Assessment of Gait

Transcript

• 00:18So we're going to talk today about
• 00:21the assessment of gait and how
• 00:23you can use evaluating someone's
• 00:25gait to help identify problems,
• 00:27target your examination and
• 00:29learn what might going on might
• 00:31be going on with the patient.
• 00:35So we're going to talk about the
• 00:38actual physical components of walking,
• 00:42about the muscles used in walking,
• 00:45about the disorders that
• 00:47might occur in walking,
• 00:49about the evaluation of gait
• 00:50and then what to do with that,
• 00:53what the next steps are once
• 00:55we've done our gait evaluation.
• 00:57So walking is taken for granted
• 00:59until there is a problem.
• 01:01So that problem might be acute,
• 01:03such as a hip fracture or a stroke,
• 01:06or more typically a chronic neurologic
• 01:09or musculoskeletal condition will
• 01:12cause some difficulty in walking.
• 01:14Gait abnormalities may indicate
• 01:16a fall risk or provide early
• 01:19evidence of an underlying condition.
• 01:22So the goals of walking are two things.
• 01:25First of all,
• 01:26you have to get your leg from
• 01:27behind you to in front of you.
• 01:29So to Lance, to advance your leg
• 01:31from behind you to in front of you,
• 01:33you have to flex your hip,
• 01:35bend your knee and dorsiflex your ankle
• 01:38to clear your foot off the ground.
• 01:41And you also want to, by walking,
• 01:43navigate your environment safely.
• 01:46And you do that by advancing
• 01:49your center of gravity.
• 01:51So when the erect position you
• 01:53move your center of gravity
• 01:56forward to maintain your balance.
• 01:58You want to keep that center of
• 02:00gravity over your base of support,
• 02:02and the base of support is an area
• 02:06bounded by the placement of your feet.
• 02:09To attain stability, the spine
• 02:12balances both static and dynamic function,
• 02:16including both weight,
• 02:17bearing, and balance.
• 02:19Once the center of gravity moves,
• 02:22reaction forces activate other body parts,
• 02:26particularly those in the lower extremity.
• 02:29Active control of muscles at the hip,
• 02:32knee, and ankle is required.
• 02:36As the cycle repeats,
• 02:38the body displaces in space
• 02:40for a specific distance.
• 02:43The segment or distance covered
• 02:45from 1 foot strike to striking the
• 02:48ground again is called a stride.
• 02:51To achieve energy efficient ambulation.
• 02:54There's a synchronized patent
• 02:56of movement at the foot, ankle,
• 02:58knee, hip and pelvis,
• 03:02so muscles are important in walking.
• 03:04The gluteus maximus muscle is the
• 03:07largest muscle in the human body
• 03:09and it prevents the body from moving
• 03:12forward when the foot strikes the ground.
• 03:15The abductor muscles of the hip
• 03:18prevent tilt of the body when the
• 03:21opposite leg is lifted off the ground.
• 03:25The ankle dorsiflexor keeps the foot
• 03:28clear of the ground when walking.
• 03:31The ankle plantar flexor is one
• 03:33of the major muscles to provide
• 03:36propulsion to drive ambulation.
• 03:38The extension, hip flexion,
• 03:41and hip extension are all important.
• 03:46Postural reflexes are a series of
• 03:49adjustments that occur in the trunk
• 03:52and leg muscles during stance,
• 03:55sometimes called writing reflexes.
• 03:58These reflexes require reliable
• 04:01afferent information from the visual system,
• 04:04the vestibular system,
• 04:06and proprioception in the lower limbs.
• 04:10So gait disorders may be the result
• 04:13of motor defects,
• 04:15weakness or difficulty with
• 04:16the initiation of walking,
• 04:18usually due to degenerative
• 04:21neurologic conditions,
• 04:22may be due to impairment of balance,
• 04:25or may be due to a joint or
• 04:29musculoskeletal problem.
• 04:30To evaluate the gait,
• 04:32we first checked the
• 04:34person's posture, Any difficulty that
• 04:36person might have with initiation,
• 04:38the velocity of gait,
• 04:40the length of the step, the cadence.
• 04:42The cadence is the number of steps
• 04:44that occur in a minute, fluidity of
• 04:47movement and in the instability of gait.
• 04:50So in the gait cycle,
• 04:521 foot is raised and accelerated forward,
• 04:57the hip and the knee flex,
• 04:59and the ankle dorsal flex.
• 05:00So again you need to do that.
• 05:03Flex the hip, flex the knee,
• 05:05endorse the flex the ankle to get your
• 05:07foot from behind you to in front of you.
• 05:09So to clear the ground,
• 05:11those 3 maneuvers have to occur.
• 05:14Muscle action on the
• 05:16supporting contralateral leg,
• 05:18primarily the ankle plantar flexors,
• 05:21accelerate the body's central
• 05:22of center of gravity forwards.
• 05:25The contralateral leg pushes the leg,
• 05:28pushes the body forward and pushes
• 05:30the center of gravity forward.
• 05:32The moving foot is placed on the ground
• 05:35and the weight then transferred to that leg.
• 05:39The heel strikes the ground first.
• 05:41The weight is then transferred
• 05:43to the sole and the toes.
• 05:45But as you know from Olympic walking,
• 05:46the heel has to strike the ground first to
• 05:49be considered to be considered walking.
• 05:52The other foot is raised
• 05:55and accelerated forward.
• 05:56The body is erect,
• 05:58the head forward,
• 05:59the arm swing equally smoothly and loosely.
• 06:03The pelvis and the shoulder
• 06:06should remain level.
• 06:07As the body passes over the weight
• 06:09bearing leg it displaces the center of
• 06:12gravity towards the weight bearing side.
• 06:14There is side to side movement
• 06:17with each step and the body
• 06:19rises and falls with each step.
• 06:22So in a normal gait cycle,
• 06:24it begins when the right
• 06:26heel touches the ground.
• 06:28That's the initial stance phase
• 06:30for the right leg and 60 to 65% of
• 06:33the time the right foot maintains
• 06:36contact with support surface and is
• 06:39considered to be in stance phase.
• 06:42Swing phase begins when the
• 06:45right toe leaves the ground.
• 06:48Now about 20 to 25% of the time,
• 06:51both legs are in stance phase.
• 06:53So when both feet are on the ground together,
• 06:56we call that double limb support.
• 06:59The flexor muscles are very important
• 07:01and active in the swing phase of gait.
• 07:05The extensor muscles have their
• 07:07role in the stance phase of gait.
• 07:10So you observe somebody walk,
• 07:12watch your patient place their
• 07:15foot on the ground,
• 07:16Does their heel touch first?
• 07:19Then the heel and foot should be
• 07:22flat and then finally this push
• 07:25off with the heel off the floor.
• 07:28Does the patient shift weight from
• 07:30the right to the left leg equally?
• 07:32Do they spend the same amount
• 07:35of time on each leg?
• 07:37What is the length of stride?
• 07:40Is the gate wide based?
• 07:43Does the patient search with his or her feet?
• 07:47Does the patient bend forward when they walk?
• 07:50Do they pick up their feet off the ground?
• 07:53Does the patient leave their foot flat
• 07:56on the ground for as long as possible?
• 07:59Do they walk in a relatively
• 08:01straight line or shift
• 08:02from side to side?
• 08:04Do they lean forward or lean
• 08:06towards one side when they walk?
• 08:09Do they look at the ground
• 08:12when they're walking?
• 08:13Do they walk slowly or at a normal pace?
• 08:16And do they have a normal swing of arms,
• 08:19important to look for Swing of arms,
• 08:21particularly the patients
• 08:23that might have Parkinson's.
• 08:26So if the patient bends
• 08:27forward when they walk,
• 08:28there are two common causes for that.
• 08:31One of them is immobility of the hips.
• 08:34So the hips are the hinge
• 08:36on which the legs move.
• 08:38So if the hinge is quite limited,
• 08:40the patient bends forward as they walk.
• 08:43There's also condition known
• 08:44as lumbar spinal stenosis,
• 08:46and that produces pain as the
• 08:49nerve roots are irritated by the
• 08:52structures of a lumbar spine.
• 08:54When you flex your spine,
• 08:56you open up the lumbar spine so
• 08:59patients realize they can walk further
• 09:01if they bend forward and open up that
• 09:04spine and have less nerve root pain.
• 09:07If the patient looks at the
• 09:09ground when they're walking,
• 09:10that may be because they have a
• 09:12loss of proprioception or they may
• 09:14have a tremendous fear of falling
• 09:16and have a so-called cautious gait,
• 09:18which we'll talk about.
• 09:20So we one test that's essential
• 09:22to evaluate gait is what we
• 09:24call the get up and go test.
• 09:26Very simple. You need to do that.
• 09:28Not your nurse, not your MA, OK.
• 09:30The patient gets up from a chair,
• 09:33walks 10 feet, turns,
• 09:35walks back and sits on the chair.
• 09:39You can time that.
• 09:40But the most important part of
• 09:42this test is observing the patient
• 09:44as they're getting off a chair,
• 09:46walking, turning and sitting down.
• 09:49That's the key part of this test.
• 09:51So we're going to talk about different
• 09:53types of gait abnormalities.
• 09:54So to understand frontal gait,
• 09:56you need to understand this
• 09:58concept that we call apraxia.
• 10:00So patients with dementia often cannot
• 10:03carry out a purposeful movement.
• 10:06Even though the muscles and
• 10:07nerves are fully intact,
• 10:09they can't coordinate that movement.
• 10:11So if they have that problem,
• 10:14they have a practice or gait.
• 10:16We call it a frontal gait.
• 10:17Patients stand with their feet wide apart.
• 10:21They have difficulty initiating
• 10:22ambulation and difficulatory
• 10:24picking feet off the ground.
• 10:26They walk as if their feet
• 10:28are stuck to the ground.
• 10:30They take small shuffling steps,
• 10:32variating with moderate steps
• 10:35as a start start cycle.
• 10:38The inability to perform coordinated
• 10:40movements in the absence of motor
• 10:43or sensory impairment is called
• 10:46gait apraxia and this can be seen
• 10:48in normal pressure hydrocephalus,
• 10:49but also can be seen in all types of
• 10:53dementia. A cautious gait patent.
• 10:55If someone has a tremendous fear of falling,
• 10:59then they'd go through strategies
• 11:01to minimize their disequilibrium.
• 11:04So they widen their stance based they
• 11:07slightly flex their hips and their knees,
• 11:10they take shallow short steps,
• 11:12keeping their feet flat on the ground,
• 11:14and they reduce and guard
• 11:17their upper body motion.
• 11:18And they do this to lower
• 11:20their center of mass
• 11:22and limit their motion of
• 11:24that center during stepping.
• 11:26And this is normal if you're
• 11:27walking on a very slippery surface.
• 11:29So this is all how we all walk.
• 11:32Walking across a an icy driveway
• 11:35in February in New England,
• 11:39a ******* hemiparadicate.
• 11:40The affected arm is adducted at the shoulder,
• 11:45flexed at the elbow,
• 11:46and flexed at the wrist and the fingers.
• 11:49The upper extremity does not swing and
• 11:52is held against the chest or the abdomen.
• 11:56It's difficult to flex the hip and
• 11:58the knee and dorsiflex the ankle.
• 12:01Therefore, the patient walks by sweeping
• 12:03their leg out to avoid foot dragging.
• 12:07This is a so-called circumducted gait
• 12:10and the upper body often rocks to the
• 12:14contralateral side during this circumduction.
• 12:17Parkinson's disease is a disease where
• 12:19we've always diagnosed by observing
• 12:21the patient and examining the patient.
• 12:24Those are the key steps in
• 12:27diagnosing Parkinson's.
• 12:28And one of the first things we notice is
• 12:30that people aren't swinging their arms.
• 12:32So if your patient's not swinging their arms,
• 12:34you start looking for Parkinson's.
• 12:37The patients stand immobile.
• 12:39They have a lack of spontaneous movements.
• 12:43They have a flexed posture.
• 12:45Their spine is flexed.
• 12:46Their head is held down.
• 12:48Their elbows, hips and knees are flexed.
• 12:51They have difficulty initiating ambulation.
• 12:54Their trunk will bend forward
• 12:56and their lower extremities,
• 12:57however, will remain fixed.
• 13:00Their upper extremities,
• 13:02as we've already said, don't swing.
• 13:04So if someone's not swinging their arms,
• 13:06look for Parkinson's.
• 13:08Their step leg is reduced,
• 13:11their feet barely clear the ground,
• 13:14and they have this rather unusual gait
• 13:17pattern that we call fascination.
• 13:20And there what they will do is they
• 13:22will start with short, very rapid steps.
• 13:25And the theory is they're bending forward.
• 13:29Their center of gravity is moving
• 13:31forward and they're trying to take
• 13:33their feet to catch up their base of
• 13:36support with the center of gravity.
• 13:38So they'll start taking very rapid,
• 13:40short steps as they walk further.
• 13:43And that's called a fascinating pattern
• 13:47of patients with Parkinson's disease.
• 13:50Cerebellar,
• 13:50A taxier I think of as the atrial
• 13:54fibrillation of gait disorders.
• 13:55And that is, it's irregularly irregular,
• 13:58so the feet are placed wider apart than
• 14:01normal, tend to be externally rotated.
• 14:05The patient staggers from side to side
• 14:09searching for mechanical support.
• 14:11They often have a 4 1/2 tremor
• 14:14of their head and trunk,
• 14:16something we call titubation.
• 14:19The steps are of varying length.
• 14:21The feet are placed erratically,
• 14:23again, irregularly irregular.
• 14:25OK,
• 14:25they can't do a tandem gait and they
• 14:29can't stand with their feet together.
• 14:32Patients with sensory ataxia
• 14:34have lost their proprioception,
• 14:36so they don't know where their limbs are.
• 14:38They need to stand and walk with their
• 14:41feet set widely apart and eyes on the ground,
• 14:44so they're sort of searching with
• 14:46they when they walk with their feet,
• 14:48if they have significant
• 14:50proprioceptive problems,
• 14:52they have a positive Ronberg sign.
• 14:55Their legs often are lifted high in
• 14:57the air and allowed to slap on the
• 15:01ground a so-called slapping gait.
• 15:03So back when syphilis and
• 15:05particularly secondary syphilis
• 15:07with Tabis Dorsalis was common,
• 15:09your patients would be seen with a
• 15:12so-called slapping gait because they had
• 15:14so such an absence of proprioception.
• 15:20Patients with a myelopathic gate
• 15:22look like the Frankenstein monsters
• 15:25and that is they walk stiff legged,
• 15:28wide based and jerky.
• 15:29And the key to a myelopathic
• 15:32gate is the action reaction that
• 15:35occurs when we bend a joint.
• 15:37So when we flex our elbow,
• 15:39we contract our biceps muscle,
• 15:41but at the same time we have
• 15:43to relax our triceps muscle.
• 15:45So it's that relaxation that's impaired in
• 15:48patients with upper motor neuron disease,
• 15:50the so-called myelopathy.
• 15:52So the movements of the hip and knee are
• 15:56slow and stiff requiring considerable effort.
• 15:59Their toe clearance is compromised
• 16:01by reduced knee flexion and spasmic
• 16:04plantar flexion of the ankle.
• 16:06So again they're having a difficult time
• 16:08getting their leg from in front of them.
• 16:10So I'm sorry.
• 16:11From behind them to in front of them.
• 16:14So what they do is circumduct,
• 16:16so they move their entire leg together.
• 16:18So they take their leg and
• 16:20they swing it out like this.
• 16:21So this movement,
• 16:23this abducting the hip is called
• 16:26circumduction and it occurs when
• 16:28the patient can't flex their
• 16:30knee and dorsiflex their ankle.
• 16:32They circumduct their leg.
• 16:34They often move from side to side,
• 16:37their walking speed is reduced,
• 16:40their step length is decreased,
• 16:42and the time of double limb support
• 16:46and step width are both increased.
• 16:49A step edge gate,
• 16:52I think of the changing of the
• 16:54guard at Buckingham Palace when
• 16:56I see a step edge gate.
• 16:57So these are people that have foot drop,
• 16:59they have weakness of their ankle
• 17:02dorsiflexers and they compensate that by
• 17:04lifting their foot as high as possible.
• 17:07So they'll walk like this.
• 17:08They'll hyperflex their hip
• 17:10and hyperflex their knee.
• 17:12As they walk,
• 17:13the toe of the affected leg hits
• 17:16the ground before the heel or
• 17:19the sole of the foot.
• 17:21An intelligent gate is what a person
• 17:23does if they have a painful limb,
• 17:26so they want to spend less time in the
• 17:30stance phase of their affected painful limb.
• 17:33So the affected limb is placed on the
• 17:36ground just long enough to quickly
• 17:38swing the unaffected limb to stand,
• 17:41so less time on the ground is what you see.
• 17:44If the patient has a painful limb,
• 17:46it allows the patient to diminish
• 17:49pain by minimizing the weight
• 17:51bearing time on that limb.
• 17:53So if you want to charge a large consultation
• 17:56fee, you'll call that an intelligent gate.
• 17:59If you want to communicate with your patient,
• 18:02you'll call it limp.
• 18:03It's the same thing.
• 18:04It's a limp.
• 18:04But you again with the limp,
• 18:06you're spending less time on the painful
• 18:08limb and you need to look carefully
• 18:11and that'll help you determine what
• 18:14the source of that limp might be.
• 18:16The inability to flex the knee affects
• 18:20the swing phase of the gate cycle.
• 18:22Again,
• 18:23because you can't fully flex
• 18:25the knee and it's an extension,
• 18:27you can't get it from behind you to
• 18:29in front of you in a normal fashion.
• 18:32So you abduct or circumduct
• 18:34the limb as we've just
• 18:35demonstrated to get your leg from
• 18:37behind you to in front of you.
• 18:40Circumduction is sometimes accompanied by
• 18:42elevating the hemi pelvis on the same side,
• 18:46so-called hip hiking and leaning of
• 18:48the trunk to the contralateral side.
• 18:51And both of those occur if somebody
• 18:54can't flex their knee and have
• 18:56a so-called circumducted gait,
• 18:58an inadequate hip extension gait,
• 19:01because the stride length is decreased.
• 19:04So again, the hip is the the
• 19:09hinge on which the legs move.
• 19:12So if that hinge is narrowed,
• 19:14the stride length is going to
• 19:17be decreased hip extension.
• 19:18If it's inadequate,
• 19:20it keeps the thigh forward.
• 19:22You have an exaggerated curvature
• 19:24of the spine,
• 19:25exaggerated lumbar lordosis to compensate
• 19:28for your lack of hip extension.
• 19:31So hip flexion, contractures,
• 19:34contractions, contractions mean
• 19:35you can't fully extend the hip,
• 19:37can be compensated by knee flexion
• 19:40resulting in a crouched gate.
• 19:42So for functional ambulation you need
• 19:44to be able to stabilize your hip,
• 19:47have anti gravity,
• 19:49hip flexion and abduction,
• 19:51and stable knees and ankles.
• 19:54You need to have adequate balance.
• 19:56You need to be able to bear
• 19:59weight sequentially.
• 20:00So after you've done a gait assessment,
• 20:02what are the next steps?
• 20:04Well, you want to assess balance,
• 20:08you want to determine the
• 20:09patient's fall risk.
• 20:11You want to do a full
• 20:14neurological examination.
• 20:14And that gait assessment should
• 20:16target that about that examination
• 20:19to parts that are most important
• 20:20to you and that should include
• 20:23a manual muscle examination.
• 20:25You should do a complete
• 20:26examination of the joints,
• 20:27again targeted by the gait assessment.
• 20:31And then what do you do in follow up.
• 20:33So an example,
• 20:34if somebody has a myelopathic gait,
• 20:37that Frankenstein type gait
• 20:38where they can't relax muscles,
• 20:40you want to assess muscle tone.
• 20:43Does the person have so-called
• 20:45class knife spasticity?
• 20:47If they do,
• 20:48you'll check for abnormal reflexes for
• 20:50upper motor neuron disease such as the
• 20:53Babinski and the Hoffmann reflexes.
• 20:56If a patient has increased muscle
• 20:59tone and positive reflexes,
• 21:01you want to clearly evaluate them
• 21:04for cervical spinal stenosis
• 21:06because this is a treatable cause
• 21:08of upper motor neuron disease.
• 21:10A patient with a stepage gait you
• 21:12know has some degree of a foot drop,
• 21:14but you want to know whether that
• 21:16foot drop or weakness of ankle
• 21:18dorsal flat dorsal extension is due
• 21:20to central nervous system problems,
• 21:22spinal cord problems,
• 21:24nerve root problems,
• 21:26or peripheral nerve problems.
• 21:27What is the cause of the weakness
• 21:30of the ankle dorsal flexors?
• 21:33So the goals of your gait
• 21:35assessment should be to maintain the
• 21:38individual's ability to navigate
• 21:40his or her environment safely,
• 21:43to provide assistance as needed,
• 21:45to enhance mobility,
• 21:48to identify limitations to normal gait,
• 21:52to intervene to overcome these limitations.
• 21:56Thank you very much.