Our second session today is gait examination for advanced practice providers with Dr. Robert Irwin. Dr. Irwin is currently the vice chair for operations in the Department of PM&R at the University of Miami Miller School of Medicine. His main clinical field of interest is spine, sports care, and electrodiagnostic medicine, focused on interventional skills for spine and sports injuries. Welcome to this session on gait evaluation. My name is Dr. Robert Irwin, and I'm at the University of Miami. We're going to talk about the different portions of the gait, starting with the gait cycle. This is from the beginning of one step all the way through to the second step and on. The other things I'm going to want you to learn are the six determinants of gaits, and these are the things that we look at when you're seeing somebody walk. Now, we're going to use that then to assess different abnormal gaits after I go through and show you how to do the initial gait evaluation on a normal gait. I hope that this is helpful, and we're going to start with a small PowerPoint presentation, and then we'll move on to the exam itself. This is the PowerPoint presentation that I had mentioned earlier. We're going to get started, but first I need to let you know I have nothing to disclose, so no disclosures here. I talked already about what it is we want you to learn from this, that being the basic gait cycle, and then understand the six determinants of gait so that we can use that in assessing different gaits, which will include the normal gait, hemiplegic gait, Trendelenburg gait, steppage gait, scissoring gait, and a shuffling gait. This is the gait cycle, and if you'll notice, the gait cycle starts with the right foot strike all the way through to the next time the right foot strikes. That goes through the whole thing of the right foot being foot-planted, swinging through, coming from the back, and moving forward. That's what's called one cycle. Below you can see that people have divided up the cycle into different portions, which include the double-limb stance phase, as well as the single-limb stance and the swing phase. You should know that the stance phase is about 60% of the gait cycle, and the swing phase is only about 40%. When we talk about the six determinants of gait, these are there so that our body can be more efficient with ambulation. What it does is keeps the center of gravity from moving up and down or side to side, thus making the movement very smooth. When you talk about efficiency, you don't want to be changing your center of gravity up and down, as that costs energy. What you'd rather do is use that energy to go faster or control what it is you're doing. Now, the six determinants that we'll be talking about are the pelvic rotation, pelvic tilt, knee flexion and stance phase, foot mechanisms, ankle mechanisms. These are kind of generically discussed, and then the lateral displacement of the pelvis. When we start with pelvic rotation, what we're looking at is forward rotation of the pelvis, which then allows... When we talk about the determinants of gait, we talk about pelvic rotation as the first one. This is forward rotation of the pelvis in the horizontal plane, approximately 8% in the swing phase. Now, this is what allows you to move your hips forward. You can watch and see some people with a shorter stride don't move their hips as forward as others. It reduces the angle of hip flexion and extension by extending this out, and it enables you to get a longer step. In other words, it extends your leg. It makes it functionally a longer limb by doing this. The next thing we talk about is pelvic tilt. This really is rotation of the pelvis on the sacrum. This gives you an extra maybe 5 degrees on the swinging side. This is because both sides together add up about 2% to 3%. They move in what's called nutation and counter-nutation. These are the names of the way the pelvis rotates in order to help extend the leg again. We will talk about a Trendelenburg gait in the future, but that goes along with dipping of the hip. What we try to do with these things is keep the hip from dipping down and therefore making us more efficient. When you have heel strike, your leg is generally in the extended fashion. You need to flex your knee in order to swing over top of that leg. Otherwise, you'll be pole vaulting and going up and down. When you go up and down, you change your center of gravity. Going up actually spends a lot of energy, and you don't gain it back when you come down. This keeps us from having to do the extra work of bouncing up and down in our gait. It does shorten the length of the leg. Remember, everything we've done up to this point has been to extend the length of the leg, but since we don't want to be pole vaulting over this leg, we're going to be shortening the leg so that we can get over it. Ankle mechanisms are what allows the ankle to go from a heel strike that may be in 90 degrees to a foot flat. This allows more stability as your knee flexes and you go through and over in the stance phase. Just as the ankle mechanisms do, we also have foot mechanisms. Most of them are more at the end of the stance phase as we get ready to push off. If you'll notice in the very end here, the toe off is where we have the foot really taking place, and we do have to push off there. That gives us a little extra energy in order to do that. Lastly, the lateral displacement of the body or pelvis allows us to not waddle from side to side. This allows us to be a little bit more efficient in our walking, and you will see there are some gaits that you do need to waddle in order to make up for weaknesses. The reduced muscular energy consumption that we get helps to keep the gait smooth and efficient. This is my APP, Alan, who has volunteered to be our guinea pig for the gait analysis. I'm going to have Alan turn around and walk away and walk down the hall and then turn around and come back to us. As we follow Alan here, what we're looking for is his arm swing, and you can notice the arms do swing. In some neuromuscular diseases, they don't swing. The other thing you want to look is pelvic rotation and pelvic tilt. Those are the starting points, and as we look further down, we look towards the knees. We look to see if he hyperextends his knees, if he has good flexion, and if he's able to keep them in line. The next thing we want to look at, as we talked about in the six determinants of gait, is how his heel strikes. That's better seen posteriorly, but that then adds to the foot and ankle flexion. That then adds to the foot and ankle mechanisms. Then the last thing is lateral rotation or lateral sliding of the pelvis. That's what keeps him from having a jerky gait. As you'll notice, he walks nice and smoothly. He doesn't bounce up and down. He's not slipping from side to side, almost falling over. He's able to keep a nice stride. Now we're going to take a look at this from the side and see what it looks like as he continues to walk. You notice on the side that the knee is in partial flexion when he has heel strike. Also notice his arms moving. His hips do drop a little, which we do expect. You can see that his legs are artificially extended by him tilting his pelvis. Now we're going to talk about the hemiplegic gait. We see this after strokes. An MCH stroke is the most common of this. These patients usually will have a flexion of the upper extremity and then they'll have extension of the lower extremity. This makes it harder for them to clear. If you'll notice, their hips are no longer in flexion. They're not in a straight line. This makes it harder for them to clear. If you'll notice, their hips are no longer even. In addition to that, these patients can't relax the lower extremity as much because of spasticity and different recruitment of muscles once you cut the pyramidal tracts. These patients will often circumduct their leg around to try and get it to move. They have to swing their hip in order to get it to clear. It can't clear straight forward because it's actually longer functionally than the other leg. When they turn around, they take small steps. Then again, circumduct to try and get around. You can see here, the foot is plantar flexed, a little bit internally rotated, and the hip is higher than the others. This is what forces them to come around. They don't have the flexion at the knee like we see when Alan was walking for us. Now we're going to talk about the steppage gait. Steppage gait is for people who have weakness of dorsiflexion. They may also have some plantar flexion weakness if it's a sciatic nerve injury. When they walk, they can't have heel strike and control the foot moving down. When they walk, you'll see they have to pick their whole knee up and slap it down. It slaps down instead of being a nice smooth walk. It's characterized by excessive flexion of the knee and the flopping of the foot. Excessive flexion of the knee and flopping of the foot. It's a steppage gait because of the weakness and they can't clear. If they were to walk without doing a steppage gait, they would trip on their foot because they can't pick it up. This is what they're trying to avoid. The next gait we're going to talk about is the Trendelenberg gait. It's seen a lot of times in myopathies or anything with proximal weakness. Just weakness on one side would give you the traditional Trendelenberg gait. This is where the hip girdle is not strong enough to hold up the body when they step. Normally when I go to step, I lift up my knee and my gluteus medius picks up all the strength and keeps my hip from falling. In somebody who's got weakness here, their hip falls to the side. What they end up doing is, in order to keep from falling over every time they walk, they throw their body over to the side so that they can actually walk. Everything else works fine, they just have to lean over in order to get things to walk. Again, they lean over to the weaker side to move their center of gravity so that they don't fall. That's the Trendelenberg gait. The next gait we're going to talk about is the scissoring gait. We can see this in spastic diplegia. This happens as we get older, after someone who's had cerebral palsy, their gait changes as the spasticity changes. They may even have this when they're younger. What happens is they have adductor tightness, which doesn't allow them to spread out and actually walk. What we see is more of a crossover, that's why we call it scissoring. They are walking and crossing over as they do this. It's not a particularly stable gait, but it is something that can allow people to propel. Often times you'll see the knees come in because the adductors are so tight. This is called a scissoring gait and seen in spastic diplegia. The next thing we want to talk about is a gait seen in Parkinson's, which is a shuffling gait. Normally we walk with our feet about shoulder width apart. But in Parkinson's, everything seems to kind of flex up. Their feet come narrow-based and they shuffle. It's sort of a festinating gait where they can't take long steps. You notice when we're talking about stride, these people have a very short stride because they have very short steps. If they've got medications on board, they may be a little straighter, but they'll still take a very short shuffling type gait. This is the gait of Parkinson's, also known as a shuffling gait. Thank you for your attention. Now let's just review a few of the things that we've gone over today during this presentation. The gait cycle is one stride. It's made up of one step on each foot. We have six things to look at in gait, those six determinants of gait. What we're doing here is really just a basic overview, and I'm hoping that this will get you interested in assessing your patient's gaits. What I do is I look at everybody's gait when I'm sitting down watching things. So somebody's coming towards me, I look at their gait. Someone's going away, I look at their gait. It becomes fun, and you can actually just grab some of your friends. When you have time, get together and sit there and watch people go by and talk about their different gaits. So welcome. My name is Bob Irwin, and thanks for being here today, and I hope it was helpful. I'm going to kind of go over what there is in the chat, and right now I only see one. And the thing is, are there normal changes in gait that can be seen with age? Most of the changes that we see in gait, if you want to say normal changes, are the result of weakness, and therefore we end up getting somewhat of a shorter stride, but it's not as short as like we see in Parkinson's. The other things that you might see is that if somebody's got arthritis or other pains as they get older, they take a different approach to their gait, and they may lean over more to one side or the other to protect the hip that's in pain. So there's not an overall one thing that you'll look for, but generally you'll also see a slower pace. We talk about people having a self-selected pace, and as you get older, you select your pace to be a little bit slower. This also goes along with cardiovascular changes in the body, so that you adapt to what your body can do. I see another question is, are there differences seen in males and females? The one thing you see in females that you don't see in males, so males, the hips and legs kind of come straight down from the pelvis. But in females, because of the wider pelvis, we have what we call a Q angle at the knee, and that means that the knees may look like they're valgus to begin with. It doesn't really affect the stride, it doesn't affect any of the six determinants of gait, but it may look a little different and still yet be normal. And that's just because when you look at them in stance, you'll be able to see that little change there, and you have to keep that in mind when you're looking at them. Remember to look at gait by looking from behind, from in front, and from the side. Thank you both for the questions so far. The other thing I wanted to point out, just to go along with the previous lecture, we talked about Trendelenburg. That's seen in either an L5 injury, it can also be seen in a superior gluteal nerve injury from the plexus. Both of which, of course, will affect the L5 muscle, which is the gluteus medius, which is what really is where the Trendelenburg comes from. The other thing that we see, and I want to bring up, is a steppage gait. And the steppage gait you see in foot drop, which, again, is also from an injury either to the peroneal nerve. I think the anatomist mentioned that you'd hear these people coming down the hall with their foot slapping, because it does kind of slap right to the ground. They have no way of actually holding their foot up, and it just slaps. So peroneal nerve injury, or possibly an L4 nerve injury. So I'm coming to you from the University of Miami. I hope it's nice weather everywhere else. We're having summer here. And getting ready for hurricane season. I'm just going to be watching the chat box for any further questions. I do recommend watching other people's gaits. It's really kind of fun, and you can tell people coming from a long way away, just by their gait, once you've learned what their gait looks like. I'll look and see people, and it's like, yeah, that's so-and-so, and you recognize them a block away, just from behind, from the way they walk. I also try to listen to how people walk, so you can pick that up, the way their feet hit as they're walking down the hall. It's little fun things that kind of make this a fun part of the physiatric practice. All right. So when pain is a factor, so pain affects people's gaits, it really is difficult to assess them, and you may not be able to get them to take more than one or two steps. In general, what I try to do is make sure there's no weakness. So first, I want to see, are they limping when they walk? And so I have them walk across the room, just to see if they limp. Now, the next thing I do is I try to get them to walk on their tiptoes, looking to see if there's any evidence of sciatic nerve injury, S1 nerve injury, that would make them too weak to be able to do that. Some people can't do it because of the pain, and you have to ask them, why can't you do that? And they say, it's so painful. Some people can't do that because they have plantar fasciitis, or maybe they have an Achilles tendonitis. Again, you ask about pain, is that what's keeping you from doing it? Sometimes they'll say, no, it's just too weak, it won't stay up. The next thing I do with someone who's got pain is I'll have them walk with their toes up, so you have them walk on your heels. I always grab their hands and follow with them so that they don't fall, because when you're on your heels, you're a little bit less stable, and you don't need anyone following in your office. So it's harder to assess from the front and the back when you're doing that, but you can actually get a pretty good idea if there's any subtle weakness in the peroneal muscles that cause dorsiflexion. So I'm looking to see if there's anything else here. One thing I hope that you all are excited that the AANEM has initiated education for our APPs. I think that this is a good collaboration as medicine continues to develop and APPs are a more important part of our practice overall. I think that we need to take time to train you, just like we do with medical students and residents. And that way we can get more of you into our nest of physical medicine rehab and neurology here. It's a good mix of people, and it's a good way to learn some new things. Comment on frontal gait disorder is the next question, and I'm not quite sure what you mean on frontal gait disorder. Okay, so you're talking about someone who's got a frontal lobe injury and how they walk. That generally is because you've got the nerve injury in the brain, you end up seeing a wide base gait. The other thing that you see is they have an apraxia. So apraxia is when you don't coordinate the muscles to go in the normal movement and so they may have, it's not just a steppage gait and it's not just a shuffling gait but sort of a magnetic type gait as they're walking. So remember the first thing you're going to see a wider base gait because they're not quite stable if they have a shorter gait and then they don't move as smoothly as others. The other thing you may see in a frontal injury is really a disinhibition. These people don't realize sometimes what they can't do and they go to do movements that just don't seem to work. So they may have more falls as well. Over time they may become shuffling if they actually do learn that they can fall when they move too quickly. So you know it all depends on where you are in your disease process and actually what part of the frontal lobe has been affected. So are there any questions here? I think we've had some good questions. I appreciate you all for watching and listening and paying attention. After about an hour and a half I think learning sort of starts to shut down. So this has been good. Thank you so much Dr. Irwin. It was such a pleasure. All right well you all have a great day and enjoy the summer as it shows up. We'll see everybody next week. Same time. Take care.

gait evaluation

components of gait cycle

abnormal gait patterns

hemiplegic gait

steppage gait

Trendelenburg gait