Pathological Gait Patterns

• Pathological gait is the atypical patterns of walking

Objectives

• The main goal is to describe atypical gait patterns.
• Another goal is to evaluate the clinical presentation
• The last objective is to evaluate changes in gait from a movement systems / ICF perspective

International Classification Functioning (ICF)

• The international classification of functioning (ICF) is an organization
• The ICF is a bio-psycho-social Model of Functioning, Disability and Health, of the World Health Organization (WHO)

Framework

• Health condition influences body functions/ body structures, activities, and participation
• Environmental factors and personal factors are components

International Classification of Functioning

• The overall health condition is specified as a disease or disorder
• Body structures and functions lead to impairments
• Abnormal gait patterns stem from impairments
• Activity limitations include issues with mobility
• Restrictions involve an inability to change/maintain postures
• Walking limitations entail challenges with distance, surfaces, and obstacles.
• A restricted ability to move/walk can be in the home, in other buildings or outside
• Activity limitations affect participation restrictions

Methods of identifying gait pathologies

• There is a Ranchos approach
• There is classification based on the specific pathology, e.g. CVA, although presentations can be variable,
• A further approach is impairment-focused, looking at elements like weakness or paresis
• The latter method is function-focused, which relates biomechanics to gait determinants like progression, stability, and adaptability.

Classification of Gait Deviations

• Deviations originate from an underlying impairment
• Possible impairments may include muscle weakness
• Another factor is normal ROM of joints
• There could be abnormal movement patterns

Abnormal Movement Patterns

• Abnormal synergies may occur
• Coordination deficits (sensory, whether centrally mediated or peripheral) can also occur
• Pain may cause Gait Deviations
• It is not an exhaustive model

Clinical Decision-Making Pathway

• Initial step in gait analysis is to understand "normal" gait
• Next, identify gait deviation
• Then, develop an hypothesis based on the deviation’s cause
• Differentiate the deviation from compensation
• Next, test the hypothesis
• After the hypothesis, develop an intervention to address the cause of the gait deviation
• Reassess gait to determine if the intervention is successful
• Reimbursement considerations also matter.
• Intervention involves identifying and treating impairment which impacts the functional loss and compensatory action.

Step 1: Identify the Gait Deviation

• Use Ranchos Observational Analysis for indentification

Step 2: Develop Hypothesis

• Consider the underlying impairment
• Is it muscle weakness, ROM, abnormal movements

Step 3: Test The Hypothesis

• This step involves testing which underlying impairment is likely the cause of the observed gait deviation

Step 4: Implement An Intervention

What intervention is suitable for the patient

Step 5: Reevaluate You Hypothesis

• Step 5 involves reevaluating the original hypothesis

Pathologies Involving Muscle Weakness

• One factor is weakness of the muscle
• A further factor is supraspinal mediated weakness

Plantarflexor Weakness

• Observe sides and sagittal plane
• Excessive dorsiflexion during the stance phase can be observed
• There is also Ground Reaction Force
• The stance phase and swing phase are affected
• Within the stance phase, the ankle and forefoot rockers are affected
• Requirements of gait change such as progression, and gait speed is also affected
• In compensation, there is increased knee and hip flexion moments (pre-swing phase)
• When there are weak quads there will be knee hyperextension
• When quads are normal there will be knee flexion
• The patient has slower walking/shorter steps

Dorsiflexor Weakness (High Steppage/Steppage Gait)

• Observe sides and sagittal plane
• The "foot drop" in the swing phase and foot slap at initial contact
• In the stance phase, there is a lack of eccentric control of the foot at initial contact
• In the swing phase, there is an incomplete dorsiflexion and foot clearance is affected
• There are disruptions in gait such as its progression, and postural control,
• There is also toe drag
• There is compensation with excessive hip and knee flexion in the swing phase
• One more factor is eccentric control of the foot at terminal stance
• Another factor is postural control

Hip Hiking and Circumduction

• Observe the frontal/coronal plane with Hip Hiking
• Circumduction is greater than normal coronal thigh angle during limb mid-swing
• During the swing phase, circumduction is employed
• The swing phase also has postural controls and toe drag is reduced

High Steppage/Steppage gait other causes

• Ankle plantarflexion contracture
• Increased extensor tone
• Proprioceptive impairments (distally).

Weak Quadriceps

• Observe sides and sagittal plane, excessive knee flexion
• Stance phases (loading response and mid stance)
• Swing phase (slows progression and can cause toe drag)
• Gait progression is limited in its speed
• Postural control (toe drag) is also affected
• With compensation, hip extension at initial contact and premature plantarflexion are observed
• Forward trunk lean also occurs

Hip Flexor Weakness

• Observe sides and sagittal plane with inadequate hip flexion in swing
• Front and back view
• Swing phase can be affected with less knee flexion
• There are limitations during progression and with stumbles
• There is compensation with Posterior pelvic tilt
• There is circumduction
• and vaulting

Hip Extensor Weakness (Gluteus Maximus Gait)

• Observe sides using trunk extension at initial contact
• There are limitations in stance (initial contact) impacting postural control and speed
• The person stabilizes HAT on LEs since the hip flexors are weak
• Backward trunk lean (not usable if quadriceps are weak) occurs
• Less hip flexion in late swing occurs

Hip Abductor Weakness (Trendelenburg Gait)

• Observe in front and back
• Stance (single limb)
• Swing (contralateral swing) may be seen
• Progression and step width are limited
• There is compensation with a trunk lean

Lateral Trunk- Other Causes

• Other causes of Lateral Trunk issues include:
  • Painful hip
  • Abnormal hip joint (congenital dislocation of the hip)
  • Walking with an abnormally wide base
• Leg length deformity

Pathologies Affecting Normal Joint Movement: Muscle Spasticity and Limited Musculoskeletal ROM

• Factors associated with Spasticity include:
  • Increased muscle activity during muscle lengthening
• Decreased activation of normally active muscles

Plantarflexor Spasticity/ROM Limitation

• Observe sides and sagittal plane
• Excessive ankle plantarflexion at IC (beyond neutral)
• There will be knee hyperextension in stance
• Observation of the front and back shows equinovarus or inversion
• Load response and push off
• In the gait cycle the pre and initial swing Compensation includes trunk lean Reduce gait velocity (this can limit velocity on spastic muscles)

Quadriceps Spasticity/ROM Limitation (Stiff Knee Gait)

• Observe sides and sagittal knee
• Knee extension in initial contact
• Loading Response In the swing phases there will be hip hiking contralateral vaulting There will be loading problems, postural control issues etc
• Limited movement
• Spasticity

Hamstring Spasticity/ROM

• Observe sides and sagittal plane
• There will be knee flexion in initial contact
• Crouched/flexed knees
• Stance
• loading response
• Swing terminal

Hip Flexor Spasticity/ROM Limitation

• Observe sides
• There will be limited hip extension
• Trunk will flex and the COM anterior

Hip Adductor Spasticity

• Hip Adduction can cause scissoring

Abnormal Movement Patterns: Abnormal Synergies

• An abnormal coupling of muscles can cause the issues

Extensor Synergy

• Extensors activated in the stance phase
• Decreased stance (gluetus muximus
• There will be hipking
• Knee extension and aduction
• Plantarflexion

Flexor Synergy

• Knee flexion
• Ankle dorsiflexion hip internal rotation

Abnormal Movement Patterns: Coordination Deficits

• Impaired coupling among body segments causes the problems

Ataxic Gait (Peripheral Sensory/Cerebellar Involvement)

• Uncontrolled movement
• Staggering
• Wide stepping

Parkinsonian Gait (Basal Ganglia Involvement)

• Shuffing steps
• Freezing
• Defragmented turns

Lack Of Reciprocal Arm Swing/ No Arm Swing

• Typically right upper extremity will swing with the left lower extremity
• No arm swing

Musculoskeletal Involvement: Pain

• Antalgic gait is a limp with one side bearing more weight

Antalgic Gait

• Decreased single limb support
• Decreased the push of is present
• Reduced velocity and the loading will be reduced