Hello this is Dr. Amanda Witt. This is our second set of slides reviewing gait analysis for our neuromuscular patients. In the last video, labeled one, we talked about the strategies for gait analysis and looked at a very interesting gait. In this program we'll review a little bit and then we'll focus on a different gait but a very common gait to our patient population. So let's just review. Remember to scan and if you have the patient have them go back and forth a few times as long as that's safe and they're not fatiguing because it may take a few turns to really focus on what each joint is doing. So look at the hips first and then the knees and then scan down the ankles and really kind of focus especially on a gait that is a little more complicated and has more going on. And remember some gaits look altered. Forward flexion and some stiffness in gait can of course be painful and remember in neuromuscular disease we do need to watch the back to see if they have any compensatory hyperlordosis at the spine. So this is a very sweet lady who comes to our muscular dystrophy clinic. She's got a good arm swing, good shoulder movement. Her hips, although she's got the sweater on, don't have a lot of movement to them. She holds it pretty stable. Sometimes you can fake a Trendelenburg or cover it up by moving your arms instead of your hips. Some people will alter that but she's doing neither. You can tell really at the end there on the video that she's having some trouble picking those feet up. Her ankles are floppy. So she has a little bit of a heel strike but it goes away very quickly. That was kind of flat-footed, flat foot, flat foot. Look at that last little step she took there. She had a hip hike a bit. There you go, whoop, and that one. She had a steppage there and used her hip and knee flexion to clear her toes. So here she comes from the front and there you really are seeing that steppage gait more on the right. The left has a very floppy ankle. She does not have a lot of control over there. She tries to get a heel strike and it just goes flat so quickly and so she has dorsiflexion on exam that is around 3 plus 4 minus but that's with pushing against somebody's hand. When you're actually walking, that eccentric contraction of the tibialis anterior when you move from heel strike to foot flat really strains the muscle. That's the contraction that requires the most energy and that's really where you see that issue. She has this asymmetric weakness that's subtle. It's not dramatically asymmetric. She has a diagnosis of inclusion body myositis. She also has weakness that is proximal and in her quads so she doesn't quite keep a straight line. She wanders back and forth a bit and she does lose her balance easily because those ankle dorsiflexors are weak. She doesn't have a lot of control in her ankle and it's easy for her to be off balance. She has a slap on one side and a steppage on the other. You can see that steppage is more prominent as she walks back and forth. Coming back it's more prominent than going forward because she does fatigue and so we have to watch length of walking with her especially if we're in clinic. I tend to wait until the end especially if it's a known patient and have them walk for me as they're walking back and forth to go to the exit and that way I'm not fatiguing their sit to stand and I'm not having them go back and forth with ambulation too much and make them too tired to walk out in the parking lot to their car. You also have to think about what testing the patient can tolerate so if you wanted a six minute walk test in a Duchenne child for example do you think they have the endurance to do that or not because we have had a fall due to that in a young child actually. So it's just a thoughtful energy conservation process even in the clinic.

gait analysis

neuromuscular patients

movement patterns

inclusion body myositis

six-minute walk test