GAIT TRAINING

Definitions of normal gait:"A method of locomotion involving the use of the

two legs, alternately, to provide both support and propulsion. In order to exclude running, we must add 'at least one foot being in contact with the floor at all times'

In order that a person can walk, the locomotion system must be able to accomplish four things:

1-Each leg must be able to support the body weight without collapsing.

2-Balance must be maintained statically and dynamically during single leg stance.

3-The swinging leg must be able to advance to a position where it can take over the supporting role.

4-Sufficient power must be provided to make the necessary limb movements and to advance the trunk.

In normal walking each of these requirements achieved without any difficulty.

However, in many pathological conditions these requirements can be achieved by means of abnormal gait or by the use of walking aids such as walker, crutches, cane or orthotic devices. Failure to achieve all four requirements means that the subject is unable to walk.

The pattern of gait is the outcome of a complex interaction between the many neuromuscular and structural elements of the locomotion system. Abnormal gait may result from a disorder in any part of this system. It may also result from the presence of pain.

CUASES OF GAIT ABNORMALITYA-The movement being forced by weakness,

spasticity or deformity.B-The movement is a compensation, which the

subject is using to correct for some other problem.

SPECIFIC GAIT ABNORMALITY1- Lateral trunk bending: bending of the trunk

toward the supporting limb during the stance phase {Trendelenburg gait}. During the double support phase the trunk is usually upright but as soon as the swing leg leaves the ground, the trunk leans across towards the side of the stance phase leg, returning to the upright attitude again at the beginning of the next double support phase.

In case of bilateral hip problem, the trunk swaying from side to side, to produce a gait pattern called waddling.

Standing on one-leg leads to increase the load on the stance hip because of three components:

1-The whole of the weight of the trunk is now supported by the stance hip joint, instead of being shared between the two hips.

2-The stance hip now takes the weight of the swing leg, instead of by the ground.

3-The gluteus medius of the stance leg contract to keep the pelvis from dipping on the unsupported side, the reaction force of this contraction passes through the stance hip joint.

Causes of trendelenburg gaitPainful hip (osteoarthritis, rheumatoid arthritis)Hip abductor weaknessAbnormal hip joint {congenital dislocation of the

hip, coxa vara and Slipped femoral epiphysis Wide walking baseUnequal leg length

2-Anterior trunk bending: the subject fiexes his trunk forward at the time of heel contact. The purpose of this gait pattern is to compensate for an inadequacy of the knee extensors .

3-Posterior trunk bending: around the hell contact the subject moves the whole trunk backward in the sagittal plane. The purpose of this gait pattern is tocompensate for ineffective hip extensor early in the stance phase.

A different type of posterior trunk bending may occur early in the swing phase, where the subject may throw the trunk backward in order to propel the swinging leg forward. This is most often to compensate for weakness of the hip flexors or spasticity of the hip extensors. Posterior trunk bending may also occur when the hip is ankylosed.

4-Increased lumbar lordosis: The most common cause of increased lumbar Lordosis is a flexion contracture of the hip. This deformity cause the stride length to be very short by preventing the femur from moving backward from its flexed position

5-Functional leg length discrepancy: means that the legs are not necessarily different lengths when measured on the examination table, but that one or both are unable to adjust to the appropriate length for a particular phase of the gait cycle. Four gait abnormalities {circumduction, hip hiking, steppage and vaulting} are closely related, in that they are designed to overcome the same problem. This gait abnormality is frequently the result of a neurological problem

• Circumduction: by which the ground contact by the swinging leg can be avoided if it is swing outward.

• Hip hiking: the pelvis is lifted on the side of the swinging leg by contraction of the spinal muscles and the lateral abdominal wall

• Steppage: it consisting of exaggerated knee and hip flexion to lift the foot higher than usual for increased ground clearance. It is usually used to compensate for foot drop.

• Vaulting the ground clearance for the swinging leg will be increased if the subject goes up on the toes of the stance phase leg .

6-Abnormal hip rotation: the gait pattern may involve both stance and swing phase, and it may result from

A problem with the muscles producing hip rotation

A fault in the way the foot makes contact with the ground

As a compensatory movement to overcome some other problem as foot inversion or eversion, quadriceps weakness and/or hip flexor weakness.

7-Excessive knee extension: the normal stance phase flexion of the knee is lost, to be replaced by full extension or even hyperextension, in which the knee is angulated backwards. The cause of this gait pattern is quadriceps weakness

8-Excessive knee flexion: the knee is normally fully extended twice during the gait cycle, one or both of these movements into extension fails to occur. This gait pattern can be caused by

A flexion contracture of the knee flexorsSpasticity of knee flexorsFunctional leg length discrepancyStiffness of the ankle joint

9-Inadequate dorsiflexion control: It gives rise to two distinct gait abnormalities

• Between heel contact and foot flat, the dorsiflexors resist the external planterflexion moment, thus permitting the foot to be lowered gently. If they are weak, the foot is lowered abruptly in a foot slap.

• Failure to raise the foot sufficiently during early swing phase may cause toe drag. If it is bilateral subject may avoid toe drag by high steppage gait

10-Abnormal foot contact: the foot may be abnormally loaded in that the weightis primarily borne on only one of its four quadrants.

• Talipes calcaneus {pes calcaneus}: loading of the heel occur in this deformity.

• Talipes equinus {pes equinus}: in this deformity the forefoot is fixed in plantarflexion, usually through spasticity of the plantarflexors. In mild cases the foot may placed flat on the floor. But more commonly the foot' never touch the floor (Primary toe strike gait) ,talipas equinuverus .

• Excessive medial contact: occur in weakness of invertors or spasticity of evertors.

• Excessive lateral contact: occur in Talipes equinuvarus in which the medial border of the foot is elevated or the lateral border depressed by spasticity or by weakness.

• Stamping gait: occur in loss of the sensation in the foot.

11-Insufficient pushes off: the weight is taken primarily on the heel, and there is no push off phase, the whole foot being lifted off the ground at once. The main cause of this pattern is a problem with the triceps surae, Achilles tendon or intrinsic muscles of the foot. It may also result from any foot deformity or pain under the forefoot.

12-Abnormal walking base: either increase or decrease in the walking base beyond the normal range.

• An increased walking base may be due to deformity (abducted hip, valgus knee), instability or fear of falling

• A decreased walking base may result from adduction hip or varus knee deformities.

GAIT ANALYSIS

1-Visual gait analysisThe subject needs to walk minimum of 8 m

with different speed for the visual gait analysis. It is the most simplest gait analysis, but it suffers from four serious limitations.

• It is transitory, gives no permanent record• The eye cannot observe high-speed events• It is only possible to observe movements, not

forces• It depends entirely on the skill of the individual

observer.

Common gait abnormalities and best viewpoint for observationSide view: From the side view you can see the following abnormalities,lateral trunk bending, anterior trunk bending, posterior trunk bending, increased lumbar lordosis, steppage, excessive knee flexion, excessive knee extension, inadequate dorsiflexion control, insufficient push off, rhythmic disturbances and vaulting.Front and behind view: From the Front and behind views you can seethe following abnormalities, circumduction, hip hiking, vaulting, abnormal hip rotation, abnormal foot contact and abnormal walking base.

2-Videotape examination: It helps to overcome two of the limitation of visual gait analysis- the lack of a permanent record and the difficulty of observing high speed events. In addition, it confers the following advantage:

• It reduce the number of walk the subject needs to do

• It makes it possible to show subjects exactly how they are walking

• It makes it easier to teach visual gait analysis to someone else

General gait parametersCadence

Cadence may be measured with the aid of a stopwatch, by counting the number of individual steps taken during a known period of time. It is seldom practical to count for a full minute, so a period of 10 or 15 seconds is usually chosen.

Stride lengthStride length can be determined in two-ways-

by direct measurement, or indirectly from the velocity and cadence. The simplest direct method of measurement is to count the stride taken while the subject covers a known distance. A more useful method is where the subject steps with both feet in a shallow tray of talcum powder, and then walks across a polished floor, leaving a trial of foot prints.

. As an alternative to using talcum powder, felt adhesive pads, soaked in different colored dyes my be fixed to the feet. The subject walks along a stripe of paper and leaves a pattern of dots which gives accurate indication of the location of both feet.

These may be measured, to derive left and right step lengths, stride length, walking base, toe-out angle, and some idea of foot contact pattern. This investigation is able to provide a grate deal of useful information for the sake of a few minutes of mopping up the floor after ward

VelocityThe velocity my be measured by the subject

while he or she walks a known distance, for example between two marks on the floor, or between two pillars in a corridor. The distance walked is a mater of convenience, but somewhere in the region of 6x10 m is probably adequate. Again the subject should be to walk at their natural speed, and they should be allowed to get into their stride before the measurement starts.

3-Footswitches:Footswitches are used to record the timing of gait.4-Instrumented walkway5-Electrogoniometer6-Electromyography

WALKING AIDS

Walking aids can modify the gait pattern considerably. While some people using the walking aids to reduce the pain in a painful joint, some others are totally unable to walk without some form of aid. It is very important to put in our consideration under water gait training and gait training in the parallel bars.

1-Canes: by means of which force can be transmitted to the ground through the wrist and hand. Canes can be used for three purposes

A-To improve stability, this is achieved by increasing the size of the area of support. If more stability is required two canes my be used.

B-To generate a moment, if the cane used on the opposed side of the affected leg, a vertical force is applied through the cane, which generate a counterclokwise moment applied to the shoulder girdle and hence to the pelvis. This reduces the size of the moment, which the hip abductor muscles generated to keep the pelvis level.

C-To take part of the load away from the legs, If the cane used in the same side of the affected leg, and placed closed to the foot. In this way, load-sharing can be achieved between the leg and the cane.

Types of canes:1.Straight cane2.Tripod cane 3.Tetrapod cane 4.(L) shaped handle 5.(U) shaped handle6.Angular shaped handle Adjustable in high

2-Crutches:The main different between cane and crutches is

that a crutch is able to transmit significant forces in the horizontal plane.

Types of crutch:• Axillary crutches: they fit under the axilia, it can be

used with some modification or addition like a platform which help to transfer the point of pressure.

• Forearm crutches (elbow crutches)

4-Walking frames and rollators (walkers):The most stable walking aid, which enable

the subject to walk within the area of support provided by its base.

Types of walkers:• Regular walker• Rolling walker

GAIT PATTERN WITH WALKING AIDS1-Gait with a single aid: if only a single cane or

crutch is used. The aids moved forwards together with the worse of the two legs during the stance phase of the better one.

2-Three-point swing-through gait: it is used when it is impossible to support the body weight on one leg. Three-point gait involves support of the body weight by the two crutches while the leg or legs are moving forwards, and by the legs while the crutches are moved.

3-Three-point swing-to gait: this gait pattern is similar to three-point swing-through gait, except that feet are advanced by a much shorter distance, being placed on the ground behind the level of the crutches.

4-Four-point gait: It is only appropriate when both legs are able to support partof the body weight. Subject who have only minor stability problems my use two canes, each of which is moved forwards during the swing phase of the opposite leg, during which time the body has only two points of contact with the ground.

Planing of gait training1-Safety measures:A-Gait belt B- Dry surface C-Slippers or

shoesD-Therapist to be on the affected side in cane walking and

behind thesubject with walker training.

E-Turning around always towards the good leg2-Point to start with: It depends on the level of static and

dynamic balance,according to the therapist's evaluation, gait training starts from the easier to the hardest way of walking as the following graduation

A-Under water gait training b- Walking in the parallel bars

C-Walker d- CrutchesE-Cane f- Independent

3-Weight bearing status• None weight bearing (NWB)• Toe touch weight bearing (TTWB, TDWB)• Partial weight bearing (percentage of the body

weight) (PWB) we need to use weight scale• Weight bearing as tolerated (WBAT)• Full weight bearing (FWB)

4-Mental status: level of awareness or orientation of

the subject to understand the instruction5-Preparing of the treatment area• Usage of the mirror in the treatment area• Draw a line on the floor as a guidance in case of

dynamic balance or coordination ex• Decide the distance of walking according to the

patient's tolerance• The surface of the training area (level or ramp)

Amputee gait

The mechanical coupling between the stump and the prosthetic limb cannot be as good as in the normal, for these reasons:

1.The lever arm between the hip joint and the socket is relatively small.

2.Relative motion between the stump and the socket.

3.Uncomfortable socket makes the patient reluctant to apply large forces to the prosthetic limb.

Walking up and down stairs training:Go up stairs with good leg first and down stairs

with the affected leg first.Patients using canes, go up stairs with good leg

first followed by cane then the affected leg and vise-versa going down stairs.

Patients with crutches go up stairs with the legs first followed by the crutches, or crutches first followed by good leg then the affected leg; and vise-versa going down stairs.