Gait examination

Definition of the term

By gait examination we mean the assessment of gait through sensory information with the possible support of video recordings. We call the evaluation of gait parameters using devices 'gait analysis.

Clinical use of the examination

Gait examination provides us with information to determine the optimal course of treatment, helps us to establish or refine the diagnosis or documents the characteristics of the patient's gait. A series of gait tests is used to document the patient's progress during treatment. It can identify areas in which treatment is not effective or determine the end of therapy in the event that no improvement is noted.

Gait examination often differentiates cases of deviations with a pathological basis and reversible anomalies arising from the habit of an incorrect walking stereotype. One of the clues in this case is that the pathology reduces the ability to change gait, so the small gait variability corresponds to the gait pattern imposed by the pathology.

For the choice of an adequate therapeutic intervention, the differentiation between the primary pathology and the secondary deviation, which arose as part of the adaptation to the primary pathology, is essential. It is necessary to realize that the observed walking stereotype is not a direct result of the pathology, but a consequence of the pathological process associated with the effort to compensate for it.

Characteristics of the examination of walking aspects

From the physiology of human perception, the following limitations of the examination of walking aspects arise:

• The human eye is not able to capture events lasting less than 60 ms, so it is not competent to describe fast movements.
• We are not able to accurately record the amount of detail occurring at any one moment in the step cycle.
• Visual perception does not provide reproducible data.
• Gait rating depends on the observer's ability.

Some of these caveats are partially addressed by the use of high speed video recordings'. The video recording provides a permanent record of the patient's gait, reduces the time for which the patient has to walk and at the same time allows the examiner the necessary number of views of the step cycle, the process can be slowed down or stopped at certain moments. Looking at one's own walking stereotype provides feedback to the patient that can facilitate communication between therapist and patient.

Methods of gait examination

1. Measurement of time-space parameters of walking, especially walking speed, cadence (step frequency) and step length.
2. Systematic examination of gait and its modification.
3. Comparison of movement stereotypes.

Systematic gait examination

A systematic approach to gait analysis eliminates the natural tendency to focus on the most prominent features while overlooking subtler deviations that can be very important. Several gait monitoring strategies have been created, the embodiment of which are diagrams in which we systematically record the deviations occurring in a given phase of the step cycle in a certain joint. In order to be able to focus attention on a certain phenomenon and describe it as accurately as possible, we divide walking into several phases.

The simplest is the division into the "standing and the "swing phase, if we consider events involving one limb, and the ``single-support and double-support phases from from the point of view of the entire step cycle.

The stationary phase is divided into:

1. “initial contact“;
2. “loading response“;
3. “midstance”;
4. “terminal stance”;
5. “preswing phase”.

We divide the swing phase into:

1. “initial swing“;
2. “midswing”;
3. “terminal swing”.

During these phases, the lower limb gradually fulfills the requirements placed on it during the step cycle, without which it is not possible to walk.

Additional terminology:

• nomenclature according to Vaughan (1992)

1. „heel strike“;
2. „foot flat“;
3. „midstance“;
4. „heel off“;
5. „toe off“;
6. „acceleration“;
7. „midswing“;
8. „deceleration“.

• nomenclature according to Wall et al. (1987)

1. „initial contact“ (IC);
2. „opposite toe off“;
3. „heel rise“;
4. „opposite IC“;
5. „toe off“;
6. „feet adjacent“;
7. „tibia vertical“.

During the standing phase of one limb, the swing phase takes place on the other limb at the same time. The duration of one step cycle is further divided into the time of the standing phase and the time of the swing phase. The standing phase occupies 60% (of which 10% is the moment of double support) and the swing phase 40% of the total time. However, this ratio changes with different walking speeds. With increasing speed, the swing phase and the standing phase become proportionally longer, and therefore the time of the double support is shortened.
The process of obtaining information about the progress of the step cycle should be carried out in two phases. The first is global movement monitoring, during which we get an overview of the coordination of the individual phases of the step, the flow and speed of walking, and more pronounced asymmetries. This is followed by a motion analysis'' in the various joints. An in-depth knowledge of the course of movement in all joints at normal momentum, direction and speed of movement in each phase of the stride is required. Pathology is then identified as a deviation from the norm, deviations are recorded. The obtained information is interpreted on two levels. First, we summarize the deviations and describe the function of the legs in the individual phases of the step. In this way, we differentiate primary pathologies from compensatory movements. In the next stage, we will compare the established facts with the results of examinations identifying muscle weakness, spasticity, contracture or sensorimotor disorders. We find out the mechanisms that prevent the effective transfer of body weight from one leg to the other, stabilization during support on one leg, forward movement of the limb in the swing phase or increase the energy demand of walking.

Muscle activity during the step

When walking, a large number of muscles are involved, the cooperation of which is precisely timed. It is an alternating cyclic movement of the lower limbs with movements of the whole body, especially the upper limbs, in an upright position. During the swing phase, the limb bends at the hip and knee, and towards the end there is knee extension and dorsiflexion of the ankle joint so that the heel can touch the mat again and the next standing phase can begin.

1. Standing phase:

At the moment of initial contact, the most m. tibialis anterior, m. gluteus maximus, m. biceps femoris, m. semitendinosus and m. semimembranosus. Their main task is the correct position of the foot to start the step and also to complete the deceleration phase.

When reacting to the load, it develops the greatest activity m. quadriceps femoris, m. gluteus medius and mm. gastrocnemius, which ensure proper weight bearing, partially stabilize the pelvis and completely eliminate deceleration.

In the middle of the standing phase, mm. gastrocnemius and soleus muscle - by isometric contraction that stabilizes the knee joint. In the phase of final standing, mm are also activated. gastrocnemius and soleus muscle - by concentric contraction, and thus indicate the acceleration of the standing limb.

The pre-swing phase is preparation for the swing phase and mainly involves the hip flexors - the iliopsoas muscle and the rectus femoris muscle.

1. Swing phase:

In the initial swing, the tibialis anterior muscle, the iliopsoas muscle and the rectus femoris muscle are mainly involved, whose task is to release the foot from the mat and change the tempo. During the middle of the swing phase, the tibialis anterior muscle is used to keep the foot above the mat.

The final swing is characterized by deceleration, preparation for contact with the mat and correct foot position for the next step, which is ensured by the semitendinosus, biceps femoris, semimembranosus, tibialis anterior and quadriceps femoris muscles.

A method of comparing movement stereotypes

In clinical practice, the most frequently used method is a quick gait examination method, in which we assign the observed movement pattern to similar stereotypes, the structure of which we have stored in our memory based on study or experience.

This procedure requires relatively considerable experience of the investigator. The examiner must be familiar with both the normal gait pattern and possible pathological stereotypes. Many pathological types of walking are caused by neurological diseases.

• Antalgic walking is an adaptation to pain arising when one limb is loaded. By trying to minimize the load on the painful limb, the standing phase on the affected limb is shortened, attacks on the healthy limb and limping occur. The cause of pain can be degenerative changes in the joints and spine, sometimes trauma, but also neuropathic pain (e.g. in diabetic polyneuropathy).
• Coxalgic gait is characterized by a tilt of the trunk to the affected side in the standing phase. The pelvis leans towards the standing leg.
• Vestibular gait in the case of a vestibular apparatus disorder is characterized by a widened base, staggering with a significant pull to one side.
• Atactic gait results from a lesion of the posterior cords of the spinal cord (tabatic gait) or the cerebellum (cerebellar gait).
• Cerebellar gait has a widened base, increased flexion of the upper limbs, the trunk leans back, there is unevenness in the duration of the steps and the placement of the feet, titubation to the side, hypermetric steps.
• Tabic gait is manifested when the posterior roots and cords of the spinal cord are damaged (tabes dorsalis, neuroanemic syndrome), during which the proprioceptive signaling from the periphery is interrupted, and thus a disorder of polocution. The patient cannot properly transfer the weight of the body from one limb to another, falls easily. The balance disorder is often aggravated by the fear of falling.
• Parkinsonian gait is characterized by shorter shuffling steps, semiflexed posture, absent upper limb flexion, difficult start and change of direction. In initial states, only half of the body may be affected.
• Semiflexed posture of the upper limb, circumduction of the lower limbs and lack of flexion of the upper limbs are significant for 'hemiparetic walking, at the same time there is increased muscle tone on the affected side. The affected lower extremity has extension at the knee and plantar flexion, sometimes with inversion. Contact with the floor is the front and more the outer part of the foot.
• Paretic gait is associated with weakness of one or both lower limbs. The patient has problems with rebound and stabilization on the diseased limb, when walking he attacks the healthy leg, sometimes he drags the diseased one behind him, sometimes he takes shorter steps with it or just pulls it towards the healthy one. With localized paresis, the patient is unable to walk on the heel or toe (innervation areas of the peroneus and tibialis nerves - spinal segments L5 and S1), with a lesion of higher segments (nervus femoralis - segments L2-4) he bends at the knees and is unable to get up on a chair or to higher stairs.
• Walking with binding dorsiflexion of the leg is sometimes also called a cock. The ``rooster walk related to damage to the function of the peroneal nerve can be recognized by the excessive lifting of the affected limb, which compensates for the lack of dorsiflexion of the leg, and the stepping first on the toe, then on to the heel, so that walking resembles stepping (stepping). With this disorder, there is a significant risk of tripping over the tip of the plantar flexed foot.
• During spastic walking, the affected limb is stiff, the limb is difficult to lift from the mat due to limited flexion in the knee joint, the impact is hard, the dorsiflexion of the leg is restricted, which is compensated by circumduction in the swing phase, in case of bilateral impairment it can be a bilateral circumduction as well. Very often, spasticity manifests itself during the examination of walking or is much more pronounced than it appeared during the examination lying down.

Sources

Connected articles

• Parkinson disease
• Parkinson syndrome
• Disorders of the cerebellum
• Spastic phenomena
• Root syndromes
• Posterior spinal cord syndrome

Literature

• KOLÁŘ, Pavel. Rehabilitace v klinické praxi. 1. edition. Galén, 2009. pp. 713. ISBN 978-80-7262-657-1.

• ROSE, Jessica – GAMBLE, James. Human walking. 3. edition. Lippincott Williams & Wilkins, 2006. pp. 273. ISBN 0-7817-5954-4.

• WHITTLE, Michael. Gait analysis : an introduction. 4. edition. Butterworth Heinemann/Elsevier, 2007. pp. 255. ISBN 0-7506-8883-1.

• BERNACIKOVÁ, Martina – KALICHOVÁ, Miriam – BERÁNKOVÁ, Lenka. Základy sportovní kineziologie [online]. Fakulta sportovních studií Masarykovy univerzity, ©2010. [cit. 2.11.2012]. <https://is.muni.cz/do/1451/e-learning/kineziologie/elportal/pages/chuze.html>.