Human gait depends on a complex interplay of major parts of the nervous, musculoskeletal and cardiorespiratory systems.
The individual gait pattern is influenced by age, personality, mood and sociocultural factors.
The preferred walking speed in older adults is a sensitive marker of general health and survival.
Safe walking requires intact cognition and executive control.
Gait disorders lead to a loss of personal freedom, falls and injuries and result in a marked reduction in the quality of life.
Gait – the manner or style of walking.
Gait Analysis –
An analysis of each component of the three phases of ambulation is an essential part of the diagnosis of various neurologic disorders and the assessment of patient progress during rehabilitation and recovery from the effects of a neurologic disease, a musculoskeletal injury or disease process, or amputation of a lower limb.
The time it takes to walk a specified distance, usually 6 m or less. Slower speeds correlate with an increased risk of mortality in geriatric patients.
Normal walking speed primarily involves the lower extremities, with the arms and trunk providing stability and balance.
Faster speeds – body depends on the upper extremities and trunk for propulsion, balance and stability with the lower limb joints producing greater ranges of motion.
The gait cycle is a repetitive pattern involving steps and strides
A step is one single step
A stride is a whole gait cycle.
Step time – time between heel strike of one leg and heel strike of the contra-lateral leg.
Step width – the mediolateral space between the two feet.
The demarcation between walking and running occurs when
periods of double support during the stance phase of the gait cycle (both feet are simultaneously in contact with the ground) give way to two periods of double float at the beginning and the end of the swing phase of gait (neither foot is touching the ground).
The Gait Cycle
The sequences for walking that occur may be summarised as follows:
Registration and activation of the gait command within the central nervous system.
Transmission of the gait systems to the peripheral nervous system.
Regulation of joint forces and moments across synovial joints and skeletal segments.
Generation of ground reaction forces.
The normal forward step consists of two phases: stance phase; swing phase,
Stance phase occupies 60% of the gait cycle, during which one leg and foot are bearing most or all of the body weight
Swing phase occupies only 40% of it, during which the foot is not touching the walking surface and the body weight is borne by the other leg and foot.
In a complete two-step cycle both feet are in contact with the floor at the same time for about 25 per cent of the time. This part of the cycle is called the double-support phase.Gait cycle phases: the stance phase and the swing phase and involves a combination of open and close chain activities.
The 90 second video below gives the basics of this cycle
Pelvic region – anterior-posterior displacement, which alternates from left to right. Facilitates anterior movement of the leg (each side anterior-posterior displacement of 4-5°).
Frontal plane – varus movement in the: foot between heel-strike and foot-flat and between heel-off and toe-off; hip, in lateral movements (when the abductors are too weak, a Trendelenburg gait can be observed). Valgus movement between foot-flat and heel off in the feet.
A disorder in any segment of the body can have consequences on the individual’s gait pattern.
Gait disorders – altered gait pattern due to deformities, weakness or other impairments eg loss of motor control or pain.
Prevelence increases with age and the number of people affected will substantially increase in the coming decades due to the expected demographic changes.
Lead to a loss of personal freedom and to reduced quality of life.
Precursors of falls and therefore of potentially severe injuries in elderly persons.
Causes of gait disorders include
Neurological, orthopedic, medical and psychiatric conditions and multifactorial etiology becomes more common with advancing age, making classification and management more complex.
Any gait disorder should be thoroughly investigated in order to improve patient mobility and independence, to prevent falls and to detect the underlying causes as early as possible.
Thorough clinical observation of gait, careful history taking focussed on gait and falls and physical, neurological and orthopedic examinations are basic steps in the categorization of gait disorders and serve as a guide for ancillary investigations and therapeutic interventions.
This is not an exhaustive list.
Antalgic gait a limp adopted so as to avoid pain on weight-bearing structures, characterized by a very short stance phase.
Ataxic gait an unsteady, uncoordinated walk, with a wide base and the feet thrown out, coming down first on the heel and then on the toes with a double tap.This gait is associated with cerebellar disturbances and can be seen in patients with longstanding alcohol dependency. People with ‘Sensory’Disturbances may present with a sensory ataxic gait. Presentation is a wide base of support, high steps, and slapping of feet on the floor in order to gain some sensory feedback. They may also need to rely on observation of foot placement and will often look at the floor during mobility due to a lack of proprioception
Equine gait a walk accomplished mainly by flexing the hip joint; seen in crossed leg palsy.
Parkinsonian Gait (seen in parkinson’s disease and other neurologic conditions that affect the basal ganglia). Rigidity of joints results in reduced arm swing for balance. A stooped posture and flexed knees are a common presentation. Bradykinesia causes small steps that are shuffling in presentation. There may be occurrences of freezing or short rapid bursts of steps known as ‘festination’ and turning can be difficult.
Trendelenburg gait, the gait characteristic of paralysis of the gluteus medius muscle, marked by a listing of the trunk toward the affected side at each step.
Hemiplegic gait a gait involving flexion of the hip because of footdrop and circumduction of the leg.
Steppage gait the gait in footdrop in which the advancing leg is lifted high in order that the toes may clear the ground. It is due to paralysis of the anterior tibial and fibular muscles, and is seen in lesions of the lower motor neuron, such as multiple neuritis, lesions of the anterior motor horn cells, and lesions of the cauda equina.
Stuttering gait a walking disorder characterized by hesitancy that resembles stuttering; seen in some hysterical or schizophrenic patients as well as in patients with neurologic damage.
Tabetic gait an ataxic gait in which the feet slap the ground; in daylight the patient can avoid some unsteadiness by watching his feet.
Waddling gait exaggerated alternation of lateral trunk movements with an exaggerated elevation of the hip, suggesting the gait of a duck; characteristic of muscular dystrophy.
Diplegic Gait (Spastic gait). Spasticity is normally associated with both lower limbs. Contractures of the adductor muscles can create a ‘scissor’ type gait with a narrowed base of support. Spasticity in the lower half of the legs results in plantarflexed ankles presenting in ‘tiptoe’ walking and often toe dragging. Excessive hip and knee flexion is required to overcome this
Arthritis is a common cause of pathological gait. An arthritic hip has reduced range of movement during swing phase which causes an exaggeration of movement in the opposite limb ‘hip hiking.
Excessive Hip Flexion can significantly alter gait pattern most commonly due to; • Hip flexion contractures • IT band contractures, • Hip flexor spasticity, • Compensation for excessive knee flexion and ankle DF, • Hip pain • Compensation for excess ankle plantar flexion in mid swing. The deviation of stance phase will occur mainly on the affected side. The result is forward tilt of the trunk and increased demand on the hip extensors or increased lordosis of the spine with anterior pelvic tilt. A person with reduced spinal mobility will adopt a forward flexion position in order to alter their centre of gravity permanently during gait.
Hip Abductor Weakness. The abductor muscles stabilise the pelvis to allow the opposite leg to lift during the swing phase. Weak abductor muscles will cause the hip to drop towards the side of the leg swinging forward. This is also known as Trendelenburg gait
Hip Adductor Contracture. During swing phase the leg crosses midline due to the weak adductor muscles, this is known as ‘scissor gait’
Weak Hip Extensors will cause a person to take a smaller step to lessen the hip flexion required for initial contact, resulting in a lesser force of contraction required from the extensors. Overall gait will be slower to allow time for limb stabilisation. Compensation is increased posterior trunk positioning to maintain alignment of the pelvis in relation to the trunk
Hip Flexor Weakness results in a smaller step length due to the weakness of the muscle to create the forward motion. Gait will likely be slower and may result in decreased floor clearance of the toes and create a drag
Weak Quadriceps. The quadriceps role is to eccentrically control the knee during flexion through the stance phase. If these muscles are weak the hip extensors will compensate by bringing the limb back into a more extended position, reducing the amount of flexion at the knee during stance phase. Alternatively heel strike will occur earlier increasing the ankle of plantar flexion at the ankle, preventing the forward movement of the tibia, to help stabilise the knee joint.
Severe Quadriceps Weakness or instability at the knee joint will present in hyperextension during the initial contact to stance phase. The knee joint will ‘snap’ back into hyperextension as the bodyweight moves forwards over the limb
Knee Flexion Contraction will cause a limping type gait pattern. The knee is restricted in extension, meaning heel strike is limited and step length reduced. To compensate the person is likely to ‘toe walk’ during stance phase. Knee flexion contractures of more than 30 degrees will be obvious during normal paced gait. Contractures less then this will be more evident with increased speeds.
Ankle Dorsiflexion Weakness results in a lack of heel strike and decreased floor clearance. This leads to an increased step height and prolonged swing phase.
Calf Tightening or Contractures due to a period of immobilisation or trauma will cause reduced heel strike due to restricted dorsiflexion. The compensated gait result will be ‘toe walking’ on stance phase, reduced step length and excessive knee and hip flexion during swing phase to ensure floor clearance.
Hallux Rigidus results in a lack of dorsiflexion of the great toe. The MPJ uses the windlass effect to raise the arch and stiffen the foot during dorsiflexion of the hallux. This stiffness increases the efficiency of the propulsion portion of the gait cycle. To be efficient in creating stiffness, the hallux should be able to dorsiflex at least 65 degrees.
Leg length discrepancy can be as a result of an asymmetrical pelvic, tibia or femur length or for other reasons such as a scoliosis or contractures. The gait pattern will present as a pelvic dip to the shortened side during stance phase with possible ‘toe walking’ on that limb. The opposite leg is likely to increase its knee and hip flexion to reduce its length.
Antalgic gait due to knee pain presents with decreased weight bearing on the affected side. The knee remains in flexion and possible toe weight-bearing occurs during stance phase
Antalgic gait due to ankle pain may present with a reduced stride length and decreased weight bearing on the affected limb. If the problem is pain in the forefoot then toe-off will be avoided and heel weight-bearing used. If the pain is more in the heel, toe weight-bearing is more likely. General ankle pain may result in weight-bearing on the lateral border.
Antalgic gait due to hip pain results in reduced stance phase on that side. The trunk is propelled quickly forwards with the opposite shoulder lifted in an attempt to even the weight distribution over the limb and reduce weight-bearing. Swing phase is also reduced.
Below are links to videos demonstrating normal gait and various gait abnormalities:
Any threat to balance induces changes in the strategies for standing and walking – the stance and gait base is widened, bipedal floor contact is prolonged, step length becomes shorter, the feet are lifted less high during the swing phase, walking becomes slower and the posture becomes stooped.
The fear of falling and the actual risk of falling increase with age.
Older persons are therefore more likely to use these protective gait strategies.
As muscle power diminishes and proprioception and vision become impaired with age, body sway on standing, which is constantly present to a slight degree, increases.
In younger persons this sway can be compensated by activating the muscle groups around the upper ankle joints. Older persons shift this compensation to the proximal muscle groups around the hips due to loss of distal proprioception.
This requires an increased reliance on vestibular afferents, which undergo less change during the ageing process.
The preferred walking speed in apparently healthy elderly subjects declines by 1 % per year from a mean of 1.3 m/s in the seventh decade to a mean of 0.95 m/s in those aged over 80 years (caused by a decrease in step length rather than by a change in cadence).
Gait changes are to some degree a consequence of normal ageing however individual walking speed in elderly subjects is a strong indicator of general health and survival
The analysis of the gait cycle is important in the biomechanical mobility examination to gain information about lower limb dysfunction in dynamic movement and loading.
When analysing the gait cycle, it is best to examine one joint at a time.
Objective and subjective methods can be used.
Different gait patterns – We might ask the individual to walk normally, on insides and outsides of feet, in a straight line, running (all the time looking to compare sides and understanding of “normal”).
Ask/observe the type of footwear the patient uses (a systematic review suggests shoes affect velocity, step time, and step length in younger children’s gait).
An objective approach is quantitative and parameters like time, distance, and muscle activity will be measured. Other objective methods to assess the gait cycle that use equipment include:
Jump up↑The biomechanics of running Tom F. Novacheck Motion Analysis Laboratory, Gillette Children’s Specialty Healthcare, Uni6ersity of Minnesota, 200 E. Uni6ersity A6e., St. Paul, MN 55101, USA Received 25 August 1997; accepted 22 September 1997 Available from:
Background: Functional electrical stimulation (FES) applied to the paretic peroneal nerve has positive clinical effects on foot drop secondary to stroke.
Objective: To evaluate the effectiveness of FES applied to the paretic peroneal nerve on gait speed, active ankle dorsiflexion mobility, balance, and functional mobility.
Methods: Electronic databases were searched for articles published from inception to January 2020. We included randomized controlled trials or crossover trials focused on determining the effects of FES combined or not with other therapies in individuals with foot drop after stroke. Characteristics of studies, participants, comparison groups, interventions, and outcomes were extracted. Statistical heterogeneity was assessed with the I2 statistic.
Results: We included 14 studies providing data for 1115 participants. FES did not enhance gait speed as compared with conventional treatments (i.e., supervised/unsupervised exercises and regular activities at home). FES combined with supervised exercises (i.e., physiotherapy) was better than supervised exercises alone for improving gait speed. We found no effect of FES combined with unsupervised exercises and inconclusive effects when FES was combined with regular activities at home. When FES was compared with conventional treatments, it improved ankle dorsiflexion, balance and functional mobility, albeit with high heterogeneity for these last 2 outcomes.
Conclusions: This meta-analysis revealed low quality of evidence for positive effects of FES on gait speed when combined with physiotherapy. FES can improve ankle dorsiflexion, balance, and functional mobility. However, considering the low quality of evidence and the high heterogeneity, these results must be interpreted carefully.
Background: The review is intended to provide the effectiveness of robotic-assisted gait training (RAGT) for functional gait recovery in poststroke survivors through a systematic review and to provide evidence for gait speed improvements through the meta-analysis of randomized controlled trials (RCTs).
Summary: In this systematic review, PubMed, Web of Science, Wiley Online Library, Science Direct, Science Robotics, Scopus, UpToDate, MEDLINE, Google Scholar, -CINHAL, EMBASE, and EBSCO were reviewed to identify relevant RCTs. Articles included in the study were thoroughly examined by 2 independent reviewers. The included RCTs were having a PEDro score between 6 and 8 points. The initial database review yielded 1,371 studies and, following further screening; 9 studies finally were selected for systematic review and meta-analysis. Out of the 9 studies, 4 were on chronic stroke and 5 were on subacute stroke. The meta-analysis of gait speed showed an effect size value ranging between -0.91 and 0.64, with the total effect size of all the studies being -0.12. During subgroup analysis, the subacute stroke total effect size was identified as -0.48, and the chronic stroke total effect size was noted as 0.04. Meta-analysis revealed no significant differences between RAGT and conventional gait training (CGT). Key Messages: Our systematic review revealed that the RAGT application demonstrated a better or similar effect to that of CGT in a poststroke population. A meta-analysis of gait speed involving all the studies identified here indicated no significant differences between RAGT and CGT. However, the subanalysis of chronic stroke survivors showed a slight positive effect of RAGT on gait speed.
The following article has just been accepted for publication in Journal of Neurologic Physical Therapy:
“Minimal Detectable Change For Gait Speed Is Dependent On Baseline Gait Speed In Individuals With Chronic Stroke”
Michael D Lewek, PT, PhD; Robert Sykes III
Background and Purpose: Given the heterogeneity of mobility outcomes post-stroke, the purpose of this study was to examine how the minimal detectable change (MDC) for gait speed varies based on an individual’s baseline walking speed.
Methods: Seventy six participants with chronic stroke and able to walk without therapist assistance participated in two visits to record overground self-selected comfortable gait speed (CGS) and fast gait speed (FGS). Based on the CGS at visit one, participants were assigned to one of three speed groups: LOW (<0.4 m/s; N=32), MOD (0.4 m/s to 0.8 m/s; N=29), and HIGH functioning group (>0.8 m/s; N=15). Participants were then reclassified using updated gait speed cutoffs of 0.49 and 0.93 m/s. For each group, we determined test-retest reliability between visits, and the minimal detectable change for CGS and FGS.
Results: Gait speed significantly increased from visit one to visit two for each group (p<0.001). The reliability for CGS declined with increasing gait speed, and MDC95 values increased with increasing gait speed (LOW: 0.10 m/s; MED: 0.15 m/s; HIGH: 0.18 m/s). Similar findings were observed for FGS, and when participants were recoded using alternative thresholds.
Discussion and Conclusions: Slower walkers demonstrated greater consistency in walking speed from day to day, which contributed to a smaller MDC95 than faster walkers. These data will help researchers and clinicians adjust their expectations and goals when working with individuals with chronic stroke. Expectations for changing gait speed should be based on baseline gait speed, and will allow for more appropriate assessments of intervention outcomes.
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Functional electrical stimulation (FES) for patients with stroke and foot drop is an alternative to ankle foot orthoses. Characteristics of FES responders and non-responders have not been clarified.
1. To investigate the effects of treatment with FES on patients with stroke and foot drop. 2. To determine which factors may relate to responders and non-responders.
Multicenter, non-randomized, prospective study.
Multicenter clinical trial.
Participants, who experienced foot drop resulting from stroke, greater than 20 years old, and could provide consent to participate, were enrolled from hospitals between January 2013 and September 2015 and performed rehabilitation with FES.
Stroke Impairment Assessment Set Foot-Pat Test (SIAS-FP), Fugl-Meyer Assessment for Lower Extremity (FMA-LE), modified Ashworth scale (MAS) for ankle joint dorsiflexion and plantar flexion muscles, range of motion (ROM) for ankle joint, 10-m walking test (10mWT), timed up & go test (TUG), and 6-minute walking test (6MWT) were evaluated pre- and post-intervention. Age, sex, type of stroke, onset times of stroke, paretic side, Brunnstrom stage of the lower extremity (Br. stage-LE), functional independent measure (FIM), functional ambulation category (FAC), post-stroke months, number of interventions, total hours of interventions, and whether a brace was used were extracted from patients’ medical records and collected on the physiological examination day.
Main Outcome Measurements
We examined 10mWT and age, sex, type of stroke, onset times of stroke, paretic side, Br. stage-LE, FIM, FAC, post-stroke months, number of interventions, total hours of interventions, whether a brace was used, SIAS-FP, FMA-LE, MAS, ROM, TUG, and 6MWT before intervention. We divided participants into non-responders and responders with a change in 10mWT of <0.1 and ≧0.1 m/s, respectively. Single and multiple regression analyses were used for data analysis. Additionally, we compared the changes between groups.
Fifty-eight responders and 43 non-responders were enrolled. The between-group differences, compared for changes between pre- and post-intervention, were significant in terms of changes in SIAS-FP (P=.02), 10mWT (P<.001), 10-m gait steps (P<.001), TUG (P=.04), and 6MWT (P=.006). In the adjusted regression model, sex (OR, 3.92; 95% CI, 1.426–12.25; P=.007), number of interventions (OR, 1.028; 95% CI, 1.003–1.070; P=.03), and active ankle joint dorsiflexion ROM (OR, 1.047; 95% CI, 1.014–1.088; P=.005) remained significant.
The factors related to 10mWT showing changes beyond the minimally clinically important difference were found to be patient sex, number of interventions, and active ankle joint dorsiflexion ROM before intervention. When Patients with stroke who are greater active ankle joint ROM in female, use FES positively, they may benefit more from using FES.
Introduction: Gait recovery is one of the main objectives in the rehabilitation of post-stroke patients. The study aim was to assess the correlations between gait speed in post-stroke hemiparetic patients and the level of motor control in the paretic lower limb, the time from stroke onset, the subjects’ age as well as the impairment of proprioception and visual field.
Materials and methods: This retrospective study was performed at the Clinical Rehabilitation Ward of the Regional Hospital No. 2 in Rzeszow. The study group consisted of 600 patients after a first stroke who walked independently. The measurements focused on gait speed assessed in a 10-meter walking test, motor control in the lower limb according to Brunnström recovery stages, proprioception in lower limbs, visual field as well as functional independence according to The Barthel Index.
Results: The study revealed a slight negative correlation between gait speed and the subjects’ age (r = − 0.25). No correlation was found between mean gait speed and the time from stroke onset. On the other hand, gait speed strongly correlated both with the level of motor control in the lower limb (p = 0.0008) and the incidence of impaired proprioception. Additionally, a strong statistically significant correlation between the patients’ gait speed and the level of functional independence was found with the use of The Barthel Index.
Conclusions: The level of motor control in the paretic lower limb and proprioception are vital factors affecting gait speed and functional independence. Patients with a higher level of functional independence demonstrated higher gait speed.
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Purpose/Hypothesis: The objective of the study was to determine if sensory amplitude electrical stimulation (SES) delivered via sock electrode during task-specific leg exercises improved gait speed, sensation, balance, and participation in individuals with chronic stroke. It was hypothesized that SES would enhance the effectiveness of exercise, resulting in reduced impairment and improved function in individuals with post-stroke hemiplegia.
BACKGROUND AND PURPOSE: Effects of high-intensity exercise on endurance, mobility and gait speed of adults with chronic moderate-to-severe acquired brain injury (ABI) were investigated. It was hypothesized that intensive exercise would be associated with improvements in impairment and activity limitation measures.
PARTICIPANTS: Fourteen adults with chronic ABI in supported independent living who could stand with minimal or no assist and walk with or without ambulation device were studied. Eight presented with low ambulatory status.
METHODS: This was a single group pre- and post-intervention study. Participants received a 6-week exercise intervention for 60-90 minutes, 3 days/week assisted by personal trainers under physical therapist supervision. Measures (6MWT, HiMAT and 10MWT) were collected at baseline, post-intervention and 6 weeks later. Repeated measures T-test and Wilcoxon Signed Ranks test were used.
RESULTS: Post-intervention improvements were achieved on average on all three measures, greater than minimal detectable change (MDC) for this population. Three participants transitioned from low-to-high ambulatory status and maintained the change 6 weeks later.
DISCUSSION AND CONCLUSION: People with chronic ABI can improve endurance, demonstrate the ability to do advanced gait and improve ambulatory status with 6 weeks of intensive exercise. Challenges to sustainability of exercise programmes for this population remain.
A patient with a left middle cerebral artery stroke was seen for physical therapy treatment for 8 sessions from 4/17/15 to 5/15/15 at the Department of Physical Therapy at California State University, Sacramento. Treatment was provided by a student physical therapist under the supervision of a licensed physical therapist.
The patient was evaluated at the initial encounter with the Five Times Sit to Stand to assess lower extremity muscular strength, the Six Minute Walk Test to assess cardiovascular endurance, the 10 Meter Walk Test to measure ambulatory status and gait speed, the Timed Up and Go test to measure fall risk, and the Falls Efficacy ScaleInternational to measure fall risk, and a plan of care was established. Main goals for the patient were to improve lower extremity strength, neuromuscular control, cardiovascular endurance, gait speed, and decrease risk for falls. Main interventions used were repetition, task-specific training, over-ground gait training, and neuromuscular control training.
The patient improved lower extremity strength, cardiovascular endurance, gait speed, and reduced her risk for falls. The patient was discharged to remain living at home with a home exercise program.
Background. Evidence supports peroneal nerve functional electrical stimulation (FES) as an effective alternative to ankle foot orthoses (AFO) for treatment of foot drop poststroke, but few long-term, randomized controlled comparisons exist.
Objective. Compare changes in gait quality and function between FES and AFOs in individuals with foot drop poststroke over a 12-month period.
Methods. Follow-up analysis of an unblinded randomized controlled trial (ClinicalTrials.gov #NCT01087957) conducted at 30 rehabilitation centers comparing FES to AFOs over 6 months. Subjects continued to wear their randomized device for another 6 months to final 12-month assessments. Subjects used study devices for all home and community ambulation. Multiply imputed intention-to-treat analyses were utilized; primary endpoints were tested for noninferiority and secondary endpoints for superiority. Primary endpoints: 10 Meter Walk Test (10MWT) and device-related serious adverse event rate. Secondary endpoints: 6-Minute Walk Test (6MWT), GaitRite Functional Ambulation Profile, and Modified Emory Functional Ambulation Profile (mEFAP). Results. A total of 495 subjects were randomized, and 384 completed the 12-month follow-up. FES proved noninferior to AFOs for all primary endpoints. Both FES and AFO groups showed statistically and clinically significant improvement for 10MWT compared with initial measurement. No statistically significant between-group differences were found for primary or secondary endpoints. The FES group demonstrated statistically significant improvements for 6MWT and mEFAP Stair-time subscore.
Conclusions. At 12 months, both FES and AFOs continue to demonstrate equivalent gains in gait speed. Results suggest that long-term FES use may lead to additional improvements in walking endurance and functional ambulation; further research is needed to confirm these findings.