Transcript GAIT - ndtpediatrictherapy

GAIT
Margo Prim Haynes, PT, DPT, MA, PCS
Mary Rose Franjoine, PT, DPT, MS, PCS
2009
Overview
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Definitions
Video of typical gait
Developmental changes
Gait cycle
Ground reaction force vectors
Atypical gait
Lab
Margo Prim Haynes & Mary Rose Franjoine
Learning Objectives
At the conclusion of this lecture the learner will:
1.
Describe the characteristics of early gait.
2.
Describe the key developmental factors that influence the
development and refinement of gait.
3 . Identify and describe the characteristics of typical gait
differentiating components of stance phase from swing
phase.
4. Visually identify key components of typical gait.
5. Describe the impact of ground reaction forces on the
stance limb.
6. Discriminate typical from atypical components of gait.
7. Design intervention strategies to address key impairments
that contribute to an atypical gait pattern.
Margo Prim Haynes & Mary Rose Franjoine
An Early Walker
Video Clip
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Margo Prim Haynes & Mary Rose Franjoine
Characteristics of Early Gait
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BOS wider than hips,
therefore hindfoot pronation
(eversion) results
Contact with floor occurs
with foot flat
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Heel to toe gait develops
by 2 yrs/ process complete
by 3.5 yrs
Uneven step length
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Margo Prim Haynes & Mary Rose Franjoine
Characteristics of Early Gait
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Hyperextension of knees
throughout stance phase
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Greater ant.-post. pelvic
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movement
Less lateral (pelvic tilting )
& rotational pelvic
movement
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Margo Prim Haynes & Mary Rose Franjoine
Characteristics of Early Gait
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Greater hip & knee flexion
with abduction & external
rotation of hip and tibia
during swing phase
Margo Prim Haynes & Mary Rose Franjoine
Characteristics of Early Gait
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Upper Extremities (UE) in high, medium, then
low guard with improved trunk balance
Reciprocal arm swing developing at 18
months
Margo Prim Haynes & Mary Rose Franjoine
Kinematic Changes between
1 - 7 Years of Age
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↑ duration of single limb stance (esp. to 2.5 yrs)
↑ walking velocity (esp. to 3.5 yrs)
↓ cadence and its variability
↑ step length (esp. to 2.5 yrs)
Ratio of body width to stride width: ↑s rapidly
until 2.5 yrs, more slowly to 3.5 yrs, then
plateaus
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Margo Prim Haynes & Mary Rose Franjoine
Indicators of Mature Gait
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Greater % time in single limb stance with
increased limb length and stability
Increased velocity
Decreased cadence
Greater step length
Decreased base of support
Margo Prim Haynes & Mary Rose Franjoine
Gait
Video
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Margo Prim Haynes & Mary Rose Franjoine
40% of cycle
60% of cycle
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Margo Prim Haynes & Mary Rose Franjoine
Perry 1992
Gait Cycle
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Typical walking has 50-60 steps taken per
minute
Two phases
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Stance phase
Swing phase
Margo Prim Haynes & Mary Rose Franjoine
Stance Phase
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Heel contact (weight acceptance) to toe off
60% of gait cycle
Margo Prim Haynes & Mary Rose Franjoine
Swing Phase
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Toe off to before heel strike
40% of gait cycle
Margo Prim Haynes & Mary Rose Franjoine
Quiet Standing
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Slow shifting of body weight between limbs
due to cardiac dynamics & lack of absolute
proprioception
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Feet generally parallel
COG slightly anterior to the ankle joint
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Tendency for trunk to move forward & plantarflexors
(pf) must hold to stand in place
To move, pf must “let go” (very difficult for children to
do with CP as they rely on extension to stay up)
Margo Prim Haynes & Mary Rose Franjoine
Functional Phases of Gait
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Stance Phase (60%)
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Initial contact
Loading response
Single limb stance
 Midstance
 Terminal stance
Pre-swing=toe off
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Swing Phase (40%)
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Pre-swing
Initial swing
Midswing
Terminal swing
Margo Prim Haynes & Mary Rose Franjoine
Initial Contact
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The instant at which foot touches floor
Ankle locked in supination
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Adduction, inversion, and plantarflexion
Margo Prim Haynes & Mary Rose Franjoine
Loading Response
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Begins immediately after
heel contact (heel strike) &
continues until other foot is
lifted for swing (foot flat)
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Ankle unlocked in pronation
(abduction, eversion, and
dorsiflexion
Double Stance
Deceleration
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Margo Prim Haynes & Mary Rose Franjoine
Single Limb Stance
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Period of time when opposite limb is going
through swing phase
Foot/ankle moves to locked position of
supination preparing the foot and ankle for
push off.
Margo Prim Haynes & Mary Rose Franjoine
Weight bearing Surface of Foot
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At heel contact, weight is lateral to the
midline of the heel
Weight moves forward in a straight line
towards head of third metatarsal
Then weight shifts medially to allow push off
from first metatarsal head when initial swing
begins
Margo Prim Haynes & Mary Rose Franjoine
Weight Bearing Surface of foot
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Margo Prim Haynes & Mary Rose Franjoine
Pre-Swing
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Begins with initial contact of opposite limb
and ends with ipsilateral toe-off
Margo Prim Haynes & Mary Rose Franjoine
Initial Swing
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Begins with lift of the foot from the floor
and ends when swinging foot is opposite
the stance foot
Margo Prim Haynes & Mary Rose Franjoine
Midswing
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Begins when swing limb is opposite stance
limb and ends when swinging limb is forward
and tibia is vertical
Margo Prim Haynes & Mary Rose Franjoine
Terminal Swing
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Begins with vertical tibia and ends when foot
contacts (strikes) the floor
Margo Prim Haynes & Mary Rose Franjoine
Sinusoidal Pattern
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Limb motion during walking is based on
maintaining a symmetric and low amplitude
displacement of the center of gravity (COG)
in the lateral and vertical directions.
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Initial Contact
Double limb support
Midstance
Margo Prim Haynes & Mary Rose Franjoine
Sinusoidal Pattern
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Margo Prim Haynes & Mary Rose Franjoine
Perry, 1992
Sinusoidal Pattern
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COG:
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Lowest during initial contact
Central and low during double limb support
Highest and most lateral in midstance
Moves 4 cm medial-lateral shift, 2 cm
vertical shift
Margo Prim Haynes & Mary Rose Franjoine
Ground Reaction Force Vectors
(GRFV)
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Determines the stability or instability by
relating alignment of GRFV to the joint
centers
Ankle gains stability with 5° dorsiflexion
Three forces (body vectors)
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Falling body weight
Ligamentous tension
Body vector as passive stability when the joints
are hyperextended
Margo Prim Haynes & Mary Rose Franjoine
Body vector as passive stability
when the joints are
hyperextended
Joints are locked by body
weight vector on one side
and ligamentous tension
on the other.
This explains the posture of
the child with hypotonicity
← iliofemoral ligament
Posterior oblique ligament →
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Margo Prim Haynes & Mary Rose Franjoine
Perry 1992
Ground Force Reaction Vector
Initial contact to loading
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Margo Prim Haynes & Mary Rose Franjoine
Perry 1992
Muscle Activation
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Margo Prim Haynes & Mary Rose Franjoine
Perry 1992
Critical Events for:
 Initial
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contact is heel first contact
Margo Prim Haynes & Mary Rose Franjoine
Critical Events for:
 Loading
response is hip stability,
controlled knee flexion, and
plantarflexion
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Margo Prim Haynes & Mary Rose Franjoine
Ground Force Reaction Vector
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Margo Prim Haynes & Mary Rose Franjoine
Perry 1992
b
Muscle Activation
(muscles are more balanced,
therefore less hard work)
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Margo Prim Haynes & Mary Rose Franjoine
Perry 1992
b
Critical Events is:
 Controlled
tibial advancement to
create a forward fall position.
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Margo Prim Haynes & Mary Rose Franjoine
Ground Force Reaction Vector
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Margo Prim Haynes & Mary Rose Franjoine
c
Perry 1992
Muscle Activation
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Margo Prim Haynes & Mary Rose Franjoine
c
Perry 1992
Critical Events is to have
Ankle locked in dorsiflexion with heel
rise; trailing limb
 Ankle mobility
 (This is where the children with
plantarflexion contractures have
problems)
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Margo Prim Haynes & Mary Rose Franjoine
Gait Analysis
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Observation
Pedograph
Motion analysis
Dynamic electromyography
Force plate recordings
Energy cost measurement
Margo Prim Haynes & Mary Rose Franjoine
Five Determinants of Gait
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Lateral pelvic movement (gluteus medius
prevents positive Trendelenberg)
Rotational pelvic movement (one side
moves forward of the other side to minimize
vertical shift of the COG, allows for stride
length)
Knee flexion(allow for limb length
adjustment)
Knee/ankle/foot interactions (minimizes the
vertical shift of the COG)
Physiologic valgus (narrows BOS)
Margo Prim Haynes & Mary Rose Franjoine
Five Determinants of Gait
1.
Lateral pelvic movement (gluteus medius
prevents positive Trendelenberg)
2.
Rotational pelvic movement (one side moves forward of the other side
to minimize vertical shift of the COG, allows for stride length)
Knee flexion(allow for limb length adjustment)
Knee/ankle/foot interactions (minimizes the vertical shift of the COG)
Physiologic valgus (narrows BOS)
3.
4.
5.
2009
Margo Prim Haynes & Mary Rose Franjoine
Five Determinants of Gait
1.
Lateral pelvic movement (gluteus medius prevents positive
Trendelenberg)
2.
Rotational pelvic movement (one side moves
forward of the other side to minimize vertical
shift of the COG, allows for stride length)
3.
Knee flexion(allow for limb length adjustment)
Knee/ankle/foot interactions (minimizes the vertical shift of the COG)
Physiologic valgus (narrows BOS)
4.
5.
2009
Margo Prim Haynes & Mary Rose Franjoine
Five Determinants of Gait
1.
2.
Lateral pelvic movement (gluteus medius prevents positive
Trendelenberg)
Rotational pelvic movement (one side moves forward of the other side
to minimize vertical shift of the COG, allows for stride length)
3.
Knee flexion(allow for limb length
adjustment)
4.
Knee/ankle/foot interactions (minimizes the vertical shift of the COG)
Physiologic valgus (narrows BOS)
5.
2009
Margo Prim Haynes & Mary Rose Franjoine
Five Determinants of Gait
1.
2.
3.
Lateral pelvic movement (gluteus medius prevents positive
Trendelenberg)
Rotational pelvic movement (one side moves forward of the other side
to minimize vertical shift of the COG, allows for stride length)
Knee flexion(allow for limb length adjustment)
4.
Knee/ankle/foot interactions (minimizes the
vertical shift of the COG)
5.
Physiologic valgus (narrows BOS)
2009
Margo Prim Haynes & Mary Rose Franjoine
Five Determinants of Gait
4.
Lateral pelvic movement (gluteus medius prevents positive
Trendelenberg)
Rotational pelvic movement (one side moves forward of the other side
to minimize vertical shift of the COG, allows for stride length)
Knee flexion(allow for limb length adjustment)
Knee/ankle/foot interactions (minimizes the vertical shift of the COG)
5.
Physiologic valgus (narrows BOS)
1.
2.
3.
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Margo Prim Haynes & Mary Rose Franjoine
Bibliography
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Perry J: Gait Analysis Normal and Pathological
Function, NJ: SLACK Inc. 1992
Shumway-Cook & Woollacott: Motor Control Theory
and Practical Applications, Baltimore: Williams &
Wilkins, 1995
Sutherland D: Gait Disorders in Childhood and
Adolescence, Baltimore: Williams & Wilkins, 1984
Weber & Weber: Mechanics of the Human Walking
Apparatus, Berlin: Springer-Verlag, 1992
Margo Prim Haynes & Mary Rose Franjoine
Original Template designed by:
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2009
Margo Prim Haynes, PT, DPT, MA, PCS
Jane Styer Acevedo, PT
Margo Prim Haynes & Mary Rose Franjoine