GAIT ANALYSIS Department of Rehabilitation Medicine,Faculty of Medicine, Chulalongkorn University,Bangkok,Thailand 1
Scope in 60 mins Gait cycle: Terminology Motion analysis machines Gait determinants Gait control structures Abnormal gait Cases studies 2
One gait cycle 3
Spatial-Temporal Parameters 4 Step length 78 cm. Stride length 156 cm. Cadence 120 steps per min or 60 strides per min Stride width 5-11 cm. Foot angle 6-7 degree.
Gait in the young The walking base is wider. The stride length and speed are lower and the cycle time is shorter (higher cadence). 5 Small children have no heel strike, initial contact being made by the flat foot. There is very little stance phase knee flexion. The whole leg is externally rotated during the swing phase. There is an absence of reciprocal arm swinging. Mature gait is at 7 yrs old.
Gait velocity Cadence Gait in the elderly Stride length ('marche à petit pas') Swing phase, double-support phase Posture stooped Walking base Vertical joint movement Lateral joint movement 6
DILEMMA 7 Gait changes product of normal aging? Gait changes product of (age-related) disorders? Consequence: what is 'normal' gait in the elderly? Practical approach: describe suspect findings identify additional findings establish specific diagnosis or contribute findings to ageing
Normal data of elderly 8
Movements in Sagittal Plane 9 Pelvis anterior and posterior tilting Knee flexion and extension Ankle dorsiflexion and plantar flexion
Movements in Coronal Plane 10 Pelvis obliquity up or down Hip abduction and adduction Foot varus and valgus
Movements in Transverse Plane 11 Pelvis protraction and retraction Hip internal and external rotation Knee internal and external rotation Foot: In Toeing and Out Toeing
Clinical Gait Analysis History taking/physical examination/special tests Videotape examination: slow motion and freezing - frame Measurement of general gait parameters: cadence (steps/min), stride length (m), speed (m/s) Kinematic analysis Kinetic measurement Electromyography 12
Video Observation 13 Low cost/easier Advantages Permanent record for subsequent analysis. Slow motion, freeze frame facilities and time coding can all enhance greatly the accuracy of observation Disadvantages Difficult to assess rotational movement No kinematic data: joint angle No information on forces/muscle firing
Gait and Motion Analysis Machines 1. High speed camera and computer 14 Arrange the cameras to cover the entire measurement volume Cameras must be mounted firmly on tripods or other stable structures Isolate camera from movements or vibrations of any sort. 2. Marker, 2.5mm 40mm 3. Visual 3D software Oqus (1-10000Hz)
Gait and Motion Analysis Machines 2. Force plate 15 3. Pressure plate
Visual 3D Analysis 16 Speed, stride and cycle time Step length and step time Stance phase and swing phase Center of pressure and ground force Joint angles/force/moment/ power/velocity Segment center of gravity position Segment distal/proximal joint position
Kinematic analysis 17
Wireless EMG 18 EMG allows to directly look into the muscle. It allows measurement of muscular performance. Helps in decision making both before and after treatment. Helps patients to find and train their muscles. Allows analysis to improve sports activities. Detect muscle response in ergonomic activities.
Electromyography 19
Kinetic measurement 20
Attributes of Normal Walking Stability in stance Foot clearance in swing Pre-positioning of foot for initial contact Adequate step length Energy conservation 21
Gait Determinants-Energy conservation 1. Pelvic rotation Four degree each in the horizontal plane Forward leg movement with less lower CG Maximal rotation during double supportthe lowest point of CG in gait cycle 22
Gait Determinants 2. Pelvic tilt Pelvis downward during swing phase. Gluteus medius of stance limb contracts to hold pelvis in swing limb not drop too much. Vertical movement 5 degree. 23
Gait Determinants 24 3. Early knee flexion Knee flexion 15 degree during stance phase 4,5 Knee and ankle motion Weight transfer from heel to toe in sinusoidal motion 6. Motion of CG in the horizontal plane Motion of CG 2 inches from stance phase in one limb to another limb
Ankle and foot during push off 25 Ankle rockers
Gait Determinants 26 Sinusoidal movement in vertical and horizontal plane 2 inches each Highest at midstance Lowest at double support Most lateral at midstance Energy conservation
basal ganglia coordination of movement elements cerebellum sequencing of movement elements alpha-mn activation gamma-mn activation GAIT CONTROL STRUCTURES contraction motor cortex spine and joints frontal lobe 27 parietal lobe visuo-acousticospatial integrat. brainstem brainstem orthostatic reflexes spinal cord PNS muscles spinal reflexes spinal cord PNS muscles spine and joints muscle spindel afferences force joint position visual system vestibular system acoustic system movement
GAIT CONTROL STRUCTURES frontal lobe basal ganglia motor cortex parietal lobe 28 visual system cerebellum brainstem brainstem vestibular system spinal cord spinal cord acoustic system PNS PNS muscles muscles spine and joints spine and joints
JOINTS 29 Osteoarthrisis Spinal degeneration Spondylitis HLA B27 Stiff gait
GAIT CONTROL STRUCTURES frontal lobe basal ganglia motor cortex parietal lobe 30 visual system cerebellum brainstem brainstem vestibular system spinal cord spinal cord acoustic system PNS PNS muscles muscles spine and joints spine and joints
MUSCLE 31 Polymyositis/dermatom. Polymyalgia rheumatica Myopathy Ischemia Amyotrophic lateral sclerosis CK, skin changes, paraneoplastic pain, CK normal CK, EMG peripheral arterial occlusive disease gait disorder not usually presenting feature Paretic gait
GAIT CONTROL STRUCTURES frontal lobe basal ganglia motor cortex parietal lobe 32 visual system cerebellum brainstem brainstem vestibular system spinal cord spinal cord acoustic system PNS PNS muscles muscles spine and joints spine and joints
NERVE Polyneuropathy diabetis mellitus, alcoholism, neoplasms, dysproteinemia CIDP: conduction blocks Mononeuropathy diabetis mellitus Plexopathy neoplasms Polyradiculitis Guillain-Barré syndrome: CSF protein, GM antibodies Cauda syndrome spinal stenosis: MR imaging Post-polio syndrome history 33 Paretic gait
GAIT CONTROL STRUCTURES frontal lobe basal ganglia motor cortex parietal lobe 34 visual system cerebellum brainstem brainstem vestibular system spinal cord spinal cord acoustic system PNS PNS muscles muscles spine and joints spine and joints
Myelopathy Syrinx Tumors SPINAL CORD 35 Her. spastic paraparesis cervical myelopathy pathological fractures: osteoporosis metastasis multiple sclerosis intramedullary extramedullary meningeoma Spastic gait Ataxic gait
GAIT CONTROL STRUCTURES frontal lobe basal ganglia motor cortex parietal lobe 36 visual system cerebellum brainstem brainstem vestibular system spinal cord spinal cord acoustic system PNS PNS muscles muscles spine and joints spine and joints
BRAIN STEM 37 Progressive supranuclear palsy Infarction Vertebrobasilar insufficiency downward gaze bradykinesia dementia Toppling gait falls without prevention severe dysequilibrium
GAIT CONTROL STRUCTURES frontal lobe basal ganglia motor cortex parietal lobe 38 visual system cerebellum brainstem brainstem vestibular system spinal cord spinal cord acoustic system PNS PNS muscles muscles spine and joints spine and joints
CERBELLUM 39 Toxic cerebellopathy Drug-induced cp. Paraneoplastic cp. Radiation-induced cp. Infarction alcohol phenytoin Ataxic gait
basal ganglia GAIT CONTROL STRUCTURES frontal lobe 40 motor cortex parietal lobe visual system cerebellum brainstem brainstem vestibular system spinal cord spinal cord acoustic system PNS PNS muscles muscles spine and joints spine and joints
MOTOR CORTEX 41 Infarction/haemorrage Tumors Falx meningeoma hemiparesis hemiparesis paraparesis stiff gait
basal ganglia GAIT CONTROL STRUCTURES frontal lobe 42 motor cortex parietal lobe visual system cerebellum brainstem brainstem vestibular system spinal cord spinal cord acoustic system PNS PNS muscles muscles spine and joints spine and joints
BASAL GANGLIA 1 43 Parkinsonian syndromes idiopathic Parkinson's disease (IPD) multiple system atrophy (MSA) Freezing gait with festination
BASAL GANGLIA 2 44 Dystonia idiopathic d. tardive d. Stiff gait
BASAL GANGLIA 3 45 Chorea dementia Ataxic gait coordination, dysmetria, wide-based, irregular movements
basal ganglia GAIT CONTROL STRUCTURES frontal lobe 46 motor cortex parietal lobe visual system cerebellum brainstem brainstem vestibular system spinal cord spinal cord acoustic system PNS PNS muscles muscles spine and joints spine and joints
FRONTAL LOBE 47 Tumors Normal pressure hydrocephalus (NPH) gait initiation apathy disinhibition reasoning Hakim trias: gait disorder dementia urine incontinence Freezing gait without festination
GAIT CONTROL STRUCTURES frontal lobe basal ganglia motor cortex parietal lobe 48 visual system cerebellum brainstem brainstem vestibular system spinal cord spinal cord acoustic system PNS PNS muscles muscles spine and joints spine and joints
PARIETAL LOBE 49 Infarction/haemorrhagia Tumors Chronic subdural haematoma Veering gait gait deviation in one direction Cautious gait slow, short-stepped, shuffling normal: base, freezing, gait initiation
basal ganglia GAIT CONTROL STRUCTURES frontal lobe 50 motor cortex parietal lobe visual system cerebellum brainstem brainstem vestibular system spinal cord spinal cord acoustic system PNS PNS muscles muscles spine and joints spine and joints
VISUAL SYSTEM 51 visual acuity visual field age-related acuity accomodation contrast sensitivity glare sensitivity dark adaptation depth perception retinal degeneration cataract hemianopia Cautious gait
basal ganglia GAIT CONTROL STRUCTURES frontal lobe 52 motor cortex parietal lobe visual system cerebellum brainstem brainstem vestibular system spinal cord spinal cord acoustic system PNS PNS muscles muscles spine and joints spine and joints
VESTIBULAR SYSTEM 53 Acoustic neurinoma tinnitus deafness gait disorder Veering gait gait deviation in one direction
basal ganglia GAIT CONTROL STRUCTURES frontal lobe 54 motor cortex parietal lobe visual system cerebellum brainstem brainstem vestibular system spinal cord spinal cord acoustic system PNS PNS muscles muscles spine and joints spine and joints
ACOUSTIC SYSTEM 55 Presbyacusis Cautious gait
FREEZING GAIT 56 Findings Mechanism gait initiation turning blockades at narrowings normal: base access to brainstem locomotor centres FG with festination/hastening Impairment basal ganglia FG without festination/hastening Impairment frontal lobe parietal lobe vermis atrophy (gait ignition failure)
Parkinson 57
HIERARCHY OF GAIT CONTROL STRUCTURES frontal lobe gait initiation 58 parietal lobe visuo-spatialacoustic integration visual system visual gait control basal ganglia coordination of movement elements vestibular system vestibular gait control brainstem orthostatic reflexes cerebellum sequencing of movement elements spinal cord afferent conduction efferent conduction spinal reflexes PNS muscles muscle spindles afferences joint afferences motoneurons force production spine and joints mechanics
Simplified Gait Analysis Check Sheet 59 Moseley & Moore et al 1993
Case study 60
Case study 61
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Case study 68
Quit What is the most likely diagnosis in a patient with the stance duration of 55%? A. Ataxia B. Antalgic gait C. Balance problem D. Child 69
Normal stance=60%. 55% is shortened stance. Answer Ataxia and balance problems trend to result in increased stance duration. Children have longer stance times compared to adults. Stance is shortened due to pain (antalgic gait). 70
What is the muscle? 71
Answers 72
Take Home Messages 73 Clinical gait analysis is used together with the history, physical examination and other special investigations to perform a detailed assessment of a patient with abnormal gait. It usually consists of 5 elements: videotape examination, measurement of general gait parameters, kinematic analysis, kinetic measurement, and elctromyograpky (EMG). The human eye is simply not fast enough to capture and process all of the events that occur during an average gait cycle. Video recording of walking can providing a permanent record of the walk for subsequent analysis. Slow motion, freeze frame facilities and time coding can all enhance greatly the accuracy of observation. Computerized gait analysis by combining kinematic and kinetic data, is possible to calculate the joint moments and powers in three dimensions. The joint angle, moment and power,and the EMG for specific muscles,provide a detailed description of the mechanics of gait. Such information enhances much better decisions to be reached on the best way to treat the patients.
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