Don’t Shut the Gait... on the Gait Cycle!

Beth Ashley, CPOJayne Boeding, PT, DPT

Pointing You In the Right Direction Our goal is to point you in the right direction when you see concerns with your student’s walking or playing skills!

Feel free to ask questions and share thoughts along the way.

Course ObjectivesParticipants will 1. Describe typical gross motor development 2. Describe the gait cycle including lower leg anatomy 3. Learn about gait abnormalities through case studies4. Be exposed to a variety of orthotics used to improve gait skills5. Learn about play and therapeutic activities that promote gross motor

skills6. Recognize the need for collaboration to increase a child’s physical

ability to participate in fitness and learning activities

COLLABORATION

IsKEY!

Two Definitions:1. The action of working with

someone to produce or create something

2. Traitorous cooperation with an enemy.

Who is on the child’s team?

The team impacts all areas of the student’s growth… Today

we will focus on how the team can positively affect gait and

gross motor activities.

● The Child● Parents/Guardians● Special Education Teacher● Paraprofessionals● Administrative Representative● Regular Education Teacher● Adapted Physical Education

Teacher● Related Service Providers● Outside Agencies● Social Worker● Medical Professionals● Other...

Gross Motor Skills are...

Coordination of large body movements that promote:● Functional Mobility● Independence● Access to Learning● Hobbies● Vocation/Career opportunities● Physical fitness● Personal relationships

Early Development: Fighting Gravity and Making Connections• Brains are built over time, from the bottom up.• Simpler neural connections & skills form first,

then more complex circuits and skills• In the first few years of life, 700 to 1,000 new

neural connections form every second.• Connections are then reduced through

“pruning” to allow brain circuits to be more efficient.

(developingchild.harvard.edu)

Functional Mobility

Rolling Skills: (3-6 months)• Pivoting when on

stomach• Back to Sidelying• Tummy to Back rolling• Back to Tummy rolling• Pulling Tummy Up for

Crawling

Sitting Skills: (4-12 months)• Supported Sitting• Flexed Sitting• Protect Forward• Protect Sideways• Protect Backwards

All the ways we go exploring...

From 6-18 months:• Belly Creeping • Rolling• Bottom Scooting• Backwards Creeping• Classic Crawling• Bear Crawling

Walking Skills: (10-18 months)

• Pull to Stand• Cruise Furniture• Two Hands Held• Push Toys• One Hand Held• Independent Standing

OFF they GO! Exploring and Climbing Everything…

Learning Opportunities EXPLODE for Toddlers

● Uses Pull Toys● Carries objects● Begins to run● Stands on tiptoe● Kicks a placed ball● Climbs onto furniture● Uses riding toys and wagons● Walks up & down stairs with

help

Milestones in the Pre-school Years (3-5) years)• Two foot jump & one foot balancing• Goes upstairs & downstairs on own• Kicks ball with direction• Throws ball overhand with emerging form• Catches bounced ball most of the time• Changes speed and direction• Preschool playground skills• Increasing awareness of safety• Participate in simple group games

Resource: www.healthychildren.org

Kindergarten Physical Education Skill Benchmarks:● Pencil Roll● Single Jump in a Self turned Rope● Underhand Toss● Catch a ball from skilled thrower● Kick a Stationary Ball● Drop and catch a Ball● Two foot jump vertical & horizontal ● Side slide-Gallop-Skip● Balancing activities● Cooperative and Safe Play● Understanding Rules

Now you know the typical progression of gross motor skills and

walking...

Now let’s get to work onthe Gait Cycle!

Pelvic Anatomy

Function: Attach spine to lower body, support the organs and bear the weight of the upper body

● Posterior Tilt● Anterior Tilt● Lateral Tilt ● Rotation

Hip Anatomy

Function: Bear weight of the trunk and provide movement of the lower limb through its ball and socket joint

● Flexion

● Rotation

● Internal Rotation

● External Rotation

● Abduction

● Adduction

Knee Anatomy

Function: The largest joint in the body acting as a hinge to bend the lower leg.

● Flexion

● Extension

● Minimal amount of rotation at the top of the tibia

Foot AnatomyFunction: To balance and transmit the body’s weight to the ground. There are 26 bones.

Ankle joint complex is made up of

• talocalcaneal (subtalar)

• tibiotalar (talocrural)

• transverse-tarsal (talocalcaneonavicular)

Movements:

• Supination/Pronation

• Dorsiflexion/Plantarflexion

8 Categories of Gait Abnormalities★ Hemiplegic:

○ Unilateral weakness○ Toe drag, foot slap and circumduction (circle leg outward)

★ Diplegic: ○ Steppage due to calf tightness and/or dorsiflexion weakness○ Scissoring due to adductor tone

★ Neuropathic: ○ Foot drop from ALS, SCI, peroneal nerve palsy○ Equinus gait/plantarflexion contracture

★ Myopathic○ Trendelenberg (lean toward weak side) from hip abductor weakness○ Genu Recurvatum (snap knee back to compensate for hamstring/quad

weakness)

Gait Abnormalities ★ Choreiform

○ Irregular, jerky movements○ Huntington’s disease or other basal ganglia disorders with athetosis and

dystonia★ Ataxic

○ Cerebellar disorders○ Wide based, staggering quality

★ Parkinsonism○ Shuffling gait and bradykinesia○ Flexion at knees and forward trunk

★ Sensory○ Loss of proprioceptive input○ Stomping gait and toe walking

https://stanfordmedicine25.stanford.edu/the25/gait.html

The Gait Cycle

Video

The Three Rockers of Gait

Prerequisites of Gait

★ Stability in stance

★ Sufficient foot clearance during swing

★ Appropriate pre-positioning of the foot

★ Adequate step length

★ Energy conservation

★ One or more of these elements are typically absent in pathological gait

What Causes an Abnormal Gait?

● Muscle Weakness

● Structural Deformities

● Neurological Disorders

● Idiopathic (unknown)

Common Gait Pathologies That May Require Orthotics

Foot Position: Pronation and Supination

What you may see in the child’s gait...• Delayed ambulation• Wide base of support• Genu valgum or knock kneed with pronation• Impaired Balance- Difficult to stand on one

foot or jump up/forward• Callused feet• Bunions• Child complains of ankle or foot pain• Not able to keep up with peers• Quickly Fatigues

What kind of orthotics might you see?

● Inserts within the Shoe

● Supramalleolar (capture the ankle) Orthotics SMO’s

● Ankle Foot Orthotics (go just below the knee) AFO’s

● Knee Ankle Foot Orthotics (go above the knee) KAFO’s

Five Signs of an Ill Fitting Device

● Consistent and localized redness, usually seen on bony prominences

● Callusing or bruising● Toes are hanging off the end● Height is short● Child is complaining of pain

Orthoses typically need replacement every year

Measure Progress• Assessment, Evaluation, Programming

System (AEPs)• Timed Up and Go (TUG)• Peabody (PDMS-2)• Test of Gross Motor Development-2• Pediatric Balance Scale• Mobility Rubrics (Therapy Source)• School Function Assessment• Battelle Developmental Inventory• Range of Motion/Muscle Strength

Therapy Interventions ● Balance Challenges

○ Double and Single leg work with arm movements○ Stable and Unstable Surface (wobble board, grass, Bosu ball)

● Stretching Program○ Active stretching activities (like lunges, squats, downward dog/yoga

movements)○ No evidence to support passive stretching to make meaningful

difference on high muscle tone or spasticity (bracing, splinting and in certain situations, botox best approach)

○ Standing Frames for prolonged stretching with children that are not or minimally ambulatory

Therapy Interventions• Strengthening Activities

• Play based for best adherence and buy-in to the program

• Theraband, weighted and different sized balls for creativity

• Keep the number to 5-7 specific exercises to increase compliance

• Quadriceps & Hamstring coordination along with hip extension (gluteals)

• Coordinate with whole team! Make it part of the daily routine.

Gross Motor Activities for Home and School

● Obstacle Courses (under, over, around, behind concepts)

● Relay Race (cones, bean bags, soccer ball, locomotor skill)

● Ball Play (hot potato, partner play, bounce pass, underhand)

● Ribbon play (Follow the Leader, copy actions)

● Bubbles, Shape Sorters, Puzzle Activities

Activities Continued

● Movement Songs with Actions

● Action Games (hot potato, Simon Says, Red Light, Green Light)

● Ride on, Scooter & Pedal Toys (stop/go, speed control, place cones)

● Nature Hikes (scavenger hunt)

● Videos: Cosmic Kids Yoga, Fitness Fun, GoNoodle

Helpful Tips for Leading Activities

• Keep the game simple ( simple equipment & let completion be the goal, not speed).

• Model and use visual aids (pictures etc.) to show children what to do. Break down the game into sections that can be put together as children learn.

• Use the same game over many play periods. Children love repetition.

• Be available to redirect/reinforce information (verbal cues, physical assist).

• Everyone CAN TRY! Focus on success and a positive attitude about trying.

• Use only equipment that is developmentally appropriate.

• Check the play area for safety and for any fall hazards, etc.

Recommended Resources

● www.helpmegrowmn.org

● www.mndape.org

● www.inspiredtreehouse.com

● www.healthychildren.org

● www.pathways.org

ReferencesCenters for Disease Control & Prevention. (2016, August 18). Developmental milestones. Retrieved from https://www.cdc.gov/ncbddd/actearly/milestones/index.htmlFolio, M. R. & Fewell, R. R. (2002). Peabody motor development chart. Austin, TX: Pro-Ed.Minnesota Department of Education: (MN PE Standards) https://education.mn.gov/MDE/dse/stds/hpe/www.healthychildren.orgwww.helpmegrowmn.orgwww.pathways.orghttps://www.researchgate.net/publication/301935875_Human_Gait_and_Clinical_Movement_AnalysisPhotos: Google free images