Abnormal Gait

Department of Physical
Therapy
NEW YORK UNIVERSITY
Historical Perspective

 Tendency to classify gait according to

disease or injury state
 Hemiplegic gait
 Parkinsonian gait
 Spastic gait
 Quadra- or paraplegic gait
 Amputee gait, etc.
Rationale

 A specific disease or injury state

manifested as a discrete and clinically
describable problem with the mechanics
of gait
Our Starting Point

 We’ll take a deficit-oriented vs. disease-

oriented approach to abnormal gait
analysis
 Example: “How might a spastic hamstring
on one side, secondary to hemiplegia
caused by a CVA, affect gait mechanics?”
Answer

 A spastic hamstring may limit step or

stride excursion and/or pelvic transverse
rotation
Preferred Rate of
Ambulation

 Free or comfortable walking speed

 Self-selected pace
 Rate at which the normal individual is
most energy efficient
 Range: ~2.5 - 4.0 mph (cadence of ~75
- 120 steps per minute)
 Will vary from individual-to-individual
Walking Rates - Historical
Perspective

 Historically walking rates classified as:

 Slow: ~75 - 90 steps per minute
 Medium: ~90 - 105 steps per minute
 Fast: ~105 - 120 steps per minute
Energy Cost vs. Rate
Summary & Interpretation

 Oxygen expenditure is least while walking

at a rate somewhere between ~85 to 110
steps per minute irrespective of stride (or
step) length

 Individuals tend to gravitate toward a self-

selected pace which is most energy
efficient for that individual
Enter - The Idea of a
‘Preferred Rate’

 A preferred rate of ambulation is a

self-selected walking pace that an
individual assumes that is most energy
efficient
Clinical Implication

 Since there is apparently a rate-

dependent issue that drives gait efficiency
the PT should understand that going
slower than and faster than the
preferred rate will lead to inefficiency and
potential stress on the cardiovascular and
motor control systems
Why is Gait More Efficient
at Preferred Rate?

 What is the relationship between energy

efficiency and a preferred rate of
ambulation?
The Center of Gravity
(COG)

 COG located at S1 - S2
 During preferred rate walking the COG
approximates a sinusoidal curve from the:
 Sagittal perspective - no greater than a 2”
peak-to-valley excursion
 Frontal perspective - no greater than a 2”
medial-to-lateral excursion
Path of the COG
Distortion of the Path of
the COG

 A distorted path of the COG will require

mechanical and motor control
compensations that will:
 Disrupt normal timing of events
 Over-ride normal gait control
 Change from ‘automatic’ to ‘manua’l control
strategies
 Lead to over-correction of gait mechanics
The Result

Increased energy expenditure

A Simple Example

 Walking with a stiff-knee (“stiff-knee

gait”) with a cylinder cast
 During stance the HAT will vault over the
fixed foot (especially during mid-stance)
 COG will be deflected higher than the
usual 2” upward vertical displacement
with increased energy cost
Who Walks with a Stiff
Knee?

 Transient knee injury patient (e.g., surgical

repair of a ligament
 Hemiplegic with loss of knee control
 The AK amputee with a locked-knee
prosthesis
 The BK amputee with poor knee control

 Should we consider each case the SAME?

The Control of Gait

 Motor control options:

 ‘Manual’ control theory - thinking about
having to take a step each time you want to
advance the foot forward
 ‘Automatic control theory - an automatic
control system that accounts for gait
mechanics without having to think about foot
placement and other metrical details
Which one is it?

Think about this...

An Everyday Occurrence

 You’re walking along 23rd Street, heading

west toward your bus stop
 You’re thinking about what was discussed
in Kinesiology class today
 You’re also thinking that there is a lot a
traffic and it’s going to take you forever to
get home tonight...
Questions

 Are you thinking about foot placement?

 Are you thinking about how long each
step should be?
 Are you thinking about trunk and pelvic
rotation in the transverse plane and
maintaining reciprocal arm-swing?
 Are you thinking about...
Answer

 Probably NOT!

 Why?
 Your gait control is on ‘automatic pilot’

 When do you have to think about gait

control?
 When there’s a perturbation
Central Pattern Generator
(CPG)

 CPG - a group of synaptic connections

probably at the spinal cord level which are
triggered by an event or condition

 When a threshold is met via a triggering

mechanism the CPG appears to be activated
and takes over automatic control of gait
metrics - i.e., you don’t have to think about it
Evidence

 Spinalized (cord transected) cats

suspended over a treadmill will walk with
an alternating, striding quadripedal gait

 Human quadriplegics have also “walked”

this way
CPG and Supraspinal
Influence

 Gait perturbations
 Example: Someone walks across your path
from the side that you didn’t see
 There’s a need to take immediate corrective
action to avoid a collision
 Supraspinal centers appear to over-ride
the CPG and switch to a ‘manual control’
strategy
What Triggers a CPG?

 There seems to be a close relationship

between activating a CPG for gait control
and preferred rate of ambulation

 In other words, there is a rate-

dependent relationship between normal
gait mechanics and its control mechanism
So...

It appears we maintain the path of the

COG within very tight limits and
therefore expend the least amount of
energy by assuming a preferred rate
which in turn leads to an activation of
a CPG
Think About This...

What’s one of the most common things

heard during gait training in a PT
clinic?
“Mr. Jones, while you’re
walking, I want to go…”
“...very slow!”
What are some possible
implications of this?
 Mr. Jones will be safe - probably won’t fall
and break his hip (good news).
 Mr. Jones won’t sue you (good news).
 The path of the COG may be distorted
(bad news).
 Energy cost may increase (bad news)
 Suppose Mr. Jones has a cardiac condition?
What are some possible
implications of this?

 Mr. Jones may never reach his pre-

injury/disease preferred rate of
ambulation and therefore never trigger a
CPG that automates gait (bad news).

 Mr. Jones’ gait may never look ‘normal’

(bad news).
Is it possible that...

…going very slow might actually cause Mr.

Jones to lose his balance and fall?

Why?
Factors That Lead to the
Initiation of Gait
 Assume right LE will advance first:

 Weight shift to left LE (unloads right hip)

 Left hip moves into (hyper-) extension and
precedes right hip flexion
 Right side of pelvis rotates medially preceding
right hip flexion
 COG moves over right foot after it’s advanced
Factors That Lead to the
Initiation of Gait

 Successful completion of these events

probably leads to a triggering of a CPG as
preferred rate is attained
Gait Training Scenario

Mrs. Flanagan is standing in the parallel bars

with her physical therapist, Dudley
Doright, getting ready to take a left step
to start walking.

We hear the PT say, “Now, Mrs. Flanagan, I

want you to put your left foot forward and
take a step…”
What wrong with this
picture?

 Where is the patient’s COG relative to her

base-of-support?
 What is probably the size of the left step
(step length) relative to the right?
 What impact will this likely have on her
forward velocity?
 What are the chances of attaining her pre-
injury/disease preferred rate?
Deficit-Oriented Gait
Analysis

 Questions:
Do diseases/injuries specifically manifest as
a stereotypical gait pattern?
or
Does the disease/injury lead to a
deterioration of control parameters which
cause gait deficits?
Response

 If you believe the latter…it shouldn’t

matter what the patient’s problem is

 If you understand the consequence of the

disease or injury (loss of motor control,
weakness, damaged supportive structures,
loss of a part of or an entire limb, etc.)...
…you should be able to anticipate or predict
what impact a deficit has on gait
irrespective of their state of injury or
disease.
Hip Extensors - Stance
Analysis of Deficits
Hip Extensors - Stance
 Early stance (@ HS)  Early stance (@ HS)
 Prevent hip flexion weakness/absence
(jack-knifing)  Hip/trunk collapses
 Early stance (HS - FF) into flexion
 Guide hip into flexion  Early stance (HS - FF)
eccentrically  Trunk falls forward
Hip Abductors - Stance
Hip Abductors
 Prevent contra-lateral hip from dipping
greater than 5 - 80
 Stance-side abductors active

 Loss of abductors:
 Static analysis - + Trendelenburg sign
 Dynamic analysis - weakness o f abductors
manifests as ‘lurching gait’ (toward stance- side)
Analysis of Deficits
Abductors - Stance
 Early stance  Early stance
 COG shifts away from weakness/absence
stance side LE  Contra-lateral hip
 Increases moment arm drops > 5-80
of COG relative to  Compensation is to
stance side hip lean (‘lurch’) over
 Stance side abductors stance-side LE
generate counter-
rotational torque to
prevent contra-lateral
from dropping > 5-80
Quadriceps - Stance
Analysis of Deficits
Quadriceps - Stance
 Early stance (HS - FF)  Early stance
 Guides knee into 200 weakness/absence
of flexion eccentrically  Inability to absorb energy
(controls unlocking of  Buckling
the knee)
 Late stance (HR - TO)  Late stance
 Controls for knee weakness/absence
 Knee collapse into flexion
flexion (~400 at TO)
-premature flexion into
early swing - ‘rubber knee’
Pre-Tibial Group - Stance
Analysis of Deficits
Pre-tibial Group - Stance
 Early stance (HS - FF)  Early stance
 Lowers forefoot to weakness/absence
floor eccentrically  Forefoot slaps to the
 After forefoot contacts floor - ‘drop-foot’ gait
floor- pull tibia  Loss of forward pull of
forward over foot tibia
Plantar Flexors - Stance
Analysis of Deficits
Plantar Flexors - Stance
 Late mid-stance  Early stance
 Concentrically pulls weakness/absence
tibia forward  Loss of forward pull of
 Late stance (HR - TO) tibia
 Provides propulsive  Loss of forward thrust
thrust during push off - poor transition to
early swing
Ankle Stability - Late
Stance

 Ankle less stable and subject to injury (e.g.,

sprains) in plantar flexion vs.dorsiflexion
 Posterior trochlea in mortise
 Collateral ligaments swing out of collateral
position

 Position of ankle during push-off (late

stance) = plantar flexed
Analysis of Deficits
Peroneals - Stance
 Late stance (HR - TO)  Late stance
 Dynamically provide weakness/absence
collateral stability to  Ankle instability
ankle when plantar causing medial-lateral
flexed movement
 Secondary plantar  Potential for ankle
flexor for forward injury - sprains
thrust  Poor transition from
late stance to early
swing
Analysis of Deficits
Plantar Intrinsics - Stance
 Late stance (HR - TO)  Late stance
 Provide medial - weakness/absence
lateral stability to MTP  Excessive medial -
joints (especially nos. lateral ‘shimmy’ of
1 & 2) - cancels hindfoot during HR
second degree of  Inefficient forward
freedom thrust
 Improves forward
propulsion and
transition to early
swing
Paraspinals -Stance
Analysis of Deficits
Paraspinals - Stance
 Early stance (HS - FF)  Early & late stance
& late stance (HR - weakness/absence
TO)  Trunk falls forward
 Prevent forward  Loss of head and neck
flexion of trunk acting control
on pelvis
Analysis of Deficits
Hip Flexors - Swing
 Late stance - early  Late stance - early
swing (acceleration) swing
 Forward flexion of femur weakness/absence of
working with plantar forward acceleration
flexors to accelerate LE after TO
in early swing
 Toe may not clear the
 Functionally shortens LE
(with eccentric action of floor during swing
quadriceps and through
dorsiflexors) to prevent  Compensate with
‘toe-drag’ circumduction at hip
Dorsiflexors - Swing
Analysis of Deficits
Dorsiflexors - Swing
 Mid-to-late swing  Mid-to-late swing
(deceleration) weakness/absence
 Affects ‘toe-up’  Loss of ‘toe-up’
concentrically  Compensation
 Functionally shortens  Increased hip flexion -
LE during swing ‘steppage gait’
through  Circumduction at hip
Hamstrings - Swing
Analysis of Deficits
Hamstrings - Swing
 Late swing  Late swing
(deceleration) weakness/absence
 Decelerates tibial  ‘Impact on terminal
shank extension’ - knee
 Provides for smooth slapped into extension
transition between or hyperextension
late stance and early
swing
Gait in the Elderly Men -
Murray, Kory & Clarkson
 Gait did not appear
vigorous or labored
 Gait pattern did not
resemble that of
patients with CNS
damage
 Gait was guarded and
restrained - attempt to
maximal stability and
security
Gait in the Elderly Men -
Murray, Kory & Clarkson
 Gait resembled
someone walking on a
slippery surface
 decreased step & stride
legnth
 wider dynamic BOS
 increased lateral head
movement
 decreased rotation of
pelvis
Gait in the Elderly Men -
Murray, Kory & Clarkson
 toe/floor clearance
distance slightly
decreased
 lower stance-to-swing
ratio
 decreased reciprocal
arm swing more from
elbow than shoulder
Spasticity and its Impact
on Gait

 Spasticity - resistance to passive stretch

 Results from CNS (UMN) injury/disease
 Increased source of uncontrolled/poorly
controlled tension
 Probably due to loss of inhibiting action of the
CNS
 While tension production may be significant the
time-rate-of-tension development may be
delayed
Spasticity & Gait

 Spastic response may be caused by:

 Unexpected quick stretch of muscles
 Foot contact with floor
 Supraspinal overlay
 Effects:
 Restrict joint excursion
 Delay transition from one gait phase to the
next
Spasticity & Gait

 Dubo et al. showed that EMG activity of

spastic muscles increased during mid-
stance i.e., there was a loss of phasic
control of muscles
Spasticity & Gait
Examples

 Quadcriceps
 May prevent knee from unlocking during
interim between HS and FF
 Knee maintained in extension leading to a
‘vaulting’ over stance limb or circumduction of hip
 Disrupts (timing) transition to mid- and late stance
 May prevent LE bending during swing phase
Spasticity & Gait
Examples

 Plantar flexors
 Increase in spastic tone may limit forward
rotation of tibia between MS and PO
 May locate ground reaction force well behind knee
causing significant flexion moment during late MS
and knee buckling tendency
 Ankle may be locked up during PO decreasing
propulsive thrust forward - inefficient
transition from TO to early swing
Spasticity & Gait
Examples

 Hamstrings
 May limit forward swing of LE - decreasing
step length
 May prevent knee from reaching a terminally
extended position just prior to HS
Gait Training - Questions

 If gait is controlled by a rate-dependent

chain of synaptic connections at the spinal
cord level (i.e., a CPG), is it possible for a
PT to effect (physiological) changes in the
gait control system?
Gait Training - Questions

 If gait is initiated (and sustained) as

described previously (e.g., unloading of
hip, pelvis rotates medially, COG loads
over stance foot, etc.), how do we train
patients to start walking?
Gait Training - Questions

 What impact will ‘assistive devices’ have

on gait performance?
 Parallel bars
 Walkers
 Bilateral & unilateral crutches and canes
 PTs using contact guarding from the side or
behind
Gait Training - Questions

 If the rhythmic, symmetrical alternating

characteristics of gait are triggered when
a patient assumes their preferred rate,
will gait symmetry and a ‘normal’
appearing gait be possible if the patient
walks substantially slower than her
preferred rate?
Gait Training - Questions
 Are all patients’ objectives concerning walking
the same?
 Are your objectives for Ms. Walksalot, a 39
year old healthy female who broke her ankle
two weeks ago in an intensive tennis match,
the same as for Mr. Livesinathirdstorywalkup,
a frail 87 year old male, with emphysema and
a fractured, pinned hip?
Gait Training - Questions

 What’s the best thing a PT can say to

their patient while gait training?...
...Probably very
little!