Posts Tagged gait

[NEWS] Kessler Foundation tests digital therapeutic approach to improve walking after stroke

Karen Nolan, PhD, of Kessler Foundation, is site investigator for a multi-site trial of a music-based digital therapeutic device with the potential to improve mobility after stroke


East Hanover, NJ. September 16, 2020. Karen Nolan, PhD, of Kessler Foundation, received a grant from MedRhythms to test the company’s investigational digital therapeutic device, the Stride Plus, in individuals striving to recover mobility after stroke. Dr. Nolan, a senior research scientist in the Center for Mobility and Rehabilitation Engineering Research, specializes in the study of new technologies with potential applications in rehabilitation research for deficits in gait and balance that impair mobility.

Kessler Foundation is one of six sites participating in the randomized controlled study, “Post-stroke walking speed and community ambulation conversion: A pivotal study.” The other sites are the Shirley Ryan AbilityLab in Chicago, The Mount Sinai Hospital in New York, Spaulding Rehabilitation Hospital in Boston, Boston University Neuromotor Recovery Laboratory, and Atrium Health in Charlotte, North Carolina.

The study’s objective is to help individuals whose walking ability is affected by stroke to improve their walking speed and advance from limited community ambulation to community ambulation. The data collected from the six sites will support MedRhythm’s application for FDA approval of the device, which received Breakthrough Device Designation from the FDA in June 2020.

The Stride Plus device, which relies on internet connectivity, includes: 1) mobile device that provides rhythmic auditory stimulation in the form of music and rhythmic cues to facilitate the speed and quality of walking; 2) sensors that attach to each shoe to measure biomechanics; and 3) headphones that deliver the auditory cues. Feedback from the sensors is used to augment the music to encourage stable gait patterns and faster walking speed. The sensors also allow for monitoring and recording of the individual’s progress.

A total of 78 participants, including stroke survivors and controls, will be randomized to treatment and control groups. The treatment group will train in the Stride Plus three times a week for five weeks.

“Loss of mobility after stroke exerts a huge toll on individuals, their caregivers, our healthcare system, and society,” said Dr. Nolan, site investigator for the Kessler site. “Stroke rehabilitation is an area where we need to test new technologies to change the outlook for recovery. Applying digital therapeutics is a promising approach for restoring lost mobility,” she noted, “which may foster greater independence and better quality of life in this population.”

As stroke survival rates increase and the population ages, the population of stroke survivors in the U.S. is growing, according to Brian Harris, founder and CEO of MedRhythms. “Progress in stroke rehabilitation has lagged the needs of this growing population. Randomized controlled trials like this pivotal study will help us determine the potential for digital therapeutics in filling these unmet needs for rehabilitation that improves outcomes,” Harris added. “We are encouraged by the FDA’s Breakthrough Device Designation for Stride Plus, which supports our efforts to raise the standard of care for chronic stroke.”


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[ARTICLE] Exoskeleton use in post-stroke gait rehabilitation: a qualitative study of the perspectives of persons post-stroke and physiotherapists – Full Text



Wearable powered exoskeletons are a new and emerging technology developed to provide sensory-guided motorized lower limb assistance enabling intensive task specific locomotor training utilizing typical lower limb movement patterns for persons with gait impairments. To ensure that devices meet end-user needs it is important to understand and incorporate end-users perspectives, however research in this area is extremely limited in the post-stroke population. The purpose of this study was to explore in-depth, end-users perspectives, persons with stroke and physiotherapists, following a single-use session with a H2 exoskeleton.


We used a qualitative interpretive description approach utilizing semi-structured face to face interviews, with persons post-stroke and physiotherapists, following a 1.5 h session with a H2 exoskeleton.


Five persons post-stroke and 6 physiotherapists volunteered to participate in the study. Both participant groups provided insightful comments on their experience with the exoskeleton. Four themes were developed from the persons with stroke participant data: (1) Adopting technology; (2) Device concerns; (3) Developing walking ability; and, (4) Integrating exoskeleton use. Five themes were developed from the physiotherapist participant data: (1) Developer-user collaboration; (2) Device specific concerns; (3) Device programming; (4) Patient characteristics requiring consideration; and, (5) Indications for use.


This study provides an interpretive understanding of end-users perspectives, persons with stroke and neurological physiotherapists, following a single-use experience with a H2 exoskeleton. The findings from both stakeholder groups overlap such that four over-arching concepts were identified including: (i) Stakeholder participation; (ii) Augmentation vs. autonomous robot; (iii) Exoskeleton usability; and (iv) Device specific concerns. The end users provided valuable perspectives on the use and design of the H2 exoskeleton, identifying needs specific to post-stroke gait rehabilitation, the need for a robust evidence base, whilst also highlighting that there is significant interest in this technology throughout the continuum of stroke rehabilitation.


Over the period 1990–2017 there has been a 3% increase in age-standardized rates of global stroke prevalence [1] and a 33% decrease in mortality due to improved risk factor control and treatments [2]. Therefore, stroke survivors are living longer with mild to severe lifelong disabilities requiring long term assistance [1]. As a result, stroke presents a significant socioeconomic burden accounting for the largest proportion of total disability adjusted life years (47.3%) of neurological disorders [3]. Walking impairments, one aspect of stroke disabilities, negatively impact independence and quality of life [4], and recovery of walking is a primary goal post-stroke [5].

Wearable powered exoskeletons are a new and emerging technology originally developed as robots to enable persons who were completely paralyzed due to spinal cord injury to stand and walk [67], but more recently developed to provide sensory-guided motorized lower limb assistance to persons with gait impairments [8]. They require the active participation of the user from the perspective of integrating postural control/balance and the locomotion pattern in real life environments whilst simultaneously providing assistance to achieve typical lower limb movement patterns in a task specific manner [8]. The Exo-H2 is a novel powered exoskeleton in that it has six actuated joints, the hip, knee and ankle bilaterally, and uses an assistive gait control algorithm to provide lower limb assistance when the gait pattern deviates from a prescribed pattern [9]. As stroke impairments typically influence hip, knee and ankle movements the H2 was considered an appropriate exoskeleton for our study [810].

Significant limitations persist in current exoskeleton designs such as weight, cost, size, speed and efficiency [11]. Although end-users’ perspectives are essential in the design and development of assistive technology [1213], there is a paucity of literature from both persons with disabilities and physiotherapists (PTs) perspectives [1415]. Over the last decade end-user perspectives have primarily been studied in spinal cord injury (SCI) in which four studies used semi-structured interviews [16,17,18,19], and 3 studies used survey methods [20,21,22] with sample size ranging from 3 to 20 persons. However, these studies included both complete and incomplete SCI with most participants being non-ambulatory representing a very different end-user population compared to persons post-stroke. A further two studies reported end-user perspectives using survey methods with persons with multiple sclerosis (MS) [23], and persons with MS, SCI or acquired brain injury (ABI) [24]. Wolff et al.,(2014) utilized an online survey to evaluate perspectives on potential use of exoskeletons with wheelchair users, primarily persons with SCI, and healthcare professionals, but no PTs were included [25]. To date only one study by Read et al.,(2020) specifically investigated perspectives of 3 PTs on exoskeleton use using semi-structured interviews with persons with SCI or stroke. Currently, a mixed-methods study is underway to investigate perspectives of PTs and persons with stroke [26]. Thus, further research is needed to explore in-depth, utilizing a qualitative research approach, end-users’ perspectives on lower limb exoskeleton use in post-stroke gait rehabilitation.

It is important to understand and incorporate end-user perspectives [27], persons post-stroke and physiotherapists, with respect to the design of exoskeletons and their implementation to effectively facilitate uptake both in clinical practice and community settings. Therefore, the purpose of our study is to explore the perspectives of persons post-stroke and physiotherapists following a 1.5 h single-use session with a H2 exoskeleton.[…]

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[Abstract] Implementing the exoskeleton Ekso GTTM for gait rehabilitation in a stroke unit – feasibility, functional benefits and patient experiences



Reports on the implementation of exoskeletons for gait rehabilitation in clinical settings are limited.


How feasible is the introduction of exoskeleton gait training for patients with subacute stroke in a specialized rehabilitation hospital?

What are the functional benefits and the patient experiences with training in the Ekso GTTM exoskeleton?


Explorative study.


During an 18 months inclusion period, 255 in-patients were screened for eligibility. Inclusion criteria were; walking difficulties, able to stand 10 min in a standing frame, fitting into the robot and able to cooperate. One-hour training sessions 2–3 times per week for approximately 3 weeks were applied as a part of the patients’ ordinary rehabilitation programme. Assessments: Functional Independence Measure, Motor Assessment Scale (MAS), Ekso GTTM walking data, patient satisfaction and perceived exertion of the training sessions (Borg scale).


Two physiotherapists were certified at the highest level of Ekso GTTM. Twenty-six patients, median age 54 years, were included. 177 training sessions were performed. Statistical significant changes were found in MAS total score (p < 0.003) and in the gait variables walking time, up-time, and a number of steps (p < 0.001). Patients reported fairly light perceived exertion and a high level of satisfaction and usefulness with the training sessions. Few disadvantages were reported. Most patients would like to repeat this training if offered.


Ekso GTTM can safely be implemented as a training tool in ordinary rehabilitation under the prerequisite of a structured organization and certified personnel. The patients progressed in all outcome measures and reported a high level of satisfaction.

  • Implications for rehabilitation
  • The powered exoskeleton Ekso GTTM was found feasible as a training option for in-patients with severe gait disorders after stroke within an ordinary rehabilitation setting.
  • The Ekso GTTM must be operated by a certified physiotherapist, and sufficient assistive personnel must be available for safe implementation.
  • Patients’ perceived exertion when training in the Ekso GTTM was relatively low.
  • The patients expressed satisfaction with this training option.


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[WEB PAGE] Gait – Physiopedia


Gait pattern.jpg

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[1]


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.

Gait speed

  • 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.[2]
  • 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.[3]

The gait cycle is a repetitive pattern involving steps and strides[4]

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[4].

Step width – the mediolateral space between the two feet[4].

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)[5].

The Gait Cycle


The sequences for walking that occur may be summarised as follows:[6]

  1. Registration and activation of the gait command within the central nervous system.
  2. Transmission of the gait systems to the peripheral nervous system.
  3. Contraction of muscles.
  4. Generation of several forces.
  5. Regulation of joint forces and moments across synovial joints and skeletal segments.
  6. 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[4], 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.[3]

The 90 second video below gives the basics of this cycle

Phases of the Gait Cycle (8 phase model):[4][8]

  1. Initial Contact
  2. Loading Response
  3. Midstance
  4. Terminal Stance
  5. Pre swing
  6. Initial Swing
  7. Mid Swing
  8. Late Swing.[9]

Heel Strike (or initial contact) – Short period, begins the moment the foot touches the ground and is the first phase of double support.[3]


  • 30° flexion of the hip: full extension in the knee: ankle moves from dorsiflexion to a neutral (supinated 5°) position then into plantar flexion.[3][4]
  • After this, knee flexion (5°) begins and increases, just as the plantar flexion of the heel increased.[4]
  • Plantar flexion is allowed by eccentric contraction of the tibialis anterior
  • Extension of the knee is caused by a contraction of the quadriceps
  • Flexion is caused by a contraction of the hamstrings,
  • Flexion of the hip is caused by the contraction of the rectus femoris.[4]

Foot Flat (or loading response phase)

  • Body absorbs the impact of the foot by rolling in pronation.[3]
  • Hip moves slowly into extension, caused by a contraction of the adductor magnus and gluteus maximus muscles.
  • Knee flexes to 15° to 20° of flexion. [4]
  • Ankle plantarflexion increases to 10-15°.[3][4]


  • Hip moves from 10° of flexion to extension by contraction of the gluteus medius muscle.[4]
  • Knee reaches maximal flexion and then begins to extend.
  • Ankle becomes supinated[3] and dorsiflexed (5°), which is caused by some contraction of the triceps surae muscles.[3]
  • During this phase, the body is supported by one single leg.
  • At this moment the body begins to move from force absorption at impact to force propulsion forward.[3]

Heel Off

  • Begins when the heel leaves the floor.
  • Bodyweight is divided over the metatarsal heads.[3]
  • 10-13° of hip hyperextension, which then goes into flexion.
  • Knee becomes flexed (0-5°)[4]
  • Ankle supinates and plantar flexes.[4]

Toe Off/pre-swing

  • Hip becomes less extended.
  • Knee is flexed 35-40°
  • Plantar flexion of the ankle increases to 20°.[3][4]
  • The toes leave the ground.[4]

Early Swing

  • Hip extends to 10° and then flexes due to contraction of the iliopsoas muscle[4] 20° with lateral rotation.[3][4]
  • Knee flexes to 40-60°
  • Ankle goes from 20° of plantar flexion to dorsiflexion, to end in a neutral position.[3]

Mid Swing

  • Hip flexes to 30° (by contraction of the adductors) and the ankle becomes dorsiflexed due to a contraction of the tibialis anterior muscle.[4]
  • Knee flexes 60° but then extends approximately 30° due to the contraction of the sartorius muscle.[3][4](caused by the quadriceps muscles).[3][4]

Late Swing/declaration

  • Hip flexion of 25-30°
  • Locked extension of the knee
  • Neutral position of the ankle.[3]

Gait Cycle – Anatomical Considerations

  • 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°).[3][4][8]
  • 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).[3][8] 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.[10]

Gait Disorders

Gait disorders – altered gait pattern due to deformities, weakness or other impairments eg loss of motor control or pain[11].

Human falls.jpg
  • 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[1].

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.

Gait Descriptions

Trendelenburg gait.jpg

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
  • Neuropathic Gaits. High stepping gait to gain floor clearance often due to foot drop[10][11][12][2]

Musculoskeletal Causes:

Pathological gait patterns resulting from musculoskeletal are often caused by soft tissue imbalance, joint alignment or bony abnormalities affect the gait pattern as a result[11].

Hip Pathology

  • 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[11].
  • 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[12]
  • Hip Adductor Contracture. During swing phase the leg crosses midline due to the weak adductor muscles, this is known as ‘scissor gait’[12]
  • 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[12]
  • 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
  • Knee Pathologies
  • 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[12].
  • 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[12] 
  • 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[11][12]

Ankle Pathologies

  • 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[12]
  • 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[11].

Foot Pathologies

  • 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

  • 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[11].

Antalgic Gait

  • 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[11]
  • 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[11][12].
  • 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[11]

Below are links to videos demonstrating normal gait and various gait abnormalities:[13][14]

Age Related Gait Changes

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[1]

Gait Analysis

  • 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.[15]
  • When analysing the gait cycle, it is best to examine one joint at a time.[3]
  • Objective and subjective methods can be used.[16][17] 


  • 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[18]).


Gait Analysis CP.jpg

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:[19][17]

Qualitative methods to assess and analyse gait include: [17]

Clinical Bottom Line

Gait assessment.png

Good knowledge of anatomy and biomechanics is important to understand the different phases of the gait cycle. When you know the normal pattern, you can see what’s going wrong!

Related articles

Gait in prosthetic rehabilitation – Physiopedia

Running Biomechanics – Physiopedia

Gait deviations in amputees – Physiopedia

Classification of Gait Patterns in Cerebral Palsy – Physiopedia

PII: S0966-6362(97)00038-6


  1. ↑ Jump up to:1.0 1.1 1.2 Pirker W, Katzenschlager R. Gait disorders in adults and the elderly. Wiener Klinische Wochenschrift. 2017 Feb 1;129(3-4):81-95.Available from: (last accessed 27.6.2020)
  2. ↑ Jump up to:2.0 2.1 Medical dictionary Gait speed Available from: (last accessed 28.6.2020)
  3. ↑ Jump up to:3.00 3.01 3.02 3.03 3.04 3.05 3.06 3.07 3.08 3.09 3.10 3.11 3.12 3.13 3.14 3.15 3.16 3.17 3.18 Shultz SJ et al. Examination of musculoskeletal injuries. 2nd ed, North Carolina: Human Kinetics, 2005. p55-60.
  4. ↑ Jump up to:4.00 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 4.09 4.10 4.11 4.12 4.13 4.14 4.15 4.16 4.17 4.18 4.19 4.20 Loudon J, et al. The clinical orthopedic assessment guide. 2nd ed. Kansas: Human Kinetics, 2008. p.395-408.
  5. 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:
  6. Jump up↑ Vaughan CL. Theories of bipedal walking: an odyssey. J Biomech 2001;36(2003):513-523.Available from
  7. Jump up↑ Nicole Comninellis The Gait Cycle Animation Available from
  8. ↑ Jump up to:8.0 8.1 8.2 Demos, Gait analysis, (, 2004.
  9. Jump up↑ Berger W, et al. Corrective reactions to stumbling in man: neuronal co-ordination of bilateral leg activity during gait. J Physiol 1984;357: 109-125.
  10. ↑ Jump up to:10.0 10.1 Shi D, et al. Effect of anterior cruciate ligament reconstruction on biomechanical features of knee level in walking: a meta analysis. Chin Med J 2010;123(21):3137-3142.
  11. ↑ Jump up to:11.0 11.1 11.2 11.3 11.4 11.5 11.6 11.7 11.8 11.9 Malanga G and Delisa J.A. Section One: Clinical Observation. Office of rehabilitation Research and Development No Date. (accessed 6 February 2010)
  12. ↑ Jump up to:12.0 12.1 12.2 12.3 12.4 12.5 12.6 12.7 12.8 University of Washington. Pathologic Gait: Musculoskeletal (accessed 5 February 2015)
  13. Jump up↑ onlinemedicalvideoAbnormal Gait Exam : Myopathic Gait Demonstration. Available from
  14. Jump up↑ scfpta gait deviation published final 001.wmvAvailable from
  15. Jump up↑ Langer PS, et al. A practical manual of clinical electrodynography. 2nd ed. Deer Park: The Langer Foundation for Biomechanics and Sports Medicine Research, 1989.
  16. ↑ Jump up to:16.0 16.1 Terrier P, Schutz Y. How useful is satellite positioning system (GPS) to track gait parameters? A review. J Neuro Eng Rehab 2005;2:28.
  17. ↑ Jump up to:17.0 17.1 17.2 Deckers JHM, et al. Ganganalyse en looptraining voor de paramedicus, Houten, Bohnfleu van Lonhum, 1996.
  18. Jump up↑ Cranage S, Perraton L, Bowles KA, Williams C. The impact of shoe flexibility on gait, pressure and muscle activity of young children. A systematic review. Journal of Foot and Ankle Research. 2019 Dec 1;12(1):55.
  19. Jump up↑ Frigo C, et al. Functionally oriented and clinically feasible quantitative gait analysis method. Med Biol Eng Comput 1998;36:179-185.
  20. Jump up↑ Shumway-Cook A, Woollacott MH. Motor control: translating research into clinical practice. Lippincott Williams and Wilkins, 2007. p.408.
  21. Jump up↑ Van Peppen RPS, KNGF-richtlijn Beroerte, 2004, Nederlands Tijdschrift voor Fysiotherapie.
  22. Jump up↑ Baer RH, Wolf SL. Modified emory functional ambulation profile: an outcome measure for the rehabilitation of post stroke gait dysfunction. Stroke 2001;32(4):973-979.
  23. Jump up↑ Potsiadlo D, Richardson S. The timed “Up and Go”: a test of functional mobility for frail elderly persons. J Am Geriatr Soc 1991;39(2):142-148.
  24. Jump up↑ Shephard RJ, Taunton JE. Foot and ankle in sport and exercise, Toronto:Karger, 1987. p30-38.
  25. Jump up↑ Bautmans I, et al. The feasibility of whole body vibration in institutionalised elderly persons and its influence on muscle performance, balance and mobility: a randomised controlled trial. BMC Geriatr 2005;5:17.


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[ARTICLE] A randomized controlled trial of motor imagery combined with structured progressive circuit class therapy on gait in stroke survivors – Full Text


Structured Progressive Circuit Class Therapy (SPCCT) was developed based on task-oriented therapy, providing benefits to patients’ motivation and motor function. Training with Motor Imagery (MI) alone can improve gait performance in stroke survivors, but a greater effect may be observed when combined with SPCCT. Health education (HE) is a basic component of stroke rehabilitation and can reduce depression and emotional distress. Thus, this study aimed to investigate the effect of MI with SPCCT against HE with SPCCT on gait in stroke survivors. Two hundred and ninety stroke survivors from 3 hospitals in Yangon, Myanmar enrolled in the study. Of these, 40 stroke survivors who passed the selection criteria were randomized into an experimental (n = 20) or control (n = 20) group. The experimental group received MI training whereas the control group received HE for 25 minutes prior to having the same 65 minutes SPCCT program, with both groups receiving training 3 times a week over 4 weeks. Temporo-spatial gait variables and lower limb muscle strength of the affected side were assessed at baseline, 2 weeks, and 4 weeks after intervention. After 4 weeks of training, the experimental group showed greater improvement than the control group in all temporospatial gait variables, except for the unaffected step length and step time symmetry which showed no difference. In addition, greater improvements of the affected hip flexor and knee extensor muscle strength were found in the experimental group. In conclusion, a combination of MI with SPCCT provided a greater therapeutic effect on gait and lower limb muscle strengths in stroke survivors.


Stroke is one of the top causes of long-term disability and mortality in many countries throughout the world1,2, with a high potential of this population increasing further due to the ageing population3. According to the disability-adjusted life years, stroke disease stands in fourth place among the disease burden. In 2005, there were 5.7 million deaths globally and 87% of them came from developing countries4.

Gait is one of the most important functions after stroke5. Stroke survivors usually exhibit gait alterations with longer stride time and lower gait speed and cadence when compared to aged matched healthy individuals6. Gait asymmetry is shown as one of the common characteristics in stroke survivors. It has been reported that 33.3% and 55.5% of ambulating stroke survivors had significant asymmetries in the temporal and spatial variables of gait7. Asymmetry of gait is clinically important and has been related to increases in energy expenditure, reduced balance control, and risk of unaffected limb injury8. The most important factor attributing to gait asymmetry is the reduction in muscle strength in the affected side. Previous studies exploring the relationship between lower limb muscle strength and walking ability, found significant associations in all muscle groups, especially in the hip flexors and ankle plantar flexors which showed the largest contribution to gait speed9. A review article reported that muscle weakness was one of the causation factors of falls, it is therefore considered to be the primary objective of promoting mobility ability in stroke survivors10.

Task-oriented training is one of several training techniques that has been used to improve motor function in stroke survivors1114. This technique has been reported to improve functional tasks, allowing the patients to participate actively, and allows easy progression in the training levels and task adaptability15. The Structure Progressive Circuit Class Training (SPCCT) was developed based on the task-oriented training concept. The key components of this method are to provide group therapy with a minimum of 2 participants under 1 therapist supervisor and encouraging repeated practice exercises with continual progression16. This has advantages over other techniques and has been shown to increase therapy dosage and reduce treatment costs. This treatment technique may be suitable for a large number of patients, however, a limited number of therapists implement these techniques within the clinical setting.

Motor imagery (MI) is a cognitive function paradigm that involves the mental imitation of the movement without actual execution. MI has been used as part of training programs for a number of clinical conditions to improve motor ability, and has been shown to produce similar brain activity to real movement actions17,18. Imagination and motor planning are key parts of the brain’s capability to perform movement effectively. The purpose of MI training is to improve learning ability by repetitive practice of particular tasks19. Although studies support the practice with MI alone to improve lower limb function20,21, better results have been reported when MI was combined with physical training2224. However, the previous studies have been conducted on upper limb function and only a few studies have reported its use in the lower limb14,25.

For a conservative treatment, health education (HE) is one of the crucial elements in stroke management. Stroke awareness is administered in the context of the national stroke policies in countries worldwide26,27. This provides knowledge about the disease and other necessary information for the patients and caregivers, and helps to inform patients how to take care of themselves as well as to prevent recurrence. This present study aimed to investigate the effect of the combined techniques of MI and SPCCT on gait and lower limb muscle strength on the affected side in stroke survivors. We hypothesized that the intervention of MI with SPCCT would show greater improvements when compared to HE with SPCCT.[…]


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[Abstract] Water-based exercises for improving walking speed, balance, and strength after stroke: a systematic review with meta-analyses of randomized trials


Background: Water-based exercises have the potential to reduce impairments and walking limitations after stroke.

Objective: To examine the effects of water-based exercises on walking speed, balance, and strength after stroke.

Data sources: Eletronic searches on MEDLINE, CINAHL, EMBASE, Cochrane, PsycINFO, and PEDro databases.

Eligibility criteria: The review included randomized trials. Participants in the reviewed studies were ambulatory adults, who have had a stroke. The experimental intervention was comprised of water-based exercises.

Data synthesis: Outcome data related to walking speed, balance, and strength were extracted from the eligible trials and combined in meta-analyses. The quality of the included trials was assessed by the PEDro scores and the quality of evidence was determined according to the Grading of Recommendations Assessment, Development, and Evaluation system.

Results: Thirteen trials involving 464 participants were included. Random-effects meta-analyses provided moderate-quality evidence that water-based exercises significantly increase walking speed by 0.06m/second (95% CI 0.01 to 0.10) and balance by 4.5 points on the Berg Balance scale (95% CI 2.2 to 6.8), compared with land-based exercises, without concurrent changes in strength (MD 5.2Nm/kg; 95% CI -1.4 to 11.9).

Conclusions: This systematic review provided low-quality evidence regarding the efficacy of water-based exercises, compared with no intervention. However, there is moderate quality evidence, which suggested significant benefits of water-based exercises in walking speed and balance, compared with land-based exercises. Differences appear small to be considered clinically relevant, and, therefore, water-based exercises can be prescribed as alternative interventions, based upon individuals’ exercise preferences. Systematic Review Registration Number PROSPERO (CRD42018108419).


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[Abstract] Effects of trunk stabilization training robot on postural control and gait in patients with chronic stroke: a randomized controlled trial


Our study aimed to confirm the therapeutic effects of using a trunk stabilization training robot (3DBT-33) in patients with chronic stroke. A total of 38 patients with chronic stroke were randomly assigned to either an experimental or a control group. The robot group (n = 19) received 30 min of trunk stability robot training in addition to conventional physical therapy, while the control group (n = 19) received a similar conventional physical therapy as the robot group. All participants were assessed using the following: the Functional Ambulation Categories (FAC), timed up and go (TUG) test, Berg Balance Scale (BBS), Korean Modified Barthel Index (K-MBI), and Fugl-Meyer Assessment of Lower Extremity (FMA-LE). There were statistically significant improvements in all parameters at follow-up assessment after 4 weeks of intervention (P < 0.05). There were statistically significant differences in the FMA-LE, K-MBI, and BBS between the robot and control groups (P < 0.05). There was no significant difference in FAC (P = 0.935) and TUG (P = 0.442). Minimal detectable change was more significantly observed in the FMA-LE and BBS than in FAC, TUG, and K-MBI. The findings in the present study showed that trunk stabilization rehabilitation training using a rehabilitation robot in patients with chronic stroke was effective in improving the balance and functions in the lower extremities.


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[Abstract + Similar articles] Adapting to the Mechanical Properties and Active Force of an Exoskeleton by Altering Muscle Synergies in Chronic Stroke Survivors


Chronic stroke survivors often suffer from gait impairment resistant to intervention. Recent rehabilitation strategies based on gait training with powered exoskeleton appear promising, but whether chronic survivors may benefit from them remains controversial. We evaluated the potential of exoskeletal gait training in restoring normal motor outputs in chronic survivors (N=10) by recording electromyographic signals (EMGs, 28 muscles both legs) as they adapted to exoskeletal perturbations, and examined whether any EMG alterations after adaptation were underpinned by closer-to-normal muscle synergies. A unilateral ankle-foot orthosis that produced dorsiflexor torque on the paretic leg during swing was tested. Over a single session, subjects walked overground without exoskeleton (FREE), then with the unpowered exoskeleton (OFF), and finally with the powered exoskeleton (ON). Muscle synergies were identified from EMGs using non-negative matrix factorization. During adaptation to OFF, some paretic-side synergies became more dissimilar to their nonparetic-side counterparts. During adaptation to ON, in half of the subjects some paretic-side synergies became closer to their nonparetic references relative to their similarity at FREE as these paretic-side synergies became sparser in muscle components. Across subjects, level of inter-side similarity increase correlated negatively with the degree of gait temporal asymmetry at FREE. Our results demonstrate the possibility that for some survivors, exoskeletal training may promote closer-to-normal muscle synergies. But to fully achieve this, the active force must trigger adaptive processes that offset any undesired synergy changes arising from adaptation to the device’s mechanical properties while also fostering the reemergence of the normal synergies.

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[Abstract] Effects of electromechanically assisted gait trainer with Exowalk® in patients with chronic stroke: A randomized controlled trial


Objective: To assess the effect on walking ability of electromechanically assisted gait training with a gait trainer (Exowalk®) for patients with chronic stroke.

Design: Randomized controlled trial.

Subjects: Forty patients with hemiplegia after stroke.

Methods: Patients were randomly assigned to control and experimental groups. The control group underwent physical therapist-assisted gait training and the experimental group underwent electromechanically assisted gait training. Interventions were provided for 60 min, 5 days a week, for a period of 2 weeks. Primary outcome was change in Functional Ambulatory Category. Secondary outcomes were walking speed, walking capacity, leg muscle strength and balance. All outcomes were measured before and after the intervention.

Results: Although the Functional Ambulatory Category improved significantly after gait training in both groups, the change in Functional Ambulatory Category did not differ between groups. In both groups most secondary outcomes also improved after gait training, but the changes in secondary outcomes did not differ between groups.

Conclusion: In patients with chronic stroke, walking improved after gait training with or without electromechanical assistance. Electromechanically assisted gait training was not superior to conventional physiotherapy.


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[Abstract] The Effects of Vestibular Rehabilitation on Gait Performance in Patients with Stroke: A Systematic Review of Randomized Controlled Trials


Background: Patients with post-stroke hemiparesis have poor postural stability; nevertheless, it is unclear whether vestibular rehabilitation affects gait performance after a stroke or not. We performed a systematic review of randomized controlled trials to investigate the effects of vestibular rehabilitation on gait performance in patients with post stroke.

Methods: The Medline, Cochrane Central Register of Controlled Trials, Physiotherapy Evidence Database, and Cumulative Index to Nursing and Allied Health Literature databases were comprehensively searched. All literature published from each source’s earliest date to June 2019 was included. Study selection and data extraction were performed independently by paired reviewers. Outcomes of gait performance were the 10-Meter Walking Test, Timed Up and Go Test, and Dynamic Gait Index. We applied the Physiotherapy Evidence Database scale to evaluate the risk of bias and the Grading of Recommendations Assessment, Development and Evaluation system to evaluate the quality of a body of evidence.

Results: Three studies were included, and two out of three trials showed beneficial effects of vestibular rehabilitation in post-stroke patients. Quality assessment using the Grading of Recommendations Assessment, Development and Evaluation criteria found very low-quality evidence of all included studies due to inadequate allocation concealment, low participant numbers, and lack of blinding.

Conclusion: This review found beneficial effects of vestibular rehabilitation on gait performance in patients with stroke. However, due to the very low-quality evidence of previous randomized controlled trials as assessed by the Grading of Recommendations Assessment, Development and Evaluation criteria, definitive conclusions on the effectiveness of vestibular rehabilitation cannot be made. Hence, more high-quality and large-scale randomized controlled trials of vestibular rehabilitation after stroke are needed.

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