Normal gait

Objectives

• The participants understand the importance of doing a clinical gait

analysis in children with cerebral palsy

• The participants will know how to analyse gait in a clinical setting,

and can utilise the findings from the gait analysis to prescribe
adequate ankle foot orthosis.

• The partcipants know the different ways of classifying gait in

cerebral palsy.

• The participants are able to assess gait with and without an orthotic
device, and determine main effects of orthosis on the gait of
children with cerebral palsy.
Discussion

why gait/ walking ability is important?

Introduction

• The attainment of walking is an important goal for families

of young children with cerebral palsy (CP) and is a focus
of early physical therapy intervention.

• Limitations in walking present potential barriers to

participation in physical, recreational, and social activities.

• Walking without support, even for short distances, may

affect independence in mobility and participation
Predictors of Independent Walking
• Sitting without support and pulling to stand at age 2 years
have been associated with future walking.

• Reciprocal crawling on hands and knees and the number and

rate of acquisition of motor milestones in the first 30 months as
predictive of independent walking.

• children with CP who rapidly achieved gross motor skills in the

first 2 years (eg, roll from a supine to a prone position and sit
without support) walked independently between 3 and 5 years
of age.
Normal Gait

Series of rhythmical , alternating movements of the trunk

& limbs which result in the forward progression of the
center of gravity.
Analysis of gait

Quantity, speed and direction of movement is analysed by

observing:

Sagittal view:
▪ medio- lateral axis (flexion and extension)
Frontal view:
▪ anterior- posterior axis (abduction and adduction)
Superior view:
▪ vertical axist (rotation of the neck, trunk and pelvis)
7
Discussion

Share your idea about what can be the criteria for essential
walking.
Major criteria for essential walking (1)

Equilibrium: The ability to assume an upright posture and

maintain balance.
Locomotion: The ability to initiate and maintain rhythmic
stepping
Musculoskeletal Integrity: Normal bone, joint, and muscle
function
Neurological Control: Must receive and send messages telling
the body how and when to move. (visual, vestibular, auditory,
sensori-motor input)
Major criteria for essential walking (2)
Stability in stance:
This means that body must constantly alter the position of the
segments in space in order to maintatin balance over the base of
support which is changing while walking. This is also called dynamic
stability.

Sufficient foot clearance during swing –

this is a function of balance on the stance side and sufficient ankle
dorsiflexion on the swing side

Appropriate swing phase

pre‐positioning of the foot very important for the weight acceptance
Major criteria for essential walking (3)

Adequate step length –

demands sufficient stability on the stance side and adequate
hip flexion and knee extension on the swing side

Energy conservation ‐
Oxygen consumption gives an objective view of the overall
efficacy of the patient’s gait. Many factors influence energy
consumption, including
spasticity, bony deformity, strength and selective motor control.
Kinetics and kinematics

• Kinematic data correspond to the movement of the body

described in CGA by the angular variations of the different
joints/segments: ankle, knee, hip, pelvis and trunk.

• Dynamic or kinetic data describe the forces applied by the

patient during his/her gait. This information corresponds to
the ground-reaction forces, joint moments and powers of
each joint.
Discussion

• How many rockers present in the gait cycle? What are

those?
Rockers or Pivot Points in Stance (1)
Rockers or Pivot Points in Stance (2)
Rockers or Pivot Points in Stance (3)
Normal gait
Gait cycle
• One gait cycle is measured from heel-strike to heel-strike
stance phase
- period of time that the foot is on the ground
- 60% of one gait cycle is spent in stance
- during stance, the leg accepts body weight and provides
single limb support
swing phase
- period of time that the foot is off the ground moving
forward
- 40% of one gait cycle is spent in swing
- the limb advances
Discussion

• Share about gait cycle.

Temporal-spastial parameters

Temporal parameters
 Measurements affected by time
▪ Cadence-
▪ Walking speed

Spatsial parameters
 Measurements related to linear and angular
dimensions
▪ Step length
▪ Stride length
▪ Step width
▪ Angel of outtoing/ intoing
 Determinants of Gait (1)

(1) Pelvic rotation:

➢ Forward rotation of the pelvis in the horizontal plane approx. 8o
on the swing-phase side
➢ Reduces the angle of hip flexion & extension
➢ lengthens the limb as it prepares to accept weight
Determinants of Gait (2)

(2) Pelvic tilt:

➢ pelvis drops 4 degrees on swing side
➢ lowers COG at midstance
Determinants of Gait (3)

(3) Knee flexion in stance phase:

➢ early knee flexion (10-15 degrees) at heel strike
➢ lowers COG, decreasing energy expenditure
➢ also absorbs shock of heel strike
Determinants of Gait (4)
(4) Ankle mechanism:
➢ Lengthens the leg at heel contact
➢ Smoothens the curve of CG
➢ Reduces the lowering of CG
Determinants of Gait (5)

(5) Foot mechanism:

➢ Lengthens the leg at toe-off as ankle moves
from dorsiflexion to plantarflexion
➢ Smoothens the curve of CG
➢ Reduces the lowering of CG
 Determinants of Gait (6)

(6) Lateral displacement of

body:
➢ pelvis shifts over stance limb
➢ COG must lie over base of
support (stance limb)
Muscle function Ankle (1)

Tibialis anterior:
 gives first heel contact
 keeps ankle in neutral position during swing phase

Triceps surae:
 push leg and body forward during heel- and toe off

Tibialis posterior, fibularis longus and brevis:

 stabilize the ankle (in particular on ground that are uneven)
Muscle function Knee (2)

Quadriceps:
 help with shock absorption during heel strike
 stabilize the knee during stance phase

Hamstrings:
 stabilize knee during stance phase
 shorten the leg by flexing the knee during swing phase

29
Muscle function Hip (3)

Gluteus maximus:
 anterior rotation of pelvis
 stability of hip during stance phase

Iliopsoas and rectus femoris:

 initiate the swing of the leg

Gluteus medius:
 secures frontal stability of the pelvis during stance

30
Muscle function Trunk and Upper limb (4)

Trunk muscles (abdominals and paravertebralis):

 stability of trunk on pelvis and hips

Upper limbs:
 follow a diagonal pattern opposite to pelvic rotation.

31
Discussion

• Do you think that gait cycle is same for young and adult?
• If no, what are the differences?
Gait in the young (1)

1. The walking base is wider

2. The stride length and speed are lower and the cycle time
shorter (higher cadence)
3. Small children have no heel strike, initial contact being
made by the flat foot
4. There is very little stance phase knee flexion
5. The whole leg is externally rotated during the swing
phase
6. There is an absence of reciprocal arm swinging.
Gait In the young (2)

• These differences in gait mature at different rates.

• The characteristics numbered (3), (4) and (5) in the above
list have changed to the adult pattern by the age of 2
• (1) and (6) by the age of 4.
• The cycle time, stride length and speed continue to
change with growth, reaching normal adult values around
the age of 15.
Clinical gait analysis (CGA)

• CGA is generally used to identify, quantify and

understand the deficits of a specific patient with gait
disorders.

• CGA aims to determine what is causing a patient to walk

in the way he/she does.

• CGA provides detailed information on four main types of

data recorded simultaneously: spatiotemporal, kinematics,
kinetics
Why CGA is important?

 Part of an overall assessment to develop

interventions that are tailor made for each
individual child.
 Gives information relevant to the prescription of
type of orthosis.
 Gives us important information about why the
child has a specific walking pattern. If we dont
know this, we will not be able to come up with
relevant interventions.
Basic of CGA

• Assess only one joint at a time

• Look from all view
• Look at early stance, late stance, then swing
• Separate kinetics from kinematics
• KEEP IT SIMPLE!
• Take a history
• Couch examination
• Static examination
• Allow patient time to relax
• Reasonable length walkway - gait pattern changes before &
after turn
Interpretation of CGA:

 Start by looking at the general walking pattern of the

child to get an overall impression:

▪ GMFSC classification
▪ Topography

 Ask the family if the walking pattern seen in a clinical

setting is actually the pattern also used at home.
 Make a list of the impairments that are affecting the
walking pattern.
CGA: General points

• Is the gait fast or slow?

• Is it smooth?
• Does the patient appear relaxed & comfortable or pained?
• Is it noisy?
Feet 1

• Heel strike?
• Is forefoot loading lateral to medial?
• Is normal pronation occurring?
• Any medial bulging?
• Arch normal, high, low or non-existent?
• Are the feet abducted, adducted or straight?
Feet 2

• Is the MPJ functioning properly?

• Are the toes bearing weight?
• When is the heel lifting?
• Is toe off through the hallux?
• Does the swing phase appear normal?
• Are the feet too close or is the base of gait wide?
Knees and Legs

• Are the knees pointing forwards?

• Is there genu valgum or varum?
• Is there tibial varum present?
• Do they appear internally or externally rotated?
• Knees from the side – are they fully extending?
Hips & body

• Is there any excessive movements at the hips –

rotations,?
• From the side – are there any excessive curves?
Head & shoulders

• Are the shoulders level?

• Do the arms swing equally?
• Does the head & neck appear normal?
Gait deviation in Cerebral palsy
Discussion

• Share your ideas from your daily practice about gait

pattern of children with CP.
Gait pattern

• Spastic Hemiplegia / Unilateral CP

• Bilateral Spastic CP
Spastic Hemiplegia / Unilateral CP

• Type 1 – weak or paralysed/silent dorsiflexors (= dropfoot)

• Type 2 – type 1 + triceps surae contracture
• Type 3 – type 2 + hamstrings and/or Rectus Femoris spasticity
• Type 4 – type 3 + spastic hip flexors and adductors
(Winters et al,1987)
Type 1

• `drop foot' which is noted most clearly in the swing phase

• foot drop during swing phase resulting in a lack of first
rocker at initial contact.
• Due to weakness or underactivity of the anterior tibial
muscle relative to overactivity of the gastrocnemius and
soleus muscles.
• this gait pattern is rare, unless there has already been a
calf lengthening procedure.
Type 2

• Type 2 hemiplegia is by far the most common type in

clinical practice.
• True equinus is noted in the stance phase of gait because
of the spasticity and/or contracture of the gastroc-soleus
muscles.
• There are two sub-categories to type 2 hemiplegic gait
patterns, which are:
- Equinus plus neutral knee and extended hip.
- Equinus plus recurvatum knee and extended hip
Type 2

• drop foot in swing because of impaired function in tibialis

anterior and the ankle dorsiflexor.
• A pattern of true equinus can be seen, with the ankle in
the plantar flexion range through most of the stance
phase.
• The plantar flexion / knee extension couple is overactive
and the knee may adopt a position of extension or
recurvatum.
Type 3

• characterized by gastroc-soleus spasticity or contracture,

impaired ankle dorsiflexion in swing

• a flexed, `stiff knee gait' as the result of

hamstring/quadriceps co-contraction.
Type 4

• more marked proximal involvement.

• there will be marked asymmetry, including pelvic
retraction.
• In the sagittal plane there is equinus, a flexed stiff knee, a
flexed hip and an anterior pelvic tilt.
• In the coronal plane, there is hip adduction and in the
transverse plane, internal rotation.
Bilateral Spastic CP

• Torsional deformities of the long bones and foot deformities

are frequently found in bilateral spastic CP, in association
with musculo-tendinous contractures.

• The most common bony problems are medial femoral

torsion, lateral tibial torsion, midfoot breaching, with foot
valgus and abduction.
Type 1. True Equinus

• calf spasticity is frequently dominant resulting in a `true

equinus' gait with the ankle in plantar flexion throughout
stance and the hips and knees extended.

• The patient can stand with the foot flat and the knee in
recurvatum. The equinus is real but hidden.

• A few children with bilateral cerebral palsy remain with a

true equinus pattern throughout childhood and, mostly
they develop flexed contracture
Type 2. Jump Gait (With or Without Stiff
Knee)

• more proximal involvement, with spasticity of the

hamstrings and hip flexors in addition to calf spasticity.

• The ankle is in equinus, the knee and hip are in flexion,

there is an anterior pelvic tilt and an increased lumbar
lordosis.

• There is often a stiff knee because of rectus femoris

activity in the swing phase of gait.
Type 3. Apparent Equinus (With or
Without Stiff Knee)

• As the child gets older and heavier, a number of changes

may occur
• Equinus may gradually decrease as hip and knee flexion
increase.
• `apparent equinus’ is present where the child is still noted
to be walking on the toes and simple observational gait
analysis may mistakenly conclude that the equinus is real
when it is in fact apparent.
Type 4. Crouch gait (With or Without Stiff
Knee Gait)

• Crouch gait is defined as excessive dorsiflexion or

calcaneus at the ankle in combination with excessive
flexion at the knee and hip.
• the commonest cause of crouch gait in children with
spastic diplegia is isolated lengthening of the heel cord in
the younger child.
• The result is an unattractive, energy-expensive gait
pattern, followed by anterior knee pain and patellar
pathology in adolescence
Discussion

• In your daily practice which is the common pattern do you

found?
• What do you think what can be the influencing factor of
gait in CP?
66

Clinical gait analysis: Stance phase

Common gait deviations:

 Minimal (or no) heel contact
 Forefoot or foot flat pattern at initial contact
 Excessive flexion of hip and knee
 Single support excessive knee flexion: crouch gait
67

Clinical gait analysis: Swing phase

Common gait deviations:

 Equinus
 Excessive knee and hip flexion
 Foot drop
68

Impairments influencing the gait in CP

a) Spasticity
b) Muscle contracture
c) Muscle weakness
d) Malalignment of bony structures
e) Contracture of the joint capsule
69

Spasticity

• Some muscles are affected more than others (in cerebral

palsy).
• Bi- and multiarticular muscles tend to be more susceptible
• Hip adductor spasticity is often present (monoarticular
muscles).
• Presence of resting tone (inappropriate muscle activity
also when there is absence of movement).
70

Muscle contractures

Most common in children with cerebral palsy:

 Knee flexion
 Ankle plantarflexion
 Hip flexion
71

Muscle weakness

• Muscles often described as weak in children with cerebral

palsy:
Gluteal muscles (Hip abduction and extension)
Plantarflexors
72

Malalignment of bone structures

• Femur anteversion
• Tibial torsion
• Bones of the foot (calcaneus in particular)
• Spine
• Thorax
• Upper limb
73

Contracture of the joint capsule

• Common in the knee joint.

• Restriction to extension and rotation of hip also seen.
Question and answer
• https://cerebralpalsy.org.au/our-research/about-cerebral-
palsy/what-is-cerebral-palsy/severity-of-cerebral-
palsy/gross-motor-function-classification-system/
• Armand S, Decoulon G, Bonnefoy-Mazure A. Gait
analysis in children with cerebral palsy. EFORT Open Rev
2016;1:448-460. DOI: 10.1302/2058-5241.1.000052.
Task (deadline: within 12 pm, 5th december)

• Select one children with CP who has functional walking.

Identify his/her gait pattern (according to the classification
system). Share the gait pattern and cause of the gait
pattern of the child.
Thank you