GaitAnalysis and Equipment Selection

Sally Mallory, PT, ATP, CPSTsally.mallory@yahoo.com

Course Outline

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Importance of independent mobility

Analysis of gait cycle

Phases of gait

Shank & thigh kinematics

Ambulation equipment types

Considerations for equipment selection

BWSTT treadmill training vs ground training

Factors impacting functional mobility

Gait analysis with instrumentation & case study

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• The whole body is active

• Bones, joints and muscles, nerves, senses, heart and lungs work together and movements are coordinated.

• To be able to walk, head and trunk control together with balance and active use of arms and legs are needed.

During Ambulation

Importance of Independent Mobility

• Increases level of engagement in educational and recreational activities

• Promotes problem solving skills

• Enhances quality of interactive behavior with other children, adults

• Increases exploration of environment

• Promotes cognitive, perceptual and visual spatial skills by learning to navigate around obstacles, avoid stairs or other drop offs

• Promotes healthy functioning of physiological systems (heart, lungs, GI, bladder, bones)

• Increases self confidence

• Reduces learned helplessness

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Importance of Early Mobility

• Immobility associated with “Learned Helplessness”

• Established by 4 years of age in children without functional mobility

(Butler, 1991; Safford & Arbitman, 1975, Lewis & Goldberg ,1969)

• Decreased curiosity & initiative

• Poor academic achievement

• Poor social interaction skills (Kohn,1 977)

• Passive, dependent behavior

• Lack object permanence

• Dependent on vision to control posture (Bai & Berenthal, 1992)

• Poor visual spatial skills and memory (map testing difficult)

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Research

Real-World Performance: Physical Activity, Play, and Object-Related Behaviors of Toddlers With and Without Disabilities

• Logan S, Schreiber M, Lobo M, Pritchard B, George L & Galloway JPediatric Physical Therapy (2015) Volume 27 Issue 4:433–441

➢Typically developing toddlers spend 1 hour/day in direct play with peers

➢Toddlers with disabilities spend less than 20 minutes & as few as 6 minutes/day in direct play with peers

➢Toddlers with disability:

➢Less engagement with peers

➢Less interaction with environment

➢Less variability of movement

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Normal Motor Development

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Pulls up to stand Stands with support Cruises

Stands unsupported Takes few steps

10 months

Diagnoses

• Down Syndrome

• Developmental Delay

• Cerebral Palsy

• Spina Bifida

• Arthrogryposis

• Muscular Dystrophy (certain types)

• Mitochondrial Defects

• Metabolic Disorders impacting movement

• Genetic Disorders

• Head Trauma

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Factors Impacting Functional Walking

• Limitations in force generation & grading of muscle strength in head, torso, and/or extremities

• Poor endurance

• Abnormal muscle tone

• Abnormal sensory motor synergies for movement

• Range of motion issues

• Skeletal deformity

• Cardiopulmonary issues

• Balance/coordination issues

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Goal

• Promote independent mobility for active control over one’s exploration of the world

• Use of appropriate assistive technology to improve functional mobility as needed

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Therapist’s Role in Functional Mobility

• Functional performance assessment

• Therapy interventions

• Gait analysis to determine gait pattern issues

• Ambulatory equipment selection if needed

• Orthotic Selection if needed

• Body Weight Supported Treadmill Training vs BWS Overground Training

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Gait Analysis

• The systematic study of human motion, using the eye and the brain of observers, augmented by instrumentation for measuring body movements, body mechanics, and the activity of the muscle

• Gait analysis with instrumentation

• Observational gait analysis (without instrumentation)

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Phases of Gait

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Gait Cycle

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Gait Requirements

To walk 3 tasks must be accomplished:

1. Weight acceptance by a limb

2. Single limb support of body weight

3. Swing limb advancement

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Gait Cycle Summary

• Initial Contact

• Weight accepted while maintaining limb stability & forward momentum

• Hip Flexion 30, Knee Ext 0, Ankle 0 (heel strike)

• Loading Response

• Shock absorption & momentum preserved

• Slight knee flexion at loading due to deceleration by Ankle DF to lower foot to floor; Hip ABD/Extensors Active

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Task: Weight Acceptance

Phases of Gait:

Gait Cycle Summary

• Mid Stance

• Body advances from behind to ahead of ankle

• Hip & knee extension concentrically extend limb then Ankle PF eccentrically control momentum

• Ankle PF’s decelerate/counter knee extension & control tibia forward movement

• Terminal Stance

• Extreme progression of body forward past MTP heads

• Limb stability with active Hip ABD

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Task: Single Limb SupportPhases of Gait

Shank & Thigh Kinematics

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Relationship of shank, thigh, pelvis, & trunk to segments in normal gait

Owen, E (2010) The importance of being earnest about shank and thigh kinematics, especially when

using ankle-foot orthoses. Prosthetics and Orthotics International 34(3): 254-269.

Shank & Thigh Kinematics

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Relationship of shank, thigh, pelvis & trunk segments in standing

Owen,2010

Shank & Thigh Kinematics

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During mid stance: Important for stability

Shank 10-12° inclined during midstance

Knee over middle of foot

Owen,2010

Static Orthosis

1. Facilitate hip extension

2. Replicate normal, or as close to normal as possible, shank and thigh kinematics

3. Achieve stability

4. Achieve balance

5. Take account of the needs of bi-jointed and tri-jointed muscles

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Purpose of Orthotics

Gait Cycle Summary

Phases of Gait

• Pre Swing

• Foot still on floor, weight shifts to opposite limb

• Initial Swing

• Foot clearance as leg moves forward

• Active Hip Flexors, Knee Flexors (& momentum) increase

knee flexion

• Active Ankle DF for foot clearance

• Mid Swing

• Limb continues forward with active Hip Flexors

• Knee begins to extend as hamstrings turn off ; Ankle DF

become active

• Terminal Swing

• Knee extensors active to fully extend knee for full stride

length

• Ankle DF active to prepare for heel strike23

Task: Swing Limb AdvanceObjective: Swing limb advances from behind to forward of body; foot clearance

Equipment to Assist Ambulation

• Single point cane

• Quad cane

• Loft strand crutches

• Posterior walker

• Anterior walker

• Posterior or vertical gait trainer

• Anterior gait trainer

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Least to Most Assistance

Independent Walking

WalkerIndependent

WalkingGait Trainer

Types of Assisted Walking Equipment

• Walker: provides no unweighting of LE’s

• Requires UE’s to push the walker and maintain upright torso with minimal postural supports

➢R82 Crocodile, Mustang (basic)

➢Kaye Posture Walker

➢Rifton (basic)

• Gait trainer: offers both unweighted support and postural alignment to enable gait practice.

• It provides more assistance for balance and weight-bearing, than does a traditional rollator walker, or a walker with platform attachments.

➢Anterior (E8002) - Mustang, Pony, Rifton

➢Vertical (E8001) - Mustang, Crocodile, Kaye with suspension

➢Posterior (E8000) - Mustang, Kidwalk, Rifton, Kaye with suspension 25

Considerations for Selection• Stage of recovery: acute vs later rehab stage

• Head control

• Trunk control: upper or lower thoracic, lumbar spine

• UE function: active use of hands, limited dexterity or spasticity

• Ability to weight bear through LE’s (full or partial)

• LE stance & gait pattern

• Scissor pattern

• Endurance, cardiopulmonary status, balance

• Size of walker or gait trainer base of support

• Storage: collapsible or not

• Environment/setting: home, school, work, indoor or outdoor use

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Acute vs Later Stage of Rehabilitation

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Acute or early stage: BWSTT

• Debilitated patient: weakness, balance issues, fatigue, fear of falling

• BWSTT (Body Weight Supported Treadmill Training)

• Can provide good body alignment, partially unload LE’s, and provide

repetitive stepping practice at different intensity for neuroplasticity to

occur without fear of falling

Later stage rehabilitation: Overground training

• Stepping is more self generated, but gait pattern/speed may need work

• Increase challenges (obstacles, inclines, different terrain)

• Negotiate actual environment, self directed, problem solving

BWSTT

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• Treadmill training vs traditional gait training equally effective

• Definitely helpful with acute stage or debilitated patient

• Eliminates falls

• Reduces man power needed

• Provides repetitive stepping practice with variations in intensity

• Research has shown it can help attain walking, improve gait speed, and endurance for different types/degrees of CP *

*Mattern-Baxter K (2009) Effects of Partial Body Weight Supported Treadmill Training on Children with CP. Ped

PT Journal 21(1):12-22

Lite Gait

BWS Overground Training

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Mustang

Types of Equipment: Posterior Walker

Head Control

• Patient has head control

Trunk Control

• Patient has upper trunk control

• Support around pelvis may be needed (back, side support)

Active Weight Bearing

• Patient able to bear weight through legs

• If good arm strength, some of weight bearing can be through the hands or forearms

• May need flip down seat for rest or forearm supports

Active use of hands

• Forearm support may be necessary if no active use of hands

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Posterior Walker

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Crocodile

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• Posterior walker- height adjustable

• GMFCS II-III

• CP Type

• Spastic Diplegia, Hemiplegia

• Low Tone, Mild Ataxic

• Accessories

• Sling seat, flip down seat

• Back, hip & trunk supports

• Forearm support with handgrip

Crocodile

Gait: Spastic CP

• Types: Quadriplegia, Diplegia, Triplegia, Hemiplegia

• GMFCS: II-III (Posterior Walker)

• III-V (Ant./Post. Gait trainer)

• Spasticity: varies per type

• Hip: Flexors, Add, IR

• Knee: Hamstrings

• Ankle: Plantar flexors

• Possible contractures

• Muscle weakness: varies per type

• Abnormal muscle coordination, synergy

• Crocodile, Mustang, Pony

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Frame football video

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Types of Equipment:

Anterior & Posterior Gait Trainer

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Head Control

• Patient may have head control or be limited

• Head support may be needed

Trunk Control

• Upper trunk control is limited

• Chest support placed in upper thoracic area, possibly UE supports (arm troughs)

• If trunk control improves, chest support can be lowered to lower thoracic or lumbar area

Active Weight Bearing

• Unable to manage full LE weight bearing independently

• Seat with sacrum support, a sling seat, or back and hip supports used to stabilize around the pelvis and partially support body weight

Scissor Pattern

• Can be reduced by using a leg separator or ankle prompts

Anterior & Posterior Gait Trainer or Walker

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Mustang

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Posterior or Anterior Gait Trainer

• CP GMFCS III, IV, V (spastic, athetoid, ataxic)

• Head Trauma, DD, Mitochondrial Defects

• Anterior Set Up:

• Adjustable forward tilt to elicit stepping

• Posterior Set Up:

• Client with some trunk control

• Full upright support with UE’s free if able

• Center mount is dynamic to allow natural

up/down rhythm of walking

• Leg separator (removable) or ankle prompts for

LE scissoring issue

Mustang

Mustang Accessories

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Arm Rest Anterior & Chest Support

Arm Prompts; anterior or posterior

Anatomic Head Support

Sling Seat Firm Seat Hip Support

Gait: Low Tone CP

• Abnormal tone –low

• Muscle weakness

• Head, torso, extremities

• Poor ability to generate & sustain muscle force

• Poor coordination

• Requires skeletal support

• May need gait trainer with head, chest, arm, and pelvic support initially then weaned to walker

• Mustang Gait Trainer

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Mustang

Anterior set up

with headrest

Mustang Pony

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Anterior Gait Trainers

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• Anterior gait trainer

• CP GMFCS III, IV (Spastic Quad, Spastic Triplegia, Athetoid)

• Developmental Delay

• Central bar connected to chest & seat supports

• Forward tilt of chest support & seat to elicit stepping

• Central plate to prevent LE scissoring (non-removable)

• Indoor use

Pony

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• Height adjustable seat

• Adjustable forward lean

• Head, back ,chest, hip support

• Abdominal pad

• Armrest pad semicircular

• 5 caster system

Pony Characteristics/Accessories

Rifton Pacer Grillo

Prime Engineering: Kidwalk

Other Gait Trainers

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Mini walk II (Meywalk) Lite Gait Suspension Conversion Kit for Kaye Posture Walker

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Axilla height:

• For choosing the correct size of walker

• Pony, Bronco and Mustang

Chest width:

• For choosing the correct size of chest support

Total height:

• ½ the total height will be the approximate height for “handle height”

• Crocodile

Measuring for a Walker or Gait Trainer

Gait Analysis with Instrumentation

• Phases of gait

• Temporal/spatial measurements

• Center of gravity, center of mass

• Determinants of gait

• Kinematic measurements - evaluate movement patterns, specific angles between segments as body moves through gait cycle

• Kinetic measurements - evaluate forces over different joints

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Gait with more detailTerminology:

Temporal/ Spatial Measurements

• Stride Duration/Gait Cycle = same foot through one full cycle (initial contact)

• Stance & Swing Phases

• Single Limb Support – time with one foot on ground during one cycle

• Double Limb Support – time both feet are on ground during one cycle

• Stride Length = from initial contact of one foot to next initial contact of same foot

• Step Length = distance between heel strike of L foot to heel strike of R foot

• Cadence = # of steps/minute (100-115 steps/min. average )

• Speed = step length x cadence

• Velocity = distance/time

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Center of Gravity Displacement - Energy Efficiency

• Vertical Displacement - up & down movement; 5 cm

• Highest point = midstance

• Lowest point = double support

• Lateral Displacement - side to side movement; 5 cm

• Path of COG or COM = sum of these 2

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6 Determinants of Center of Gravity Change

1. Pelvic rotation - 4° on swing limb (8° Total)

Helps longer step length

2. Pelvic tilt (downward) - 5° swing limb

3. Knee flexion after heel strike in stance phase (loading response) (15- 20°)

4. Foot mechanism Early stance: Knee full ext. / Ankle DF / COG lowest

5. Knee mechanism Late stance: Knee flexing / Ankle PF / COG min change

6. Lateral displacement of body - narrower base minimizes COG displacement

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MethodologyCollection of Data

• Anthropometric measurements of the trial person are done

• Markers are mounted

• The trial person walks on a marked walking area with 1 to 2 force - plates in the floor

• Video recording: two dimensions (frontal & sagittal)

Data Presentation

• Animation of skeleton figure in 3-D

• Kinematic graphs with information about joint angles

• Kinetic graphs showing the forces over the different joints

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Gait Analysis Study

• Completed at Hvidovre Hospital, Denmark

• 01/27/2012

• Client using the R82 Mustang

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• A child’s gait will be influenced by the adjustment of equipment. This study was an attempt to measure and document the influence of different configurations of the same walking frame for a child with CP

• The R82 Mustang was assessed with an 11 year old child with bilateral CP (GMFCS V)

• Previously child had used an NF-Walker at home and a Cavalier walker in school

• Size 4 Mustang used; castors were locked in line

Background

Cavalier

Configuration #1

• The Mustang seat is mounted

• Chest support is adjusted to axilla height (95 cm from foot to top of chest support with the gas strut at max. length)

• The central bar is tilted a few degrees forward of vertical

• Note the tightness across hips and knees contributing to flexion and short steps

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Configuration #1

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Configuration #2

• Seat and chest support adjusted as in configuration #1.

• The central bar is tilted 10 degrees forward (additional tilt to that in configuration #1)

• Note the marked improvement in hip and knee extension giving the child an active stretch of the spastic muscles.

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Configuration #2

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Configuration #3

• This configuration is the same as #2 with the addition of a hand grip mounted in front of the child.

• Note that this additional accessory has not improved on #2

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Configuration #3

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Configuration #4

• The Mustang walking frame is reversed to provide support posteriorly

• The center bar is tilted 10 degrees forward.

• Note that in this configuration the stretch over the hips is not as good. However our test subject has a gait pattern close to normal in configuration #4 with longer steps.

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Configuration #4

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Configuration Summary

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Results & Recommendations

• Test subject has tightness in hips and knees.

• Configuration #2 -greatest extension at hip and knee.

• This will provide an active stretch

• If focus is on the short muscles this would be the therapeutic choice

• Configuration #4- gait pattern close to normal

• Subject has longer steps but without a good stretch over the hips

• Recommendations:

• Configuration #4 was preferred for home use only

• Configuration #2 was preferred for school use because it provided greater stability and safety in this environment with other children

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Funding

• Type of Gait Trainers

E8000 – Gait trainer, pediatric size, posterior support, includes all accessories and components

E8001 – Gait trainer, pediatric size, upright support, includes all accessories and components

E8002 – Gait trainer, pediatric size, anterior support, includes all accessories and components

• Note: There is no payment amount assigned to the above codes, so most payers regard these a

“by report” or a gait trainer miscellaneous code. It is important to identify the code for the

complete gait trainer intended for the individual. Although the codes indicate “pediatric size, it is

recommended to use these gait training codes so there is no confusion with adult walker coding

or product. Most payers will pay for the options to make the gait trainer functional and safe.

• Walkers have no funding code, so use a miscellaneous code

• If gait trainer or walker is an exclusion, appeal as medical necessity

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NCART Gait Trainer Guidelines

A Special Thanks to the Following Contributors:

K Missy Ball, MT, PT, ATP

Helle Matze Rasmussen, PT

Bente Storm, PT

Francis George, MSc, BSc, MCSP

Sally Mallory, PT, ATP, CPST

Julie Kobak, MA, CCC-SLP

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Course Evaluation and Certificate Instructions

1. Go to: www.brainsbuilder.com

2. Select “Take an assessment”

3. Enter Your Assessment ID: (provided by presenter)

4. Enter Your Login: Convaid

5. Complete evaluation

6. Certificate of Completion will be sent to the email you provide in evaluation

Contact: Annette Hodges NRRTS ahodges@nrrts.org

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