normal pathological gait

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UNDERSTANDING UNDERSTANDING NORMAL & PATHOLOGICAL NORMAL & PATHOLOGICAL GAIT GAIT DR. SANDEEP B. KADLAG (PT) DR. SANDEEP B. KADLAG (PT)

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This ppt can be used for Research Purpose, Study Purpose. Mainly useful for Physiotherapy UG and PG level students. ( from RGUHS Bangalore,India)([email protected])

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Page 1: Normal Pathological Gait

UNDERSTANDING UNDERSTANDING NORMAL & PATHOLOGICALNORMAL & PATHOLOGICAL

GAITGAITDR. SANDEEP B. KADLAG (PT)DR. SANDEEP B. KADLAG (PT)

Page 2: Normal Pathological Gait

Objectives:Objectives:

►Basis for Dx & Rx of pathological gaitBasis for Dx & Rx of pathological gait►Rational prescription of orthotic Rational prescription of orthotic

devicesdevices►Understanding & correction of Understanding & correction of

prosthetic ambulationprosthetic ambulation

Page 3: Normal Pathological Gait

Gait Cycle - Definitions:Gait Cycle - Definitions:

►Normal GaitNormal Gait = = Series of rhythmical , alternating Series of rhythmical , alternating

movements of the trunk & limbs which movements of the trunk & limbs which result in the forward progression of the result in the forward progression of the center of gravitycenter of gravity

series of ‘controlled falls’series of ‘controlled falls’

Page 4: Normal Pathological Gait

Gait Cycle - Definitions:Gait Cycle - Definitions:

► Gait CycleGait Cycle = = Single sequence of functions by Single sequence of functions by one limbone limb Begins when reference font contacts the groundBegins when reference font contacts the ground Ends with subsequent floor contact of the Ends with subsequent floor contact of the same footsame foot

Page 5: Normal Pathological Gait

Gait Cycle - Definitions:Gait Cycle - Definitions:

► Step LengthStep Length = = Distance between corresponding successive Distance between corresponding successive

points of heel contact of the opposite feetpoints of heel contact of the opposite feet Rt step length = Lt step lengthRt step length = Lt step length (in normal gait)(in normal gait)

Page 6: Normal Pathological Gait

Gait Cycle - Definitions:Gait Cycle - Definitions:

► Stride LengthStride Length = = Distance between successive points of heel Distance between successive points of heel

contact of the contact of the same footsame foot Double the step length (in normal gait)Double the step length (in normal gait)

Page 7: Normal Pathological Gait

Gait Cycle - Definitions:Gait Cycle - Definitions:

►Walking BaseWalking Base = = Side-to-side distance between the line of the Side-to-side distance between the line of the

two feettwo feet Also known as ‘stride width’Also known as ‘stride width’

Page 8: Normal Pathological Gait

Gait Cycle - Definitions:Gait Cycle - Definitions:

►CadenceCadence = = Number of steps per unit timeNumber of steps per unit time Normal: 100 – 115 Normal: 100 – 115 steps/minsteps/min Cultural/social variationsCultural/social variations

Page 9: Normal Pathological Gait

Gait Cycle - Definitions:Gait Cycle - Definitions:

► VelocityVelocity = = Distance covered by the body in unit timeDistance covered by the body in unit time Usually measured in Usually measured in m/sm/s Instantaneous velocity varies during the gait cycleInstantaneous velocity varies during the gait cycle Average velocity (m/min) = step length (m) x Average velocity (m/min) = step length (m) x

cadence (steps/min)cadence (steps/min)

► Comfortable Walking Speed (CWS)Comfortable Walking Speed (CWS) = = Least energy consumption per unit distanceLeast energy consumption per unit distance Average= Average= 80 m/min80 m/min (~ 5 km/h , ~ 3 mph) (~ 5 km/h , ~ 3 mph)

Page 10: Normal Pathological Gait

Gait Cycle - Components:Gait Cycle - Components:

► PhasesPhases::(1)(1)Stance PhaseStance Phase: : (2) (2) Swing PhaseSwing Phase: :

reference limb reference limb reference limb reference limb in contact in contact notnot in in contact contact with the floor with the floor with the floor with the floor

Page 11: Normal Pathological Gait

Gait Cycle - Components:Gait Cycle - Components:

► SupportSupport::(1) (1) Single SupportSingle Support: only one foot in contact with : only one foot in contact with

the floorthe floor

(2) (2) Double SupportDouble Support: both feet in contact with floor: both feet in contact with floor

Page 12: Normal Pathological Gait

Gait Cycle - Subdivisions:Gait Cycle - Subdivisions:

A. A. Stance phase:Stance phase:1. 1. Heel contactHeel contact: : ‘Initial contact’‘Initial contact’

2. 2. Foot-flatFoot-flat: : ‘Loading response’, initial contact of forefoot w. ground‘Loading response’, initial contact of forefoot w. ground

3. 3. MidstanceMidstance: : greater trochanter in alignment w. vertical bisector of greater trochanter in alignment w. vertical bisector of footfoot

4. 4. Heel-offHeel-off: : ‘Terminal stance’‘Terminal stance’

5. 5. Toe-offToe-off: : ‘Pre-swing’‘Pre-swing’

Page 13: Normal Pathological Gait

Gait Cycle - Subdivisions:Gait Cycle - Subdivisions:

B. B. Swing phaseSwing phase::1. 1. AccelerationAcceleration: : ‘Initial swing’‘Initial swing’

2. 2. MidswingMidswing: : swinging limb overtakes the limb in swinging limb overtakes the limb in stancestance

3. 3. DecelerationDeceleration: : ‘Terminal swing’‘Terminal swing’

Page 14: Normal Pathological Gait

Gait Cycle

Page 15: Normal Pathological Gait

► Time FrameTime Frame::A. Stance vs. Swing:A. Stance vs. Swing:

►Stance phaseStance phase = = 60% of gait cycle60% of gait cycle►Swing phaseSwing phase = = 40%40%

B. Single vs. Double support:B. Single vs. Double support:►Single support= Single support= 40% of gait cycle40% of gait cycle►Double support=Double support= 20%20%

Page 16: Normal Pathological Gait

►With increasing walking speeds:With increasing walking speeds:►Stance phase:Stance phase: decreasesdecreases►Swing phase:Swing phase: increasesincreases►Double support:Double support: decreasesdecreases

► RunningRunning::►By definition: walking without double supportBy definition: walking without double support►Ratio stance/swing reversesRatio stance/swing reverses►Double support disappears. ‘Double swing’ Double support disappears. ‘Double swing’

developsdevelops

Page 17: Normal Pathological Gait

Path of Center of GravityPath of Center of Gravity

►Center of Gravity (CG):Center of Gravity (CG): midway between the hipsmidway between the hips Few cm in front of S2Few cm in front of S2

►Least energy consumption if CG Least energy consumption if CG travels in straight linetravels in straight line

Page 18: Normal Pathological Gait

CG

Page 19: Normal Pathological Gait
Page 20: Normal Pathological Gait

Path of Center of GravityPath of Center of Gravity

A. A. Vertical displacementVertical displacement::► Rhythmic up & down Rhythmic up & down

movementmovement► Highest point: midstanceHighest point: midstance► Lowest point: double supportLowest point: double support► Average displacement: 5cmAverage displacement: 5cm► Path: extremely smooth Path: extremely smooth

sinusoidal curvesinusoidal curve

Page 21: Normal Pathological Gait

Path of Center of GravityPath of Center of Gravity

B. B. Lateral displacementLateral displacement::► Rhythmic side-to-side Rhythmic side-to-side

movementmovement► Lateral limit: midstanceLateral limit: midstance► Average displacement: 5cmAverage displacement: 5cm► Path: extremely smooth Path: extremely smooth

sinusoidal curvesinusoidal curve

Page 22: Normal Pathological Gait

Path of Center of GravityPath of Center of Gravity

C. C. Overall displacementOverall displacement::► Sum of vertical & Sum of vertical &

horizontal displacementhorizontal displacement► Figure ‘8’ movement of Figure ‘8’ movement of

CG as seen from AP viewCG as seen from AP view

Horizontalplane

Verticalplane

Page 23: Normal Pathological Gait

Determinants of Gait :Determinants of Gait :

►Six optimizations used to minimize Six optimizations used to minimize excursion of CG in vertical & horizontal excursion of CG in vertical & horizontal planesplanes

►Reduce significantly energy Reduce significantly energy consumption of ambulationconsumption of ambulation

►Classic papers: Sanders, Inman (1953)Classic papers: Sanders, Inman (1953)

Page 24: Normal Pathological Gait

Determinants of Gait :Determinants of Gait :

(1) (1) Pelvic rotationPelvic rotation:: Forward rotation of the pelvis in the horizontal plane Forward rotation of the pelvis in the horizontal plane

approx. 8approx. 8oo on the swing-phase side on the swing-phase side Reduces the angle of hip flexion & extensionReduces the angle of hip flexion & extension Enables a slightly longer step-length w/o further lowering Enables a slightly longer step-length w/o further lowering

of CGof CG

Page 25: Normal Pathological Gait

Determinants of Gait :Determinants of Gait :

(2) (2) Pelvic tiltPelvic tilt:: 55oo dip of the swinging side (i.e. hip adduction) dip of the swinging side (i.e. hip adduction) In standing, this dip is a positive Trendelenberg signIn standing, this dip is a positive Trendelenberg sign Reduces the height of the apex of the curve of CGReduces the height of the apex of the curve of CG

Page 26: Normal Pathological Gait

Determinants of Gait :Determinants of Gait :

(3) (3) Knee flexion in stance phaseKnee flexion in stance phase:: Approx. 20Approx. 20oo dip dip Shortens the leg in the middle of stance phaseShortens the leg in the middle of stance phase Reduces the height of the apex of the curve of CGReduces the height of the apex of the curve of CG

Page 27: Normal Pathological Gait

Determinants of Gait :Determinants of Gait :

(4) (4) Ankle mechanismAnkle mechanism:: Lengthens the leg at heel contactLengthens the leg at heel contact Smoothens the curve of CGSmoothens the curve of CG Reduces the lowering of CGReduces the lowering of CG

Page 28: Normal Pathological Gait

Determinants of Gait :Determinants of Gait :

(5) (5) Foot mechanismFoot mechanism:: Lengthens the leg at toe-off as ankle moves from Lengthens the leg at toe-off as ankle moves from

dorsiflexion to plantarflexiondorsiflexion to plantarflexion Smoothens the curve of CGSmoothens the curve of CG Reduces the lowering of CGReduces the lowering of CG

Page 29: Normal Pathological Gait

Determinants of Gait :Determinants of Gait :

(6) (6) Lateral displacement of bodyLateral displacement of body:: The normally narrow width of the walking base The normally narrow width of the walking base

minimizes the lateral displacement of CGminimizes the lateral displacement of CG Reduced muscular energy consumption due to Reduced muscular energy consumption due to

reduced lateral acceleration & decelerationreduced lateral acceleration & deceleration

Page 30: Normal Pathological Gait

Gait Analysis – Forces:Gait Analysis – Forces:

►Forces which have the most significant Forces which have the most significant Influence are due to:Influence are due to:

(1) gravity(1) gravity

(2) muscular contraction(2) muscular contraction

(3) inertia(3) inertia

(4) floor reaction(4) floor reaction

Page 31: Normal Pathological Gait

Gait Analysis – Forces:Gait Analysis – Forces:

► The force that the foot The force that the foot exerts on the floor due to exerts on the floor due to gravity & inertia is opposed gravity & inertia is opposed by the ground reaction by the ground reaction forceforce

► Ground reaction force (RF) Ground reaction force (RF) may be resolved into may be resolved into horizontal (HF) & vertical horizontal (HF) & vertical (VF) components.(VF) components.

► Understanding joint Understanding joint position & RF leads to position & RF leads to understanding of muscle understanding of muscle activity during gaitactivity during gait

Page 32: Normal Pathological Gait

Gait Analysis:Gait Analysis:

► At initial heel-contact: ‘heel transient’At initial heel-contact: ‘heel transient’► At heel-contact:At heel-contact:

Ankle: Ankle: DF DF Knee:Knee: QuadQuad Hip:Hip: Glut. Max&HamstringsGlut. Max&Hamstrings

Page 33: Normal Pathological Gait

GaitGait

Initial HC‘Heel transient’

HC

Foot-Flat Mid-stance

Page 34: Normal Pathological Gait

GaitGait

Initial HC‘Heel transient’

HC

Heel-offToe-off

Page 35: Normal Pathological Gait

GAITGAIT

► Low muscular demand: Low muscular demand: ~ 20-25% max. muscle strength~ 20-25% max. muscle strength MMT of ~ 3MMT of ~ 3++

Page 36: Normal Pathological Gait

COMMON GAIT ABNORMALITIESCOMMON GAIT ABNORMALITIES

A.A. Antalgic GaitAntalgic Gait

B.B. Lateral Trunk bendingLateral Trunk bending

C.C. Functional Leg-Length DiscrepancyFunctional Leg-Length Discrepancy

D.D. Increased Walking BaseIncreased Walking Base

E.E. Inadequate Dorsiflexion ControlInadequate Dorsiflexion Control

F.F. Excessive Knee ExtensionExcessive Knee Extension

Page 37: Normal Pathological Gait

“ “ Don’t walk behind me, I may not lead.Don’t walk behind me, I may not lead.

Don’t walk ahead of me, I may not Don’t walk ahead of me, I may not follow.follow.

Walk next to me and be my friend.”Walk next to me and be my friend.”Albert CamusAlbert Camus

Page 38: Normal Pathological Gait

COMMON GAIT ABNORMALITIES:COMMON GAIT ABNORMALITIES:

A. Antalgic GaitA. Antalgic Gait

►Gait pattern in which stance phase on Gait pattern in which stance phase on affected side is shortenedaffected side is shortened

►Corresponding increase in stance on Corresponding increase in stance on unaffected sideunaffected side

►Common causes: OA, Fx, tendinitis Common causes: OA, Fx, tendinitis

Page 39: Normal Pathological Gait

COMMON GAIT ABNORMALITIES:COMMON GAIT ABNORMALITIES:

B.B. Lateral Trunk bendingLateral Trunk bending

►TrendelenbergTrendelenberg gait gait►Usually unilateralUsually unilateral►Bilateral = waddling gaitBilateral = waddling gait►Common causes:Common causes:

A. Painful hipA. Painful hipB. Hip abductor weaknessB. Hip abductor weaknessC. Leg-length discrepancyC. Leg-length discrepancyD. Abnormal hip jointD. Abnormal hip joint

Page 40: Normal Pathological Gait

Ex. 2: Hip abductor load & hip joint reaction Ex. 2: Hip abductor load & hip joint reaction forceforce

Page 41: Normal Pathological Gait

Ex. 2: Hip abductor load & hip joint reaction Ex. 2: Hip abductor load & hip joint reaction forceforce

Page 42: Normal Pathological Gait

COMMON GAIT ABNORMALITIES:COMMON GAIT ABNORMALITIES:

C.C. Functional Leg-Length Functional Leg-Length DiscrepancyDiscrepancy

►Swing leg: longer than stance legSwing leg: longer than stance leg►4 common compensations:4 common compensations:

A. CircumductionA. Circumduction

B. Hip hikingB. Hip hiking

C. SteppageC. Steppage

D. VaultingD. Vaulting

Page 43: Normal Pathological Gait

COMMON GAIT ABNORMALITIES:COMMON GAIT ABNORMALITIES:

D. D. Increased Walking BaseIncreased Walking Base

►Normal walking base: 5-10 cmNormal walking base: 5-10 cm►Common causes:Common causes:

DeformitiesDeformities►Abducted hipAbducted hip►Valgus kneeValgus knee

InstabilityInstability►Cerebellar ataxiaCerebellar ataxia►Proprioception deficitsProprioception deficits

Page 44: Normal Pathological Gait

COMMON GAIT ABNORMALITIES:COMMON GAIT ABNORMALITIES:

E. E. Inadequate Dorsiflexion Inadequate Dorsiflexion ControlControl

► In stance phase (Heel contact – Foot In stance phase (Heel contact – Foot flat):flat):

Foot slapFoot slap► In swing phase (mid-swing):In swing phase (mid-swing):

Toe dragToe drag►Causes:Causes:

Weak Tibialis Ant.Weak Tibialis Ant. Spastic plantarflexorsSpastic plantarflexors

Page 45: Normal Pathological Gait

COMMON GAIT ABNORMALITIES:COMMON GAIT ABNORMALITIES:

F. F. Excessive knee extensionExcessive knee extension

► Loss of normal knee flexion during stance Loss of normal knee flexion during stance phasephase

► Knee may go into hyperextensionKnee may go into hyperextension► Genu recurvatumGenu recurvatum: hyperextension deformity : hyperextension deformity

of kneeof knee► Common causes:Common causes:

Quadriceps weakness (mid-stance)Quadriceps weakness (mid-stance) Quadriceps spasticity (mid-stance)Quadriceps spasticity (mid-stance) Knee flexor weakness (end-stance)Knee flexor weakness (end-stance)

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