All the best

1. Gait Assessment: An Integral Part of the
Comprehensive Balance Exam?
Kenneth R. Bouchard, PhD, FASHA
Ashley M. Hallberg, AuD
ASHA San Diego
Session 0120 11-17-2011

2. Outcomes
 To recognize that gait can and should be an
important part of the balance evaluation
 To understand aspects of gait assessment that is
straightforward and reliable
 To be aware that quantification of data that allows
following patients over time is a potential positive
aspect of a comprehensive assessment

3. The Balance Patient
 More and More of our Clinical Caseload
 The basis can be peripheral vestibular but
usually it is not
 What is this patient’s concern?

4. The Balance System
 Vestibular: Inner Ear (labrynthine)
– Function
– Peripheral Vestibular System
 SSCs, Otoliths, Labyrinthine, Vestibular nerve- inferior/superior
– Common vestibular disorders
 Visual: Eyes (vision)
– Function
– Visual disorders
 Somatosensory: Sensors in legs, muscles, and joints
– Function
– Abnormalities of the somatosensory system

5. The Balance System
 Assessment of the balance system
– VNG
– Rotational Tests
– Oculomotor Tests
– Posturography
– VEMPS and ECochG
 What does each test offer?
 Use of multiple tests for assessment

6. GAIT & MOBILITY
 Much can be determined by a patient’s gait
 Normal gait requires a complex combination
of functions
– Neural
– Muscular
– Multisensory Input
– Related functions

7. Center of Gravity in quiet stance
 At the middle of the hips
 Projects just forward of the
ankle joint
 Vertical projection should
fall within the base of
support (outer edge of the
feet)
 Normal sway:
1 cm anterior-posterior
0.5 cm side to side

8. Body COG centered over base
of support

9. Limits of stability boundaries during
standing, walking, and sitting

10. Center of Gravity alignment to the
limits of stability cone

11. Linear translation at the ankle

12. Three strategies to move COG
relative to base of support
during postural sway

13. Elements of Normal Gait
– Posture ~ pt walking vertically or hunched over?
– Arm Swing
– Length of Stride ~ is pt taking small steps vs long steps?
– Base ~ how close are feet to each other?
– Rhythm and Propulsion
– Associated Movements ~ are there accompanying
truncal movements? What else is going on with the
body as the pt is walking?
– Muscle Coordination and Maintenance of Equilibrium

14. The Gait Cycle
 Floor Contact Patterns
 Cycle Divisions
 Gait Cycle Timing
 Stride and Step

15. Phases of Gait
 Loading Response
 Mid Stance
 Terminal Stance
 Preswing
Obtained from Yahoo! Images (2011)

16. Swing Limb Advancement
 Initial Swing
 Mid Swing
 Terminal Swing
Obtainted from Yahoo! Images (2011)

17. The Walk
“Walking uses a repetitious sequence of
limb motions to simultaneously move the
body forward while also maintaining stance
stability”
(Perry and Burnfield, 2010)

18. Causes (differential diagnosis) of
Gait Disorders
 Neurologic
 Muscular Disorders
 Physical (leg or foot) Abnormalities
– Arthritis, peripheral vascular disease
 Environmental / Body Influences
– Uneven ground surface, Poor vision, obesity, back pain
 Dementia
 Net Impact of aging alone
 Psychological Influence
– Depression, anxiety, substance abuse

19. Examples of Abnormal Gait
 Ataxic Gait
 Spastic Gait
 Festinating (Parkinsonian) Gait
 Waddling Gait
 Antalgic/Tabetic Gait
 Staggering/Drunken Gait
 Elderly Gait
 Dyskinetic Gait
 Orthopedic Gait

20. Abnormal Gait
 Cerebellar Ataxia

21. Cerebellar Ataxia
 Wide-based with truncal instability and
lateral veering
 Unsteadiness and irregularity of steps
(seen in midline cerebellar disease such as
MS and certain tumors)

22. Abnormal Gait
 Vertiginous Gait (vestibular gait)

23. Vertiginous Gait (vestibular gait)
 Unsteady with difficulty maintaining balance
 Patient will often reach for wall or stationary
object to help balance
 Often worse with movement of the head

24. Abnormal Gait
 Antalgic (limping) Gait

25. Antalgic (limping) Gait
 Abnormal gait due to pain, such as a limp
 Examples may include peripheral
neuropathy, herniated disk, fracture, or
arthritis with pain in ankles or knees.

26. Abnormal Gait
 Myopathic (Waddling) Gait

27. Myopathic (Waddling) Gait
 Patient is unable to stabilize the pelvis as
they lift leg to step forward
 Pelvis tilts toward the non-weight bearing
leg, resulting in a waddle type of gait
(seen with muscular diseases)

28. Abnormal Gait
 Diplegic Gait

29. Diplegic Gait
 Spasticity in the lower extremities greater than
the upper extremities
 Lower extremities are circumducted and the
upper extremities are held in a mid or low
guard position
(usually seen with bilateral periventricular lesions)

30. Abnormal Gait
 Neuropathic Gait

31. Neuropathic Gait
 High stepping gait (attempt to avoid
dragging toe on the ground)
 Most often seen in peripheral nerve disease
where the distal lower extremity is most
affected

32. Abnormal Gait
 Anxious (Cautious) Gait

33. Anxious (Cautious) Gait
 Nervous, uneasy gait
 Wide based
 Slow
(patient appears to be walking on ice)

34. Abnormal Gait
 Parkinsonian Gait

35. Parkinsonian Gait
 Difficulty initiating gait
 Narrow based
 Slow
 Stooped forward and rigidity.
Example, Parkinson’s disease

36. Abnormal Gait
 Elderly Gait

37. Elderly Gait
 Slower gait
 Smaller steps
 Slightly stooped posture
 Broader base
(vague boundary between normal and abnormal)

38. Inclusion of Gait Analysis as Part of
the Vestibular or Balance
Assessment
 Why is it important for audiologists to
assess gait?
 How does gait analysis fall into the
vestibular and balance assessment?

39. Fukuda, Romberg, and Gans
Sensory Organization Performance
 Tests commonly included in a clinically
oriented assessment of gait

40.  Fukuda
– Eyes closed hands out
– 50 Steps
– 45 degrees (affected side)
 Romberg
– Feet together and arms hanging by sides
– Patient observed for 1 minute with eyes open and then with eyes
closed
– Near fall is a positive test
 Gans Sensory Organization Performance
– Conditions compared: thick foam with eyes open or closed, standing
on the floor, as well as marching
– Vestibular vs central pathology indicated

41. mCTSIB
 Modified clinical test of sensory integration of balance
1. Firm- Eyes Open (FIRM-EO)
2. Firm- Eyes Closed (FIRM-EC)
3. Foam- Eyes Open (FOAM-EO)
4. Foam- Eyes Closed (FOAM-EC)

42. Walk
 Widened stance
 Veering
 Sway
 Cadence

43. Tandem Walk
 Excessive Sway
 Staggering
 Inability to walk heel to toe

44. Computerized Quantified Gait
Measures
 Subjective interpretation results in variable
test-retest reliability
 Computerized quantified gait measures
effectively and reliably evaluate gait

45. GAITRite System

46. GAITRite System
 GAITRite was created in 1995
 It consists of a portable electronic walkway
carpet with embedded pressure sensors
 It is automatically measure and analyze
SPATIAL “distance” and TEMPORAL “timing”
parameters.

48. Clinical Applications
 GAITRite can be used clinically for a variety of different
applications, including test-retest measures
Example 1: Pre-Post measures showing improvement
following vestibular therapy in a patient with a unilateral
vestibulopathy

49. Clinical Applications
Example 2: Quantified measures in normal
pressure hydrocephalus patients (often dramatic
change in gait observed with a large volume
lumbar drain)

50. PRE-TEST
POST-TEST
Hx: 78 y/o female with NPH
Pre-post large volume lumbar drain

51. Hx: 78 y/o female with NPH
Pre-post large volume lumbar drain
Variables Pretest Post Change % Change
8/31/2011 10/3/2011
Velocity 30.1 57.8 27.7 92.0% *
Double-Support 50.4 40 -10.4 -20.6% *
Cadence 98.2 96 -2.2 -2.2%
Stride Length 37.8 73 35.2 93.1% *
FAP 53 57 4 7.5% *
Functional Ambulation Performance
(100 maximum)
* Denotes Improvement

52. Posturography
 Test of function
– 3 subtests
 Adaptation
 Motor control
 Sensory organization test

53. Posturography vs. GAITRite
 Posturography isolates various balance
subsystems to determine specific areas of
dysfunction
 GAITRite provides a variety of measures
related to the process of ambulation

54. MCT and GAITRite
 Motor control is a component of the overall
balance
 Gait is multi-factorial and abnormalities
can include many components.

55. Recent Study
 Posturography and GAITRite do assess different
aspects of balance as 25% of patients were
abnormal on one test or the other but not both
 There is a strong relationship between the
observed motor control findings and abnormalities
seen in gait

56. Dynamic
Mobility
Gaze
Stability
Postural
Stability

57. Motor System Outputs
 Reflex Response
 Spinal cord level
 Triggered by external stimuli
 Rapid, stereotypical response
 35 to 40 millisecond latency
 Regulate local muscle properties
 Postural Evoked Response Test (PER)

58.  Automatic Postural Response
 Brainstem and cortical level responses
 Balance first line of defense
 Triggered by external stimuli
 Slower, 90 to 100 milliseconds
 Coordinated patterns
 Highly adaptable to conditions
 Motor Control Test (MCT)
 Adaptation Test (ADT)
Motor System Outputs

59. Effects of Aging
 Impaired vision
 Stiffness of joints and muscles
 Muscle weakness
 Slowed reaction time
 Loss of postural reflexes
 Cognitive impairment

60. Mild age related white matter
changes (ARWMC)

61. Moderate age related white matter
changes (ARWMC)

62. Severe age related white matter
changes (ARWMC)

63.  Conclusions: Findings support a strong
association between the severity of age-
related white matter changes and the severity
of gait and motor compromise.
 Physical activity might have the potential to
reduce the risk of limitations in mobility.
Age Related Changes
Baezner, H. et al. (2008)

64. Summary
 Gait assessment will continue to become an
increasingly important component of the
comprehensive balance exam
 With the use of computerized quantitative gait
measures (e.g. GAITRite system), audiologists will
be leaders among other disciplines in the
evaluation of balance associated disease and
disorder

65. Bibliography
 Alvord, L.S. (2008).Falls Assessment and Prevention, SanDiego, Plural
Publishing
 Desmond, A.L.(2004). Vestibular Function: Evaluation and Treatment, New
York, Thieme Medical Publishers
 Jacobson, G.P. and Shepard, N.T.(2008). Balance function assessment and
management, SanDiego, Plural Publishing
 Perry, J. and Burnfield, J. M. (2010). Gait Analysis: Normal and Pathological
Function (2nd ed.), Thorofare, SLACK Inc.
 Weber, P.C.(2008). Vertigo and Disequilibrium, New York, Thieme Medical
Publishers

66. Special Thanks
 Jamie Lewis, audiology doctoral extern, for video
demonstration and recording
 Reem Alqahtani, Au.D. for her research contributions
 Mike Rowling, CIR Systems, for his assistance with
the GAITRite system and software

67. Questions and Comments
Kenneth R Bouchard, Ph.D
Email: kboucha1@hfhs.org
Ashley M Hallberg, AuD
Email: ahallbe1@hfhs.org