adduction of the weight bearing limb, facilitating the adduction of the hip adductors. Weakness= trendelenburg gait

VERTICAL PELVIC SHIFT

Keeps the COG from moving up and down more than 5cm (2 inches) during the normal gait. High point occurs during Midstance and the low point occurs during Initialcontact.

 The head is never higher during normal gait than it is when the person is standing on both feet. Swing Phase: hip is lower on the swingside and patient must flex the kneeand dorsiflex the foot to clear the toe

PELVIC ROTATION
Necessary to lessen the angle of the femur with the floor; lengthens the femur. Decreases the amplitude if displacement along the path travelled by the COG and hereby increases the COG dip

 8 deg pelvic rotation with 4 deg forward on the swing leg and 4 leg posteriorly on the stance leg. Thorax rotated in the opposite direction to maintain balance

CENTRE OF GRAVITY
5cm(2inches) anterior to the 2nd Sacral vertebra. Its vertical and horizontal displacement is a figure during walking

DETEMINNATS
The determinants of gait has twoimportant function namely:1. Lessen the movement of the centerof the gravity, therefore reducing theenergy expenditure.- COG is lowest during the period of double support highest and midstance

 COG is lowest during the period of double support highest and midstance.2. Produce a smooth sinusoidalmovement

6 dETERMINANTS
Pelvic rotation Pelvic tilt Knee flexion in the stance phase Foot and ankle motion- synchronousmotion produces gradual rise/fall of COG

Knee flexion Lateral motion of the pelvis

NORMAL GAIT VARIATIONS

For females ( compared to males)- slower speed with greater cadence- decreased arm swing- decreased lateral and vertica lhead motion- greater lateral and pelvic shift

 Elderly- slower speed with wider, shortersteps- decreased arm swing- less pelvic rotation- increased double support

 When wearing high-heeled shoes- slower speed, same cadence- increased knee flexion during earlystance- rapid movement to lower fore foot onthe floor

GAIT ABNORMALITIES
STRUCTURAL PATHOLOGIC GAITS1.1 Inequality of leg length One leg is longer with discrepancy>1.5in.tiptoe at stance of shorter extremity One leg is longer with discrepancy<1.5in.dipping of shoulder and dropping of the pelvis on the affected side

 apparent elevation of shoulder onswing side.exaggerated hip, knee, ankle flexionby contralateral extremity duringswing

 Hip Ankylosis compensatory motion of the lumbarspine Exaggerated movement of the oppositehip.

 Knee joint stability sudden knee buckling Abnormal or excessive ROM of theknee

 Knee Contractures if flexion contracture is less than 30degrees there is limping apparent infast walking If flexion contracture is greater than30 degrees- limping even in slowwalking