Lecture # 3 Dr. Ameen M.
Al-Juboori
QUALITATIVE GAIT ASSESSMENT
Lecture # 3
Artificial Limbs I
QUALITATIVE GAIT ASSESSMENT
Qualitative methods for identification and recording of gait deviations have
played a role in patient care for decades. In 1925, Robinson described
pathological gait patterns and attempted to correlate them with specific
disease processes. In 1937, Boorstein identified disease processes that could
be diagnosed with gait assessment. He described seven major gait deficit
groups. In the late 1950s, Blair Hangar, the founder of Northwestern
University's School of Prosthetics and Orthotics, and Hildegard Myers, a
physical therapist at Rehabilitation Institute of Chicago, collaborated to
develop the first comprehensive system of clinical gait analysis for persons
with transfemoral amputation. They identified 16 gait deviations and
suggested numerous clinical and prosthetic causes for each. The first Normal
and Pathological Gait Syllabus was published by the Professional Staff
Association of Rancho Los Amigos Hospital in 1977. This syllabus uses
parameters of normal gait as a comparative standard for abnormal or
pathological gait. It focuses on identifying gait deviations that affect the three
functional tasks of walking: weight acceptance, single limb support, and
swing limb advancement. A form listing the most commonly occurring gait
deviations in each subphase of gait is used to record any observed gait
deviations that interfere with these functional tasks (Figure 1). Problems in
each of the six major body segments are noted with a check in one of the
boxes, beginning with the toes, then the ankle, knee, hip, pelvis, and trunk.
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Lecture # 3 Dr. Ameen M. Al-Juboori
QUALITATIVE GAIT ASSESSMENT
This format allows the clinician to consider systematically the following
questions:
• Are the toes up, inadequately extended, or clawed?
• Is there forefoot-only contact (toe walking), foot-flat contact, foot slap,
excess plantar flexion, or dorsiflexion? Is heel-off, foot drag, or
contralateral vaulting present?
• Is knee flexion adequate, absent, limited, or excessive? Is extension
inadequate? Does the knee wobble, hyperextend, or produce an
extension thrust (recurvatum)? Is varus or valgus present, or is
excessive contralateral flexion seen?
• Is hip flexion adequate, absent, limited, or excessive? Is adequate
extension seen? Is retraction of the thigh during TSw from a previously
attained degree of flexion seen? Can internal or external rotation,
abduction, or adduction be observed?
• Does the pelvis hike? Does it tilt anteriorly or posteriorly? Is forward
or backward rotation seen? Does it drop to the ipsilateral or
contralateral side?
• Does the trunk lean or rotate backward or forward? Does it lean
laterally to the right or left?
Qualitative gait assessment is an important component of preorthotic
assessment because it assists the clinician in identifying the functional task
and the subphase of gait, that are problematic and can be addressed with
orthotic intervention. Similarly, deviations observed during gait analysis can
identify the need for adjustment of prosthetic alignment.
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Lecture # 3 Dr. Ameen M. Al-Juboori
QUALITATIVE GAIT ASSESSMENT
Figure 1: The Rancho gait analysis system facilitates recording any observable activity that
interferes with the three functional tasks of walking: weight acceptance, single limb support,
and swing limb advancement.
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Lecture # 3 Dr. Ameen M. Al-Juboori
QUALITATIVE GAIT ASSESSMENT
INSTRUMENTED GAIT ANALYSIS
Instrumented gait analysis records the process of walking with measurable
parameters collected through the use of equipment. Such basic techniques
would have enabled measurement of walking velocity (distance traversed per
unit of time) and cadence (steps per unit of time). Marks, a New York City
prosthetist, offered a more precise qualitative description of pathological gait
in 1950, when he described the gait process in eight organized phases and
discussed the implications of prosthetic component design on walking
function. Marks praised “kinetoscopic” photography as a potential diagnostic
tool for optimizing pathological gait.
Today we record gait parameters with instruments as common as a stopwatch
or as complex as the simultaneous integration of three- dimensional
kinematics, kinetics, and electromyographic (EMG) methods. A simple,
inexpensive footprint mat has been used for decades to record barefoot plantar
pressures. Clinics use individual or multiple mats to record step and stride
length as well as walking base width. Early on, video technology with slow-
motion capabilities made more precise qualitative description of the gait cycle
possible. The continued development of inexpensive video gait assessment
software has made clinical quantitative applications more practical as well.
Most quantitative and qualitative video systems, however, measure joint
angles in two dimensions, which does not offer a complete analysis of the
three- dimensional walking activity.
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Lecture # 3 Dr. Ameen M. Al-Juboori
QUALITATIVE GAIT ASSESSMENT
Measuring Temporal and Distance Parameters
Temporal (time, distance) parameters enable the clinician to summarize the
overall quality of a patient's gait. Temporal data collection systems might be
one of the most effective components available for assessment in the clinical
setting. In the gait laboratory, microswitch-embedded pads taped to the
bottom of a patient's shoes or feet can record the amount of time that the
patient spends on various anatomical landmarks over a measured distance.
Portable pressure-sensitive gait mats, connected to a laptop computer with gait
analysis software for time and distance parameters are also commercially
available to use in clinical settings (Figure 2).
Figure 2: A, The GAITRite system is an example of a portable pressure- sensitive walkway used
to assess temporal and distance parameters of gait. B, The walkway is connected to a laptop
computer, and the operator is able to quickly generate values for velocity, stride and step lengths,
cadence, time and percent of cycle spent in stance, single and double limb support, and swing.
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Lecture # 3 Dr. Ameen M. Al-Juboori
QUALITATIVE GAIT ASSESSMENT
For example, the GAITRite system, which consists of an electronic walkway
connected to a computer, records the temporal and spatial characteristics of
patients while walking as well as while performing other functional or
occupational tasks.
Assessing the Energy Cost of Walking
Metabolic data reflect the physiological “energy cost” of walking. The
traditional measures of energy cost are oxygen consumption, total carbon
dioxide generated, and heart rate. Other relevant factors include volume
of air breathed and respiratory rate. All these parameters are viewed in
relation to velocity and distance walked over the collection period. The
primary limitation of energy cost as an assessment tool is that, although it can
inform the investigator about body metabolism relative to the patient's gait, it
cannot explain why or how an advantage or disadvantage was obtained.
Kinematic and Kinetic Systems
Most kinematic systems provide joint and body segment motion in graphic
form. This information includes sagittal, coronal, and transverse motions that
occur at the ankle, knee, hip, and pelvis. The patient is instrumented with
reflective spheres that are placed on well-recognized anatomical landmarks
(Figure 3).
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Lecture # 3 Dr. Ameen M. Al-Juboori
QUALITATIVE GAIT ASSESSMENT
Figure 3: This individual is wearing reflective spheres. An infrared camera system can track
limb segment motion as the patient walks across the field of view.
Typically, an infrared light source is positioned around each of several
cameras. This light is directed to the reflective spheres, which in turn are
reflected into the cameras. Each field of video data is digitized, an operator
manually identifies the markers, and the coordinates of the geometric center
of each marker are calculated with computer software. Resultant data are
displayed as animated stick figures that represent the actual motions produced
by the patient. The operator can freeze any frame and enlarge the image at any
joint to examine gait patterns in greater depth. The operator can extract raw
numbers that represent joint placement and motion in space or produce a
printout showing joint motion in all planes plotted against the percentage of
the gait cycle (Figure 4). Angular velocities, accelerations, and joint and
segment linear displacements can be calculated. Data from other systems
(force platforms and EMG) collected during the same time sequence as the
motion data are often integrated with the kinematics.
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Lecture # 3 Dr. Ameen M. Al-Juboori
QUALITATIVE GAIT ASSESSMENT
Figure 4: The output generated by a computer-based motion analysis system includes graphs
of the mean range of motion at each body segment or joint (trunk, pelvis, hip, knee, and ankle)
in coronal (left column), sagittal (middle column), and transverse (right column) planes as the
individual being evaluated progresses through multiple gait cycles. This is the output of an 8-
year-old child with spastic diplegic cerebral palsy.
When an individual takes a step, he is exerting force against the surface he is
walking on. This kinetic information is obtained from one or more force
platforms, which collect data on the three components of the ground reaction
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Lecture # 3 Dr. Ameen M. Al-Juboori
QUALITATIVE GAIT ASSESSMENT
force: vertical, fore-aft (anterior-posterior), and medial-lateral (Figure 5).
While the typical force platform system provides data about forces and
moments occurring at the ground, or center of pressure progression, it can be
combined with kinematic data to provide additional information. By
combining these two data sets, the moments and power acting at the joints can
be calculated. This information is useful in measuring the dynamic joint
control of an individual throughout stance, particularly when used in
conjunction with EMG. Similarly, information about joint moments,
sometimes referred to as torque, is also often reported as an outcome measure
in research studies.
Figure 5: Example of output generated by a forceplate as the individual being tested
progresses through stance phase. A, The anteroposterior component of the ground reaction
force (GRF). B, The medial lateral component of the GRF. C, The vertical component of the
GRF.
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Lecture # 3 Dr. Ameen M. Al-Juboori
QUALITATIVE GAIT ASSESSMENT
The calculation process begins with the determination of the ground reaction
forces, which are obtained through the direct measurement of an individual
stepping on a force platform. Once that information is available, it is combined
with kinematic data, derived from a two- or three-dimensional motion capture
system for each lower extremity body segment, so that the joint reaction forces
can be calculated. As the forces at each of the joints are determined, then the
associated moments acting on each segment can also be calculated.
Ultimately, the power can be calculated as well (Figure 6).
Like virtually all biomechanics models, certain assumptions must be made in
order for the calculation to be carried out in a practical manner. With
assumptions come the opportunity for additional error introduction
throughout the process. This is why it is important to understand the
limitations associated with them.
• The subject has no limb deficiencies and essentially normal
musculature.
• The knee and ankle joints are frequently modeled as simple hinge
joints.
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Lecture # 3 Dr. Ameen M. Al-Juboori
QUALITATIVE GAIT ASSESSMENT
B
Figure 6: A) Calculation flowchart: the kinematic data collected from the motion
analysis system is entered into series of calculations based on the person's
anthropometric data to produce the instantaneous position of every joint and segment.
These data are then combined with force plate data collected at the same time to calculate
joint forces, moments, and powers. B) Example of joint moment calculation. Vertical
and anteroposterior ground reaction forces recorded from a force plate. Joint moments
are calculated by combining ground reaction forces and kinematic data, taking into
account the segment's center of mass.
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Lecture # 3 Dr. Ameen M. Al-Juboori
QUALITATIVE GAIT ASSESSMENT
Electromyography
Muscle action beneath skin and subcutaneous tissue cannot be directly
measured, but through the use of EMG, the activity can be approximated and
studied in relation to the action, size of muscle, and signals obtained. EMG
records the muscle activity by the electrical signal detected from the
contraction and chemical stimulation of the respective musculature.
EMG instrumentation can vary, such as is seen with surface EMG or fine-
wire EMG. With surface EMG the electrode pad is adhered to the skin above
the muscle being studied, while fine-wire EMG uses wire electrodes directly
inserted into the belly of the respective muscle. EMG records the motor unit
activation of muscle fibers in the specific muscle being studied. This is very
useful but can be problematic with surface electrode applications, in that they
can pick up the signal from surrounding musculature during testing. EMG
characterization allows for timing, relative intensity of muscular effort, as
well as resultant muscle force, all of which are necessary to understand normal
and pathological gait.
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