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HOD:DR.K.PRAKASAM M.S.ORTHO,D.ORTHO,DSc(HON)
PRESENTOR: Dr.THOUSEEF A MAJEED
Definition
 Rhythmic, cyclic movement of the limbs in
relation to the trunk resulting in forward
propulsion of the body.
NORMAL GAIT REQUIRES
 Normal functioning of musculoskeletal system of
lower limbs & spine.
 Good sensory feedback from p...
GAIT TERMINOLOGY
Base of support
Step length
Stride length
Gait cycle
Cadence
Walking velocity
Double limb support
...
BASIC GAIT TERMS
Base of suppport:
 Distance between a person’s
feet while standing or during
ambulation.
 Provides bala...
Step length
 Linear distance along the line
of progression of one foot
travelled during one gait
cycle.
 Approximately 1...
Stride length
 Linear distance in the plane of
progression between
successive point of foot to
floor contact of the same ...
Gait cycle
 Period of time from one heel strike to next heel strike of
the same limb
Cadence
 It is measured as the number of steps / sec or per
minute.
 Approximately 70 steps per minute
Double limb support
 During normal gait, for a moment , two lower extremities are
in simultaneous contact with the ground...
GAIT CYCLE COMPONENTS
1. Stance phase :60% of the gait cycle.
2. Swing phase :40% of the gait cycle.
STANCE PHASE
Heel strike
Foot flat
Midstance
Heel off
Toe off
Swing PHASE
Acceleration
Midswing
Deceleration
Heel strike phase:
 Beginning of stance phase when
the heel contacts the ground.
 Begins with initial contact & ends
wit...
Foot flat:
 It occurs immediately following heel
strike
 It is the point at which the foot fully
contacts the floor.
Mid stance:
 It is the point at which the body passes
directly over the supporting extremity.
16
Heel off:
 The point following midstance the heel of the
reference extremity leaves the ground.
17
Toe off
 The point following heel off when only the
toe of the reference extremity is in contact
with the ground.
HIP : STANCE PHASE
PHASE NORMAL MOVEMEMT NORMAL MUSCLE ACTION
Heel strike to foot
flat
30* flexion Erector spinae,gluteus
...
KNEE : STANCE PHASE
PHASE NORMAL
MOVEMEMT
NORMAL MUSCLE ACTION
Heel strike to foot flat 0*-15* flexion Quadriceps contract...
ANKLE & FOOT : STANCE PHASE
PHASE NORMAL MOVEMENT NORMAL MUSCLE ACTIVITY
Heel srike to foot flat 0*-15* plantar flexion Ec...
Swing phase
Acceleration phase:
• It begins once the toe leaves the ground &
continues until mid-swing, or the point at
wh...
Swing phase
Mid-swing:
 It occurs approximately when the reference
extremity passes directly under the body.
 It extends...
Swing phase
Deceleration
 It occurs after mid-swing
 when the referance extremity is
decelerating in preparation for hee...
HIP : SWING PHASE
PHASE NORMAL
MOVEMENT
NORMAL MUSCLE ACTION
Acceleration to mid
swing
20*-30* flexion Hip flexor activity...
KNEE :SWING PHASE
PHASE NORMAL MOVEMENT NORMAL MUSCLE ACTION
Acceleration to
mid swing
40*-60* flexion Little activity in ...
Ankle & foot : swing phase
PHASE NORMAL MOTION NORMAL MUSCLE ACTION
Acceleration to
midswing
Dorsiflexion to neutral Dorsi...
DIFFERENCE BETWEEN
WALKING AND RUNNING
Walking : Always a double support phase
no flight phase
Running
No double support phase, always flight phase
BODY
PASSENGER UNIT LOCOMOTOR
UNIT
HEAD
ARM
TRUNK
PELVIS
LOWER
LIMBS
HAS NO ROLE .
GOES ALONG THE RIDE
FUNCTIONING
SYSTEM
...
DETERMINANTS OF GAIT
I. Displacement of center of gravity (COG).
II. Factors responsible for minimizing
displacement of ce...
CENTER OF GRAVITY
 It is an imaginary point at which all the weight of the
body is concentrated at a given instant.
 Cen...
Center ofGravity
Biomechanics
 Rhythmic up & down
movement
 Highest point= midstance
 Lowest point=double
support
 Average displacement...
OVERALL DISPLACEMENT
 Sum of vertical & horizontal
displacement
 Figure ‘8’ movement of Center of
Gravity as seen from A...
Factors responsible for minimizing
the displacement of centre of gravity
Major determinants:
 Pelvic Rotation (transverse...
1. Pelvic rotation
Rotation of pelvis in Horizontal plane in swing phase, total of
8 degree
Decrease angle of hip flexion...
2. Pelvic tilt
•The pelvis slopes downwards laterally towards the leg which
is in swing phase
•Reduces the vertical moveme...
3. Knee flexion in stance
•As the hip joint passes over the foot during the support phase, there
is some flexion of the kn...
4. Ankle mechanism
•Lengthen the leg at heel strike
•Reduce the lowering of Centre of gravity, hence smoothen the
curve of...
5. Foot mechanism
•Lengthen the leg at toe off as ankle moves from dorsiflesion
to planter flexion
•Reduce the lowering of...
Trunk and Arms
• The trunk, arms and shoulders also rotate to ensure
balance
• Upper limb swings opposite to stance leg to...
6. Lateral displacement of body
•In normal gait, width of walking base is narrow,
decrease the lateral displacement of Cen...
 Due to complex interaction of muscular activity & joints
motion in lower limb Centre of Gravity follows a smooth
sinusoi...
GAIT IN CHILDREN (<2years)
 Gait of small children differs from that of adult
 The walking base is wider.
 The stride l...
GAIT IN ELDERLY
 The age related changes in gait takes place in decade
after m 70yrs.
 There is a decreased stride lengt...
Function of the 6 determinants of gait:
1) Increase the efficiency and smoothness of gait.
2) Decrease the vertical and la...
GAIT ANALYSIS
KINEMATIC
GAIT ANALYSIS
QUALITATIVE QUANTITATIVE
KINETIC GAIT
ANALYSIS
KINEMATIC GAIT
ANALYSIS
KINETIC GAIT ANALYSIS
 Describe the movement
pattern without regard for the
force involved in pro...
Gait analysis
 Observational method- naked eye examination
 Photographic method- television , video, movie analysis
 Fo...
Clinical gait analysis
1. Observational gait data:(Qualitative)
Clinician watches patients walk
Advantage:
1. Require litt...
Clinical gait analysis
2. Gait parameters (Quantitative)
• The gait parameter measurement are made by
timing progress over...
•Photographic methods are most
accurate.
•After film development, each frame
is analysed using vanguard motion
analyser an...
4. Force plate data
 It represent the ground reaction force of walking
generated by force plate
Electrogoniometer
 It is used to study
the joints during
gait.
5. Energetics
 Deals with measurement of oxygen consumption
during a specific task
 Oxygen uptake is inversely related t...
PATHOLOGICAL GAIT
Scissoring gait
In toeing gait
Out toeing gait
High stepping gait
Circumduction gait
Waddling gait...
ANTALGIC GAIT
 Gait pattern in which stance phase on affected side is
shortened due to pain in the weight bearing limb.
...
TRENDELENBERG GAIT
 Any condition which distrupts the osseo-muscular
mechanism between pelvis and femur
 Weak abductors ...
Trendelenberg gait
 Usually unilateral
 If bilateral = waddling gait
 Causes :
1. Weak abductors :poliomyelitis . muscu...
Circumduction gait
 In hemiplegic patients
 To avoid the foot from
scrapping the ground, the hip
and the lower limb rota...
High stepping gait
 Due to foot drop
 On attempt of heel strike, the toe drops to the ground
first.
 To avoid this the ...
Scissoring gait
 Here one leg crosses directly over the other with each
step due to adductor tightness.
 Seen in Cerebra...
Drunkers or reeling gait
 Patient tends to walk irregularly on wide base, swinging
sideways without stability and balance...
Genu recurvatum gait
 In Paralysis of hamstring muscles the knee goes in for
hyper extension while transmitting the weigh...
Short limb gait
 Shortening less than 1.5 cm compensated by pelvic tilt, and
shortening upto 5 cm compensated by equinus....
Festinant gait
 Seen in Parkinson's disease
 Steps are short that the feet barely clears the ground.
Quadriceps gait
 Normally the knee is locked by the quadriceps contraction
while transmitting weight to the lower limb du...
Gluteus maximus gait(BACKWARD
LURCH)
 Due to weakness in gluteus maximus
muscle, while the body propels
forward during mi...
 Seen in poliomyelities & above knee amputation with
prosthesis.
Stiff hip gait
 When the hip is ankylosed, it is not possible
to flex at the hip joint during walking to
clear the ground...
STAMPING/ATAXIC GAIT:
 It occurs in sensory ataxia in which there is loss of sensation
in lower extremity due to disease ...
 Seen in peripheral neuritis &
brain stem lesion in
children, tabes dorsalis in
adults.
Alderman’s gait:
• Seen in Tuberculosis of spine in lower dorsal and upper
lumbar vertebra.
• Patient walk with head and c...
GAIT TRAINING
 AIM:
 To achieve safe, easy, effortless normal gait pattern.
Non ambulatory phase
1. Asses and improve th...
Ambulatory phase
1. Support by orthotic & prosthesis
2. Parallel bar walking
3. Encourage reciprocal arm swinging
4. Follo...
Gait
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Gait

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Gait

  1. 1. HOD:DR.K.PRAKASAM M.S.ORTHO,D.ORTHO,DSc(HON) PRESENTOR: Dr.THOUSEEF A MAJEED
  2. 2. Definition  Rhythmic, cyclic movement of the limbs in relation to the trunk resulting in forward propulsion of the body.
  3. 3. NORMAL GAIT REQUIRES  Normal functioning of musculoskeletal system of lower limbs & spine.  Good sensory feedback from propioceptive sensation from feet and the joints.  Visual ,labrinthine sensory inputs & co ordination add smoothness, rhythm & elegance to the human gait.
  4. 4. GAIT TERMINOLOGY Base of support Step length Stride length Gait cycle Cadence Walking velocity Double limb support Single limb support Ground reaction force vector
  5. 5. BASIC GAIT TERMS Base of suppport:  Distance between a person’s feet while standing or during ambulation.  Provides balance & stability to maintain erect posture.  Normally 2-4 inches from heel to heel.
  6. 6. Step length  Linear distance along the line of progression of one foot travelled during one gait cycle.  Approximately 15 inches.
  7. 7. Stride length  Linear distance in the plane of progression between successive point of foot to floor contact of the same foot.  Normally 27 – 32 inches.
  8. 8. Gait cycle  Period of time from one heel strike to next heel strike of the same limb
  9. 9. Cadence  It is measured as the number of steps / sec or per minute.  Approximately 70 steps per minute
  10. 10. Double limb support  During normal gait, for a moment , two lower extremities are in simultaneous contact with the ground.  During this period, both legs support the body weight.  Happens between push off & toe off on same side and heel strike & foot flat on the contra lateral side.
  11. 11. GAIT CYCLE COMPONENTS 1. Stance phase :60% of the gait cycle. 2. Swing phase :40% of the gait cycle.
  12. 12. STANCE PHASE Heel strike Foot flat Midstance Heel off Toe off
  13. 13. Swing PHASE Acceleration Midswing Deceleration
  14. 14. Heel strike phase:  Beginning of stance phase when the heel contacts the ground.  Begins with initial contact & ends with foot flat
  15. 15. Foot flat:  It occurs immediately following heel strike  It is the point at which the foot fully contacts the floor.
  16. 16. Mid stance:  It is the point at which the body passes directly over the supporting extremity. 16
  17. 17. Heel off:  The point following midstance the heel of the reference extremity leaves the ground. 17
  18. 18. Toe off  The point following heel off when only the toe of the reference extremity is in contact with the ground.
  19. 19. HIP : STANCE PHASE PHASE NORMAL MOVEMEMT NORMAL MUSCLE ACTION Heel strike to foot flat 30* flexion Erector spinae,gluteus maximus,hamstrings. Foot flat to midstance 30*flexion-(neutral) Gluteus maximus at beginning to oppose flexion movement, then activity ceases as moment changes from flexion to extension Midstance to heel off extension No activity Heel off to toe off 10* hyperextension to neutral Iliopsoas,adductor magnus,adductor longus
  20. 20. KNEE : STANCE PHASE PHASE NORMAL MOVEMEMT NORMAL MUSCLE ACTION Heel strike to foot flat 0*-15* flexion Quadriceps contracts initially to hold knee in extension & then eccentrically oppose the flexion movement to controll amount of flexion. Foot flat to midstance 15*flexion- 5*extension Quadriceps contract in early part,& then no activity is required Midstance to heel off 5* of flexion-neutral No activity required Heel off to toe off 0*-40* flexion Quadriceps required to control amount of knee flexion
  21. 21. ANKLE & FOOT : STANCE PHASE PHASE NORMAL MOVEMENT NORMAL MUSCLE ACTIVITY Heel srike to foot flat 0*-15* plantar flexion Eccentric action of tibialis anterior oppose plantar flexion movement Foot flat to midstance 15*plantar flexio-10*dorsi flexion Gastronemius & soleus act eccentrically to oppose dorsiflexion movement & control tibial advance Midstance to heel off 10*-15* dorsiflexion same as above Heel off to toe off 15*dorsiflexion to 20* plantar flexion Gastronemius,soleus,peroneus brevis & longus,flexor hallusis longus contract to plantar flex the foot
  22. 22. Swing phase Acceleration phase: • It begins once the toe leaves the ground & continues until mid-swing, or the point at which the swinging extremity is directly under the body.
  23. 23. Swing phase Mid-swing:  It occurs approximately when the reference extremity passes directly under the body.  It extends from end of acceleration to the beginning of deceleration 23
  24. 24. Swing phase Deceleration  It occurs after mid-swing  when the referance extremity is decelerating in preparation for heel strike. 24
  25. 25. HIP : SWING PHASE PHASE NORMAL MOVEMENT NORMAL MUSCLE ACTION Acceleration to mid swing 20*-30* flexion Hip flexor activity to initiate swing iliopsoas,rectus femoris,gracilis,sartorius,tensor fascia lata Midswing to deceleration 30*flexion –neutral hamstrings
  26. 26. KNEE :SWING PHASE PHASE NORMAL MOVEMENT NORMAL MUSCLE ACTION Acceleration to mid swing 40*-60* flexion Little activity in quadriceps,biceps femoris(short head),gracilis, sartorius contract concentrically Midswing 60*flexion-30* extension Deceleration 30*-0* extension Quadriceps contract concentrically to stabilize knee in extension in preparation for heel strike
  27. 27. Ankle & foot : swing phase PHASE NORMAL MOTION NORMAL MUSCLE ACTION Acceleration to midswing Dorsiflexion to neutral Dorsiflexors contract to bring the ankle in neutral & prevent toes from dragging on the floor Mid swing to deceleration Neutral dorsiflexion
  28. 28. DIFFERENCE BETWEEN WALKING AND RUNNING Walking : Always a double support phase no flight phase
  29. 29. Running No double support phase, always flight phase
  30. 30. BODY PASSENGER UNIT LOCOMOTOR UNIT HEAD ARM TRUNK PELVIS LOWER LIMBS HAS NO ROLE . GOES ALONG THE RIDE FUNCTIONING SYSTEM STANCE PHASE SWING PHASE
  31. 31. DETERMINANTS OF GAIT I. Displacement of center of gravity (COG). II. Factors responsible for minimizing displacement of center of gravity.
  32. 32. CENTER OF GRAVITY  It is an imaginary point at which all the weight of the body is concentrated at a given instant.  Center of gravity lies 2 inches in front of the second sacral vertebra.  Centre of gravity follows vertical displacement and horizontal displacement
  33. 33. Center ofGravity
  34. 34. Biomechanics  Rhythmic up & down movement  Highest point= midstance  Lowest point=double support  Average displacement-5 cm Vertical displacement Horizontal displacement  Rhythmic side to side movement  Lateral limit=midstance  Average displacement-5 cm Hz plane Vt plane
  35. 35. OVERALL DISPLACEMENT  Sum of vertical & horizontal displacement  Figure ‘8’ movement of Center of Gravity as seen from Antero Posterior  These displacement require energy “Greater the displacement more energy is needed”. Horizontal plane Vertical plane
  36. 36. Factors responsible for minimizing the displacement of centre of gravity Major determinants:  Pelvic Rotation (transverse plane)  Pelvic Lateral Tilt (Obliquity)  Knee Flexion During Stance  Ankle Mechanism (Dorsiflexion)  Ankle Mechanism (Plantarflexion)  Step Width Minor determinants:  1. Neck movement.  2. Swinging of arms.
  37. 37. 1. Pelvic rotation Rotation of pelvis in Horizontal plane in swing phase, total of 8 degree Decrease angle of hip flexion & extension Enables a longer step length without further lowering of Center of gravity
  38. 38. 2. Pelvic tilt •The pelvis slopes downwards laterally towards the leg which is in swing phase •Reduces the vertical movements of the upper body, and thereby increases energy efficiency. •Decrease the displacement of Center of gravity
  39. 39. 3. Knee flexion in stance •As the hip joint passes over the foot during the support phase, there is some flexion of the knee. This reduces vertical movements at the hip. •Decrease the displacement of Centre of Gravity
  40. 40. 4. Ankle mechanism •Lengthen the leg at heel strike •Reduce the lowering of Centre of gravity, hence smoothen the curve of Center of gravity.
  41. 41. 5. Foot mechanism •Lengthen the leg at toe off as ankle moves from dorsiflesion to planter flexion •Reduce the lowering of Centre of Gravity, hence smoothen the curve of Centre of Gravity
  42. 42. Trunk and Arms • The trunk, arms and shoulders also rotate to ensure balance • Upper limb swings opposite to stance leg to produce a smooth balanced gait.
  43. 43. 6. Lateral displacement of body •In normal gait, width of walking base is narrow, decrease the lateral displacement of Centre of Gravity •Decrease muscular energy consumption due to decrease lateral acceleration & deceleration
  44. 44.  Due to complex interaction of muscular activity & joints motion in lower limb Centre of Gravity follows a smooth sinusoidal curve.  It reduce the significant energy consumption of ambulation.
  45. 45. GAIT IN CHILDREN (<2years)  Gait of small children differs from that of adult  The walking base is wider.  The stride length & speed are lower & the cycle time shorter(higher cadence).  Small children have no heel strike, initial contact being made by flat foot.  There is very little stance phase and knee flexion.  The whole leg is externally rotated during the swing phase.  There is an absence of reciprocal arm swinging.
  46. 46. GAIT IN ELDERLY  The age related changes in gait takes place in decade after m 70yrs.  There is a decreased stride length, increased cycle time(decreased cadence).  Relative increase in duration of stance phase of gait cycle.  The speed almost always reduced in elderly people.  Reduction in total range of hip flexion & extension,  Reduction in swing phase and knee flexion
  47. 47. Function of the 6 determinants of gait: 1) Increase the efficiency and smoothness of gait. 2) Decrease the vertical and lateral displacement of center of gravity. 3) Decrease the energy expenditure. 4) Make gait more graceful.
  48. 48. GAIT ANALYSIS KINEMATIC GAIT ANALYSIS QUALITATIVE QUANTITATIVE KINETIC GAIT ANALYSIS
  49. 49. KINEMATIC GAIT ANALYSIS KINETIC GAIT ANALYSIS  Describe the movement pattern without regard for the force involved in producing the movement  Determine the force that are involved in the gait.
  50. 50. Gait analysis  Observational method- naked eye examination  Photographic method- television , video, movie analysis  Force plate study method-ground reaction force method  Electromyographic study (EMG)  Electrogoniometric study  Energy expenditure/requirement method  Multichannel funtional electrical stimulation method(MFES)
  51. 51. Clinical gait analysis 1. Observational gait data:(Qualitative) Clinician watches patients walk Advantage: 1. Require little or no instrumentation 2. Inexpensive 3. Yield general description of gait variables
  52. 52. Clinical gait analysis 2. Gait parameters (Quantitative) • The gait parameter measurement are made by timing progress over a 16m walkway & identifying events by means of foot switch system. • These instrument identify the part contacting the ground with data transmitted by telemetry.
  53. 53. •Photographic methods are most accurate. •After film development, each frame is analysed using vanguard motion analyser and sonic digitizer.
  54. 54. 4. Force plate data  It represent the ground reaction force of walking generated by force plate
  55. 55. Electrogoniometer  It is used to study the joints during gait.
  56. 56. 5. Energetics  Deals with measurement of oxygen consumption during a specific task  Oxygen uptake is inversely related to the efficiency of gait.
  57. 57. PATHOLOGICAL GAIT Scissoring gait In toeing gait Out toeing gait High stepping gait Circumduction gait Waddling gait Trendelenberg gait Drunkers gait Festinant gait Antalgic gait Knock knee gait Genu recurvatum gait Short limb gait Quadricep gait Gluteal medius gait Gluteal maximus gait Stiff hip gait
  58. 58. ANTALGIC GAIT  Gait pattern in which stance phase on affected side is shortened due to pain in the weight bearing limb.  There is corresponding increase in stance phase on unaffected side  Common causes: Osteoarthritis, Fractures, tendinitis
  59. 59. TRENDELENBERG GAIT  Any condition which distrupts the osseo-muscular mechanism between pelvis and femur  Weak abductors (power),acetabulo femoral articulation defect(fulcrum),defective lever system causes trendelenberg gait.  Here the abductor action in pulling the pelvis downwards in stance phase becomes ineffective and the pelvis drops on the opposite side causing instability.  To prevent this body lurches on the same side.
  60. 60. Trendelenberg gait  Usually unilateral  If bilateral = waddling gait  Causes : 1. Weak abductors :poliomyelitis . muscular dystrophies, motor neuron disease 2. Defective fulcrum: Congenital dislocaion of hip(CDH), pathological dislocation of hip 3. Defective lever : Fracture neck of femur, Perthes disease, Coxa vara.
  61. 61. Circumduction gait  In hemiplegic patients  To avoid the foot from scrapping the ground, the hip and the lower limb rotates outward.
  62. 62. High stepping gait  Due to foot drop  On attempt of heel strike, the toe drops to the ground first.  To avoid this the patient flexes the hip and knee extensively to raise the foot and slaps it on the floor forcibly.
  63. 63. Scissoring gait  Here one leg crosses directly over the other with each step due to adductor tightness.  Seen in Cerebral palsy
  64. 64. Drunkers or reeling gait  Patient tends to walk irregularly on wide base, swinging sideways without stability and balance.  Caused due to cerebellar lesion.  With unilateral lesion of cerebellum, balance is lost towards the side of the lesion.
  65. 65. Genu recurvatum gait  In Paralysis of hamstring muscles the knee goes in for hyper extension while transmitting the weight in mid stance phase.  Seen in poliomyelitis
  66. 66. Short limb gait  Shortening less than 1.5 cm compensated by pelvic tilt, and shortening upto 5 cm compensated by equinus.  Shortening more than 5 cm the patient dips his body on that side.
  67. 67. Festinant gait  Seen in Parkinson's disease  Steps are short that the feet barely clears the ground.
  68. 68. Quadriceps gait  Normally the knee is locked by the quadriceps contraction while transmitting weight to the lower limb during midstance.  Hence patient with weak quadriceps stabilizes his knee by leaning forward on the affected side & pressing over lower thigh by his Ispilateral hand or fingers.
  69. 69. Gluteus maximus gait(BACKWARD LURCH)  Due to weakness in gluteus maximus muscle, while the body propels forward during midstance phase,trunk is lurched posterior to effect posterior pelvic and shifting the centre of gravity towards stance hip.
  70. 70.  Seen in poliomyelities & above knee amputation with prosthesis.
  71. 71. Stiff hip gait  When the hip is ankylosed, it is not possible to flex at the hip joint during walking to clear the ground in the swing phase.  Hence the person with stiff hip, lifts the pelvis on that side and swings the leg with the pelvis in circumduction and moves it forward.
  72. 72. STAMPING/ATAXIC GAIT:  It occurs in sensory ataxia in which there is loss of sensation in lower extremity due to disease processes in peripheral nerves, dorsal roots, dorsal column of spinal cord.  Due to absence of deep position sense,the patient constantly observes placing of his feet.  Hip is hyperflexed & externally rotated & forefoot is dorsiflexed to strike ground with a Stamp.
  73. 73.  Seen in peripheral neuritis & brain stem lesion in children, tabes dorsalis in adults.
  74. 74. Alderman’s gait: • Seen in Tuberculosis of spine in lower dorsal and upper lumbar vertebra. • Patient walk with head and chest thrown backward and protuberant abdomen and legs thrown wide apart.
  75. 75. GAIT TRAINING  AIM:  To achieve safe, easy, effortless normal gait pattern. Non ambulatory phase 1. Asses and improve the range of movement 2. Treat contractures 3. Improve the cardio respiratory status 4. Shadow walking 5. Assisted device
  76. 76. Ambulatory phase 1. Support by orthotic & prosthesis 2. Parallel bar walking 3. Encourage reciprocal arm swinging 4. Follow other forms of walking  Turning  Side walk  back walk  Squatting  Getting up  Walking on uneven rough surface

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