GAIT- Deepak

8/7/2019 GAIT- Deepak

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GaitGaitBasic MechanicsBasic Mechanics

..

Dr.DeepakDr.Deepak Anap Anap

[email protected]@pmtpims.or ims.or


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Why stud y Gait ?Loss of the abili ty to walk can resul t is signi f ican t heal th pr o blems

(co-morbidi ties)

Pain, injur y, paral ysis or tissue damage can al ter n ormal gai t and lead

to:

f ur ther muscul oskele tal pr o blems (c ompensa tions)

Cardi ovascular and pulm onar y pr o blems (inac tivity due to pain)

Psychological pr o blems (depressi on)


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S por ts, Exercise/Fi tness, and Rehabili tation Pr of essi onals mus t have a

sound kn owledge of normal gai t so they can accura tely detect, in terpre t,and ul tima tely correc t deviations and/ or gai t pathologies to res tore

n ormal, pain -f ree f unc tion

It is imp or tant to remember that each pers on displa ys n ormalvaria tions f r om the n ormal pa ttern of walking

ULTIMATE GOA L: K EEP YOUR S ELF AND YOUR

PATIEN TS /CLIEN TS MOVING PAIN -FREE TH ROUG HOU T

YOUR/ TH EIR LIFE S PAN S!!!


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GAIT INITIATIONGAIT INITIATIONDef:- The series or sequence of events that occur

from the initiation of movement to beginning of thegait cycle.

Gai t ini tiation begins in the erec t standing p osturewith an ac tivation of the tibialis an terior and vastus

lateralis ,in c onjunc tion with an inhibi tion of thegas ter ocnemius.

Bila teral c oncen tric c ontrac tions of tibialis an terior (pulling on the tibias) resul ting in a saggi tal torque that

inclines the b ody anteriorly form the ankles.


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K INEMATICSK INEMATICS

Generall y gai t has been described b y using ac tivities of one low er extremi ty (Re f erred to as the reference extremity ) f r om beginningto the end of gai t cycle.

Gai t cycle includes the ac tivities that occur f r om the p oint of ini tial c ontact of one lower ex tremi ty to the p oint at which the

same ex tremi ty contacts the gr ound again.


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S tance phase

Heelstrike

Foot f lat

Midstance

Heel off

Toe off

S wing phase

Accelera tion

Mid s wing

Decelera tion


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NORMAL GAIT CYCLEDuring one gai t cycle each ex tremi ty passes thr ough 2 phases , a single stance

phase&

a single swing phase.Stance phase:Heel s trike to toe off

60% gai t cycleAt normal walking speed,s tance of one leg and s tance of the o pposite leg overlap for about 22% of Gai t cycle.


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SUB-DIVISIONS OF STANCE PHAS

T Traditionally stance phase of gai t is di vided in to following subdi visions ;a) Heel S trike

b) F oot Fla t

c) Mid S tance

d) Heel off

e) Toe O ff .

Acc ording to gai t lab orator y at R ancho Los Amigos ( R LA) MedicalCen ter S tance phase is di vided in to following subdi visions

a) Ini tial c ontact

b) Loading Resp onse

c) Mid S tance

d) Terminal S tance

e) Pre S wing.


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SUBSUB--DIVISIONS OF STANCE PHASE.DIVISIONS OF STANCE PHASE.

Heel F oot Mid tance Heel Toe Accelera tion Mids wing Decelara tioS trike Fla t off off

R LA


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SUB-DIVISIONS OF STANCE PHASE.

1. Heel Strike:-it ref ers to the ins tant at which the heel of the leading ex tremi ty strikes the gr ound .

1. Initial contact :-it ref ers to the ins tant the foot of the leading

extremi ty strikes the gr ound.

Normall y, the heel c ontacts the gr ound f irst (in pa tien ts with pa thological gai t patterns, the en tire

foot or the toes contact the gr ound ini tially)


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2 . Foot Flat :-

occurs immedia tely after heel s trike & is p oint at which the foot f ully contact the gr ound.

2 .Loading response :-Occurs immedia tely following ini tial c ontact & continues un til the c ontra la teral ex tremi ty lifts off

the gr ound a t the end of double supp or t.Loading resp onse c orresp onds to the gai t cycle'sf irst peri od of double limb supp or t & ends withcontrala teral toe off , when the o pposite ex tremi ty leaves the gr ound.

Quadriceps and glu teal muscles ac t during l oadingand thr ough out earl y mids tance to main tain hip andknee s tabili ty

PHASE.SUB-DIVISIONS OF STANCE PHASE.


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SUB-DIVISIONS OF STANCE PHASE.

3. Mid Stance :-Is the p oint at which the b ody weigh t isdirec tly over the supp or ting l ower ex tremi ty

3 .Midstance :-Begins when the c ontrala teral ex tremi ty liftsoff the gr ound & continues to a position inwhich the b ody has pr ogressed over andahead of the supp or ting ex tremi ty.

by mids tance the knee is ex tended & ankle isneu tral again

the triceps surae ac ts to contr ol tibialadvancemen t (pre venting the tendenc y for the tendenc y for the ankle to dorsif lex due to

body wt and iner tia)


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4. Heel off :4. Heel off :- -Is the p oint at which heel of the re f erenceextremi ty leaves the gr ound.

4 .Terminal Stance :4 .Terminal Stance :- -

is the peri od f r om the end of mids tance to a point jus t prior to initial c ontact of thecontrala teral ex tremi ty or following heel off of the re f erence ex tremi ty.

Terminal s tance & mids tance are the only phases when the cen tre of gravity truly liesover the base of supp or t.


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5. Toe off :5. Toe off :- -is the p oint at which only toe of theipsila teral ex tremi ty is in c ontact with thegr ound.

5 .Pre Swing :5 .Pre Swing :- -

Enc ompasses the peri od form jus t following heel off to toe off .Pres wing c orresp onds to the gai t cycle'ssecond peri od of double limb supp or tat Pres wing, knee f lexes 35 degrees & ankle plan tar f lexes 2 0 degreesin these las t phases of stance, the toes,which ha ve been neu tral, d orsif lex a t themetatarso phalangeal j oints;


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SWING PHASESWING PHASESWING PHASESWING PHASE

a S wing phase begins as s oon as the toe of one ex tremi ty leaves the gr ound andcease jus t before heel s trike or contact of the same ex tremi ty.

a When the re f erence ex tremi ty is in the s wing phase,i t does n ot contact thegr ound a t any time.

a S wing phase makes up 4 0% of the gai t cycle.

During s wing, the ankle d orsif lexes b y the c oncen tric c ontrac tion of anterior tibialis muscle; all other muscles are silen t

S ub-talar j oint assumes near neu tral p osition, & toes d orsif lex sligh tly as foot prepares for nex t peri od of stance


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SUBDIVISIONS OF SWING PHASESUBDIVISIONS OF SWING PHASE

1. Acceleration :-Begins once the toe of the re f erence(ipsila teral) ex tremi ty leaves the gr ound & continues un til mids wing or the p oint at which the s winging ex tremi ty is direc tly under the b ody.

1.Initial Swing :-Begins a t the same p oint as accelera tion andcontinues un til max. knee f lexi on of theref erence (ipsila teral ex tremi ty occurs).contrac tion of the quadriceps, ini tiated be foretoe off , ser ves two purp oses

a. i t prevents heel f r om rising too high in a posterior direc tion

b. i t helps to initiate the for ward s wing of theleg


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2 . Midswing:-occurs when the ipsila teral ex tremi ty passesdirec tly benea th the b ody

2 .Mid swing :-Enc ompasses the peri od immedia tely following

max.knee f lexi on and c ontinues Un til the tibia is inver tical p osition.


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3. Deceleration:-occurs a fter mids wing when the tibia passes be yond the

perpendicular & the knee is ex tending in prepara tion of heel s trike.

3. Terminal Swing :-

Includes the peri od f r om the p oint at which the tibia is in ver tical position to a point jus t prior to initial c ontact.


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Common Obser vational Gai t Parame tersCommon Obser vational Gai t Parame tersDISTANCE AND TIME VARIABLES DISTANCE AND TIME VARIABLES

Temporal Variables:-

a. S tance Time

b. S ingle Limb S upp or t Time

c. D ouble Limb supp or t time

d. S wing time

e.S tride and S tep timef . Cadence

g. S peed. D istance Variable:-

a. S tride Leng th

b. S tep Leng th

c. Wid th of Walking base

d. Degree of toe out


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DISTANCE AND TIME VARIABLES DISTANCE AND TIME VARIABLES

Stance Time :

Stance Time :--

- is the am ount of time that elapses during the s tance phaseof one ex tremi ty in gai t cycle.

Single supp or t Time :

Single supp or t Time :---- is the am ount of time that elapses during the peri od when only one

extremi ty is on the supp or ting sur f ace in a gai t cycle.

DoubleS

upp or t Time :DoubleS

upp or t Time :---- is the am ount of time pers on spends with both f eet on the gr oundduring one gai t cycle.

- % of time spen t in d ouble supp or t decreases as the speed of walkingincreases.


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Stride leng th

Stride leng th (( 2 step leng ths)- is the linear dis tance be tween two successi ve events that are

accomplished b y the same l ower ex tremi ty during gai t.

- generall y it is de termined b y measuring the linear dis tance f r om the p oint

of heel s trike of one lower ex tremi ty to the nex t heel s trike of same l ower ex tremi ty.

- Adul t: 1.5 mS tride Dura tion :S tride Dura tion :--- is the the am ount of time taken to accomplish

one s tride.

- One s tride las ts appr oxima tely 1sec.


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Step leng th :

Step leng th :--- is the linear dis tance be tween 2 successi ve pointsof contact of o pposite extremi ties.

- more equal the s tep leng ths , the m ore s ymme tricalthe gai t.

- variabili ty in s tep leng th is a t minimum when the ra tio

of step leng th to step ra te is ab out 0

.006

m/step.Avg. adult = 2.3 feet

S tep Dura tion :S tep Dura tion :--- ref ers to amount of time spen t during a single s tep.- S ec/s tep

- when there is weakness of an ex tremi ty or pain,step dura tion ma y be decreased on the a ff ected side and increased on theuna ff ected side

S tep = The ad vancemen t of a single foot


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Cadence :Cadence :---- no. of steps taken b y pers on per uni t time.- no of steps/ sec or min- Cadence = number of steps / time- S hor ter the s tep leng th ,m ore will be cadence- As one walks with with increased cadence , the

dura tion of double supp or t time decrease.- When cadence of walking appr oaches 18 0 steps /min ,the peri od of double supp or t disappears and running c ommences.

Avg. adul t males cadence = 11 0 steps/min

appr ox. 2 s teps/sec

Females : 116 steps/min


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Walking velocity :Walking velocity :--

-- is the ra te of linear for ward m otion of the b ody- cadence mul tiplied b y step leng th- cm/s,m/s,miles/sec.

Walking Vel ocity = Dis tance Walked / timeAvg. adult cadence = 2 60 f eet/min; 1.4 m/sec

Increase in velocity up to 120 steps per minu te are br ough t about by bothincrease in cadence and s tride leng th bu t above 12 0 steps /min onlycadence increases.

Accelera tion :Accelera tion :-- - is the ra te of change of velocity with respec t to time.

S peed :S peed :-- Cm/minF ree Speed: pers ons Normal Walking speed

Slow Speed: S lower than the pers ons normal c omfor table walking speed.

F ast Speed: Faster than the pers ons normal c omfor table walking speed.

Speed = step length x step rate


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Wid th of the BO S :Wid th of the BO S :--

- is found b y measuring the linear dis tance be tween the midp oint of the heel of

one foot & same p oint on other foot

- Mean width of the BO S = 3.5 inches. ( Range 1 to 5 Inches)

Degree of Toe Ou t :Degree of Toe Ou t :--- Angle formed b y each foot s line of pr ogressi on& line in tersec ting the cen ter of heel & second toe

Normal : 0 -15 (7 at f ree speed walking)- the degree of toe out decreases as the speed of

walking increases in n ormal man.


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DETERMINANTS OF GAIT DETERMINANTS OF GAIT

- Determinan ts are supp osed to represen t adjus tmen t made b y pelvis, hip, knee

and ankles that help to keep m ovemen t of bodys COG to minimum.

- they decrease the ver tical & lateral excursi on of the b odys COG & there fore

decrease the energ y expendi ture & makes gai t more e ff icien t.

- 6 determinan ts are

1. Lat. Pel vic tilt in f r ontal plane

2. K nee f lexi on during s tance

3. K nee in terac tions

4. Ankle in terac tions5. Pel vic r ot. In trans verse Plane6 . Ph ysiologic Valgus of the K nee.


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L AT. PE LV IC TI LT IN FRONTA L PL ANEL AT. PE LV IC TI LT IN FRONTA L PL ANE

- Lat. Tilting of pel vis on the on the side of swing leg

- 5o dip of the swinging side (i.e. hip adduc tion)

- It keeps the peak of COG l ower than i f the pel vis did n ot dr o p.

- Tilting of pel vis is c ontr olled b y hip abduc tor muscles of the s tance

extremi ty.


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K NEE F LEXION DURING STANCEK NEE F LEXION DURING STANCE

- S hor tens the leg during Mids tance

- It is an other adjus tmen t that helps tokeep the COG f r om rising as much as i two uld ha ve to if the b ody had to passover a c omple tely extended knee.


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K NEE , FOOT & AN K LE INTERACTIONSK NEE , FOOT & AN K LE INTERACTIONS

Ankle mechanism :Leng thens the leg a t heelcontactReduces the l owering of CG

F oot mechanism :Leng thens the leg a t toe-off asankle m oves f r om d orsi f lexi onto plan tar f lexi onS moothens the cur ve of CGReduces the lowering of CG


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PELV IC ROTATION IN TRANS V ERSE P L ANEPELV IC ROTATION IN TRANS V ERSE P L ANE

- For ward r otation occurs on the side of the s wingingextremi ty with the hip j oint of the weigh t bearingextremi ty ser ving as the axis for the pel vic r otation.

- the s winging l ower ex tremi ty is leng thened in terminalswing b y the for wardl y r otating pel vis & the weigh t

bearing ex tremi ty is leng thened in the Pres wing b y the posterior position of the pel vis.

- There fore the s tance and the s wing ex tremi ties areleng thened as the COG descends to its lowest level in the

peri od of double supp or t.

- The rela tive leng thening helps to prevent an excessi vedr o p of the COG & main tains the COG a t higher le velthan would be p ossible i f no pelvic r otation occurred.

Pelvic R otation - minimizes the depressi on of the COG

Lateral Pel vic Tilt

K nee Flexi on minimizes the ele vation of COG


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PHYSIO LOGIC V A LGUS OF THE K NEE.PHYSIO LOGIC V A LGUS OF THE K NEE.

- Physiological Valgus a t the knee reduces the width of theBO S .

- Because the BO S is rela tively narr ow ,little la teral m otion

of pelvis is necessar y to shi ft the COG f r om one lower extremi ty to another over the BO S .


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KINE T IC S O F GA I T


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Ground R eaction F orceGround R eaction F orce

Ne wto ns third la w states that ever y action mus t have an equal ando pposite reac tion, there fore thedownward force passing thr ough thefoot when i t bears weigh t mus t bematched b y an equal and o ppositeupward force.This force ma y pass in f r ont or behindthe hip and knee and s o act as ei ther af lex or or ex tens or force, the directionof its action in relation to the joints

being dependent on the joint positionsand normally varies through the gait cycle . If the j oint positions or thecadence of the gai t are al tered f r omnormal then the e ff ect of this force

may be changed.


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K inetics: C enter Of Pressure ( C OP)

Represen ts the cen tr oid of foot forces on the f loor This is an idealiza tion,

because pressures aredis tribu ted all over

It is imp or tant, because wewant to know where theGRF is applied to the

body

When measured b y a force pla te, i t is m ore c orrec tly called the p oint of applica tion of the GRF


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Plotting the C OP as itmoves under thefoot: Normal Pa th: Cen ter

of the calcaneus or sligh tly lateral, cur ving la terall y and then medial(pr onation) and ending

be tween the 1s t andsec ond toes

Variable : Normalindi viduals can ha ve man y COP trajec tories, jus t by changing their gai t style.


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SAGG I TAL PLA NE AN ALYS I SSAGG I TAL PLA NE AN ALYS I SHeel S trike ( Ini tial c ontact) to Foot f lat ( End of loading resp onse)

Joint Motion G R F Movt. Muscles C ontraction

Hip F lex: 3 0 25 Anterior Flexi on Glu t. Max. ,Hams trings,Adduc tor Magnus

Isometric to eccen tric

K nee F lex: 0 15 Ant. To Post.

Ext. to f lex.

Quadriceps C oncen tric to eccen tric

Ankle P F : 0 - 15 Post PF Tibialis An t. ,ED L, EHL.

Eccen tric to lower foot to supp or tingsur f ace & to

contr ol ankle PF.


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SAGG I TAL PLA NE AN ALYS I SSAGG I TAL PLA NE AN ALYS I SFoot Flat ( End of Loading resp onse) to Mids tance ( End Mids tance)


Hip Ext: 25 - 0 Anterior to Posterior

Flexi on to extensi on

Glu t. Maximus C oncen tric to no activity

nee Ext : 5 5 Post. To Ant.

Flexi onto extensi on

uadriceps C oncen tric to no activity

Ankle PF : 5 of PF to 5 0 of DF Post. To Anterior.PF to DF. S oleus,

Gas ter ocnemius,PF.

Eccen tric


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SAGG I TAL PLA NE AN ALYS I SSAGG I TAL PLA NE AN ALYS I SMids tance ( Middle of Mids tance) to Heel off ( Pri or to End of terminal s tance)


Hip E xt: 0 of F lex.To 1 0 20 of

hyperextension

Posterior extensi on Hip Flex ors Eccen tric

K nee E xt : 5 of flexion to 0

Post. To Ant.

Flexi onto

extensi on

No activity

Ankle PF : 5 D F to 0 Anterior. DF. S oleus, PF. Eccen tric to concen tric

Toes

( MTP)

E xt. : 0 30 of hyperextension

Flex. Hallicus

longus&

bre vis,Abduc tor hallicus,in ter ossi,lumbricles.


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SAGG I TAL PLA NE AN ALYS I SSAGG I TAL PLA NE AN ALYS I SHeel off ( End of terminal s tance) to Toe off ( End of Pres wing)


Hip F lex: 2 0 of hyperextension

to 0

Posterior Extensi on to

neu tralIlio psoas,Add.Magn

us,Add. l ongus

Concen tric

K nee F lex.: 0 30 flexion

Post. Flexi on Quadriceps Eccen tric to No activity

Ankle PF : 0 20 PF Anterior. DF. S oleus,Gas ter ocnemius,Per oneus

bre vis,Per oneuslongus.

Concen tric n o activity

Toes( MTP)

E xt. : 5 0 60 of hyperextension

Abd. Hallicus & Flex or hallicus

bre vis,in ter ossi,lumbricles.

Closed chainresp onse to increasing PF a t the ankle.


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SAGG I TAL PLA NE AN ALYS I SSAGG I TAL PLA NE AN ALYS I SAccelera tion ( Ini tial S wing thr ough mids wing)

Joint Motion Muscles C ontraction

Hip F lex: 0 20 of flex. To 3 0 of flex.

Ilio psoas,Gracialis,S ar torius

Concen tric

K nee F lex: 3 0 of flexion to 60

of flex.

Biceps Fem oris,S ar torius

Concen tric

Ankle D F : 2 0 of P F to neutral

Tibialis An t. , ED L,EHL.

Concen tric


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SAGG I TAL PLA NE AN ALYS I SSAGG I TAL PLA NE AN ALYS I SMids wing thr ough decelera tion ( Terminal S wing)

Joint Motion Muscles C ontractionHip 30 of flex Glu t. Max. Eccen tric

K nee E xt :3 0 of flex. To 0

Quadriceps, Hams tring C oncen tric to Eccen tric

Ankle neutral Tibialis An t. , ED L,EHL.

Isometric


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R AN G E O F MOT I O NR AN G E O F MOT I O N

J OIN TS INTIAL CON TACT

END OFLOADINGRE S PON S E

END OF MIDS TANCE

END OF TER.S TANCE

END OFPRE S WING

HIP 30* of Flexi on 25 * of Flexi on 0* 10 20 * of Hy perex tensi on

0*

K NEE 0* 15* of Flexi on 5* of Flexi on 0* 35 4 0 * of Flexi on

ANKLE 0* ( Neu tral) 15 * PF 5 1 0* DF 0* DF 2 0* PF

MTP J OIN TS 0* 0* 0* 30* of Hy per ex tensi on

50 60 * of Hy perex tensi on

STA NCE PHAS E

END OF IN TIAL S WING END OF MID S WING END OF TERMINA L S WING

HIP 20* of Flexi on 30* of Flexi on 30* of f lexi on

K NEE 60* of Flexi on 30* of f lexi on 0*

ANKLE 10* of Plan tar f lexi on 0* 0*

SW IN G PHAS E


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R AN G E O F MOT I O NR AN G E O F MOT I O N

Stance Phase Swing Phase

Hip 0 -30* of Flexi on0

10

or 20

*

of Hy p. Ex tn.

20 30* of Flexi on

K nee 0 40 * of Flexi on 0 60* of f lexi on

Ankle 0 10 * of DF0 20* of PF

0 10 * of PF

TOTAL R AN G E O F MOT I O N


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Causes of Limp (abn ormal gai t) in

Childh oodS hor t LegPain (an talgic limp)

Ins tabili ty of jointsS tiff ness of jointsMuscle weakness

Muscle inc oo rdina tionPr o pri ocep tive dis turbancesHy steria


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GAIT- Deepak