physical medicine and rehabilitation

1. SKNAYAK
NILD, KOLKATA

2. THE WALKING
• THE BASIC UNIT OF WALKING IS THE GAIT
CYCLE.
• GAIT CYCLE BEGINS WHEN THE FOOT
CONTACTS THE FLOOR AND ENDS WITH
SUBSEQUENT FLOOR CONTACT OF THE SAME
FOOT.

3. GAIT CYCLE

4. • PERIODS - THE GAIT CYCLE IS SEPARATED INTO TWO
DISTINCT PERIODS OF STANCE AND SWING.
• FUNCTIONAL TASKS - WEIGHT ACCEPTANCE AND
SINGLE-LIMB SUPPORT DURING STANCE AND LIMB
ADVANCEMENT DURING SWING.
• THE STANCE PERIOD OF THE GAIT CYCLE INCLUDES
INITIAL CONTACT, LOADING RESPONSE, MIDSTANCE,
TERMINAL STANCE, AND PRESWING.
• THE SWING PERIOD INCLUDES INITIAL SWING,
MIDSWING, AND TERMINAL SWING

5. GAIT PARAMETERS
• VELOCITY (M/S)
• CADENCE (STEPS /MIN)
• STRIDE LENGTH (M)
• STANCE (% GAIT CYCLE)
• SWING (% GAIT CYCLE)
• DOUBLE SUPPORT (% GAIT CYCLE)

7. PARAMETERS CONTD..
• 1GC= 1 STRIDE = 2 STEPS
• 1 STRIDE LENGTH= 2 STEP LENGTHS
• CADENCE= FREQUENCY OF STEPPING PER MINUTE (STEPS/
MIN)
• VELOCITY= CADENCE TIMES THE STEP LENGTH

9. GAIT DETERMINANTS
• THE VERTICAL DISPLACEMENT OF THE BODY IS
MINIMIZED BY THE FACTORS, KNOWN AS THE
DETERMINANTS OF GAIT.
• DETERMINE ENERGY EFFICIENCY AND
SMOOTHNESS OF THE GAIT.

10. • DETERMINANTS OPERATE INDEPENDENTLY
AND SIMULTANEOUSLY TO PRODUCE
1. SMOOTH SINUSOIDAL VERTICAL PATH
2. HORIZONTAL PATH,
3. LATERAL SINUSOIDAL PATH

11. VERTICAL SINUSOID

12. LATERAL SINUSOID & HORIZONTAL SINUSOID

13. PATH OF THE COG

14. DETERMINANTS
• PELVIC ROTATION
• PELVIC OBLIQUITY/ TRENDELENBURG/ LIST
• KNEE FLEXION IN STANCE
• LATERAL DISPLACEMENT OF PELVIS
• TRUNK AND SHOULDER ROTATION
• ANKLE AND FOOT MECHANISM

15. PELVIC ROTATION
• THE PELVIS ROTATES TOWARDS FORWARD IN SWING
LIMB AROUND THE AXIS OF HIP JOINT ON STANCE
SIDE.
• THE HIP IN STANCE SIDE IS IN INTERNAL ROTATION.
• THIS RESULTS IN REDUCTION OF ANGLE OF
INTERSECTION OF THIGHS TO REDUCE THE VERTICAL
DESCENT OF TRUNK.
• THE AVERAGE MAGNITUDE OF THIS ROTATION IS
APPROXIMATELY 4 DEGREES ON EITHER SIDE OF THE
CENTRAL AXIS. THE TOTAL OF 8 DEGREES.

16. PELVIC TRENDELENBURG MOTION OR PELVIC LIST
• THE PELVIS DROPS ON THE SIDE OF SWING PHASE.
THE HIP OF LEG ON SWING PHASE IS LOWER THAN
THE SIDE IN STANCE PHASE.
• MAXIMUM TILTING- AT MIDSWING.
• THE AVERAGE MAGNITUDE: THE AVERAGE OF THE
ANGULAR DISPLACEMENT IS FIVE DEGREES.
• ASSOCIATED HIP MOVEMENT: RELATIVE HIP
ADDUCTION IN STANCE PHASE AND HIP ABDUCTION
IN THE SWING PHASE.
• FUNCTION: DECREASE VERTICAL DISPLACEMENT OF
CENTER OF GRAVITY 1/8 INCH.

17. KNEE FLEXION IN THE STANCE PHASE
AT INITIAL CONTACT, THE KNEE IS ALMOST (0 ±5O).
AT LOADING RESPONSE, THE KNEE BEGINS THE FIRST
EXCURSION OF FLEXION AFTER THE HEEL STRIKE ( = 15O – 20O)
IT HAS 3 FUNCTIONS:
1) SHOCK ABSORPTION.
2) MINIMIZE DISPLACEMENT OF COG.
3) REDUCES THE HEIGHT OF HIP JOINT IN MIDSTANCE.
3) DECREASE ENERGY EXPENDITURE.

18. LATERAL DISPLACEMENT OF PELVIS
• THE PELVIS AND TRUNK MOVE TO THE STANCE
SIDE.
• THE TIBIA ALIGNS IN VERTICAL POSITION
DURING STANCE PHASE.
• FUNCTION-
– BALANCES THE CENTER OF MASS OF TRUNK OVER
STANCE LIMB.
– THOUGH IT IS A NET LOSS OFF ENERGY AS IT
MOVES BODY UPWARDS, BUT IT IS ESSENTIAL FOR
BIPEDAL GAIT

19. TRUNK & SHOULDER ROTATION
• ROTATION OCCURS IN A DIRECTION OPPOSITE
TO THE PELVIC ROTATION.
• FUNCTION-
– BALANCES THE ANGULAR ACCELRATION WITH
TRUNK MOVEMENT.
– SMOOTH AND COORDINATED MOVEMENT
OCCURS.

20. FOOT & ANKLE MOVEMENT
• OBLIQUITY OF SUBTALAR JOINT-
DORSIFLEXION OF FOOT CAUSES LATERAL
MOVEMENT OF FOREFOOT AND PASSIVE
INTERNAL ROTATION OF TIBIA.
• SAGITTAL PLANE FOOT ANKLE MECHANISM-
“THE THREE ROCKER SYSTEM”

22. • Trunk counter-rotation and reciprocal arm swing.
• Head-on-body movements
• In saggital plane foot & ankle movement is
reffered to as rocker.
• Three components : at heel strike, during foot flat
& during toe off.
• Provide rolling like mechanism of foot during
stance : preserve momentum, minimize vertical
work of body movement, conserve energy.

23. FUNCTION OF THE DETRMINANTS OF GAIT
• INCREASE THE EFFICIENCY AND SMOOTHNESS
OF PATHWAY OF GAIT.
• DECREASE THE VERTICAL AND LATERAL
DISPLACEMENT OF CENTER OF GRAVITY TO TWO
INCHES EXCURSION.
• DECREASE THE ENERGY EXPENDITURE.
• MAKE GAIT MORE GRACEFUL.

24. GAIT ANALYSIS
• OBSERVATIONAL GAIT ANALYSIS
• NO AGREED APPROACH – POOR RELIABILITY
• PATTERN RECOGNITION AND MULTIPLE-
BRANCHING STRATEGIES MOST OFTEN USED
• FOCUS ON KEY EVENTS(INITIAL CONTACT, TOE
OFF) AND FUNCTIONAL TASKS (LOADING,
SUPPORT , PROPULSION)
• DISTINGUISHING BETWEEN PRIMARY PATHOLOGY
AND SECONDARY COMPENSATIONS.

25. QUANTITATIVE ANALYSIS
– TIME-DISTANCE MEASUREMENTS (STOP WATCH,
FOOTSWITCHES)
– KINETIC TECHNIQUES
– KINEMATIC ANALYSIS
– VIDEOTAPING, SEMI-AUTOMATED IMAGING
– COMBINED KINEMATIC AND KINETIC

26. PRACTICAL USES
• PLANNING FOR SURGERY
• PLANNING OF THERAPEUTIC INTERVENTIONS,
SUCH AS PHENOL, BOTULINUM TOXIN ETC
• PRESCRIPTION AND OPTIMIZATION OF LOWER
EXTREMITY ORTHOTIC AND PROSTHETIC
DEVICES
• SPORT MOVEMENT ANALYSIS
• ANALYSIS OF MUSCULOSKELETAL
CONDITIONS

27. CRITERIA FOR GAIT ANALYSIS
1. SUPPLY ADDITIONAL AND MORE PERTINENT
INFORMATION THAN THAT OF THE CLINICAL
EXAMINATION;
2. CORRELATE WITH THE FUNCTIONAL CAPACITY
OF THE PATIENT;
3. BE ACCURATE AND REPEATABLE,
4. RESULT FROM A TEST THAT DOES NOT OR ONLY
MINIMALLY ALTERS THE NATURAL
PERFORMANCE OF THE PATIENT

28. FOUR PRIMARY COMPONENTS OF QUANTITATIVE
GAIT ANALYSIS THAT CAN BE RECORDED ARE:
1. KINETICS (ANALYSIS OF FORCES THAT PRODUCE
MOTION);
2. POLY-EMG OR DYNAMIC EMG (ANALYSIS OF
MUSCLE ACTIVITY);
3. KINEMATICS (ANALYSIS OF MOTION AND
RESULTING TEMPORAL AND STRIDE MEASURES)
4. ENERGETICS (ANALYSIS OF METABOLIC OR
MECHANICAL ENERGY)

29. FORCE PLATE
• IT CONSISTS OF:
1.TOP PLATE
2.FORCE TRANSDUCERS AT
EACH CORNER
• FORCE PLATES ALLOCATE
THE MEASUREMENT OF
BOTH VERTICAL AND SHEAR
FORCES, AS WELL AS THE
CENTRE OF PRESSURE FOR
THE SUBJECT THROUGHOUT
GAIT

30. DYNAMIC POLYELECTROMYOGRAPHY
• EMG RECORDINGS PROVIDE INFORMATION ABOUT
THE TIMING AND DURATION OF MUSCLE ACTIVATION
• THE EMG SIGNAL IS AN ACCURATE INDICATOR OF
MUSCLE ACTIVATION AND CAN BE USED TO INFER
NEUROLOGIC CONTROL INFORMATION
• SUPERFICIAL MUSCLES ARE PREFERENTIALLY STUDIED
USING SURFACE BIPOLAR ELECTRODES SECURED TO
THE SKIN
• A PAIR OF INDWELLING FINE WIRE ELECTRODES ARE
USED IN DEEP MUSCLES OR WHERE CROSS SIGNALLING
CAN OCCUR

31. • EMG PATTERNS ARE HIGHLY SENSITIVE TO
WALKING SPEED
• TIMING & AMPLITUDE OF THE EMG SIGNAL MAY
PROVIDE VALUABLE INFORMATION FOR CLINICAL
DECISION MAKING
• A PARTICULAR MUSCLE MAY BE OVER- OR
UNDERACTIVE DURING A GIVEN PORTION OF THE
CYCLE
• PATIENT EMG PROFILES CAN BE COMPARED WITH
THE MEAN AND SD OF TABULATED NORMATIVE
DATA AFTER ADDING CORRECTIONS FOR SPEED

32. MOTION ANALYSIS
• MOTION ANALYSIS REFERS TO A QUANTITATIVE
DESCRIPTION OF THE MOTION OF BODY
SEGMENTS, WITHOUT REGARD TO THE FORCES
• EARLY TECHNIQUES INCLUDED PHOTOGRAPHIC
AND CINEMATOGRAPHIC ANALYSIS
• MOST MODERN SYSTEMS INVOLVE THE USE OF
SPECIALIZED OPTOELECTRONIC APPARATUS
• PASSIVE OR ACTIVE OPTICAL SOURCES ARE
ATTACHED TO THE SUBJECT AND SERVE AS
MARKERS.

33. • THE MARKERS ARE TRACKED WITH THE HELP
OF CAMERAS.
• WHEN TWO OR MORE CAMERAS TRACK A
SINGLE MARKER 3D CO-ORDINATES CAN BE
GENERATED.
• WHEN COMBINED WITH ANTHROPOMETRIC
AND KINETIC DATA, JOINT MOMENTS AND
POWERS AS WELL AS MECHANICAL ENERGY
CAN BE CALCULATED.

35. ENERGETICS
• IT IS THE CALCULATION OF ENERGY
REQUIREMENT DURING GAIT.
• NORMAL GAIT ON LEVEL SURFACES IS MOST
EFFICIENT AT A WAKING SPEED OF 1-1.3 M/S
• THERE IS A LINK BETWEEN MOTION OF THE COM
AND ENERGY EXPENDED DURING WALKING
• SUDDEN ACCELERATION OR DECELERATION OF
THE COM WILL INCREASE ENERGY
CONSUMPTION

36. • THERE ARE SEVERAL METHODS OF
METABOLIC ENERGY MEASUREMENT—
• INDIRECT CALORIMETRY,
• EXPIRED AIR COLLECTION, AND
• HEART RATE MONITORING, EG : K4B2
MACHINE.

38. Different types of Gait
• Amputee gait
• Ataxic gait
• Festinating gait
• Steppage gait
• Waddling gait
• Spastic gait
– Post stroke
– Cerebral palsy

39. CIRCUMDUCTION GAIT-HEMIPLEGIA
•knee is hyperextended
•the affected leg is
circumducted or abducted
during the swing phase to
allow the toes to clear the
ground
•seen in
-neurological or mechanical
condition leading to stiffness
in the knee or ankle joint
-limb length discrepancy

40. EQUINUS GAIT
CHILD WALKS WITH TOES
SEEN IN
-CTEV
-IDIOPATHIC TIGHT
ACHILLIES TENDON
-CALCANEAL FRACTURE
-FB IN FOOT
-LIMB LENGTH
DISCREPENCY

41. STEPPAGE GAIT
•HIP AND KNEE JOINTS ARE
FLEXED EXCESSIVELY DURING
THE SWING PHASE TO ALLOW
THE TOES TO CLEAR THE
GROUND
•SEEN IN – ANY
NEUROLOGICAL CONDITION IN
WHICH THE CHILD LOES THE
ABILITY TO DORSIFLEX THE
FOOT

42. PPOPULSIVE GAIT
SMALL SHUFFLING STEPS
HYPOKINESIA/AKINESIA
REDUCED STRIDE LENGTH
CADENCE RATE IS INCREASED
DIFICULTY IN STARTING AND
STOPPING THE GAIT
FLAT FOOT STRIKE
REDUCED FOOT LIFTING DURING
THE SWING PHASE

43. AMPUTEE GAIT

44. AMPUTEE GAIT
• INITIAL CONTACT WITH LOADING RESPONSE
– FOOT ROTATION AT HEEL STRIKE
– KNEE BUCKLING
• MID STANCE
– LATERAL TRUNK BEND OR SHIFT OVER
PROSTHESIS
• INITIAL SWING
– UNEVEN HEEL RAISE

45. Amputee gait
• SWING PHASE
– CIRCUMDUCTION ON PROSTHETIC LIMB
– WHIPS
• SUCCESSIVE DOUBLE SUPPORT
– UNEVEN STEP LENGTH

46. CROUCH GAIT
• crouch-
– excessive knee flexion in stance phase
– variable knee alignment in swing phase
– hips are often adducted and internally rotated
– seen in cerebral palsy

47. CEREBELLAR GAIT
• Wide based gait
• Lateral instability of gait
• Erratic foot placement
• Decompensation of balance

48. SENSORY ATAXIA
• BALANCE AMONG VISUAL VESTIBULAR &
PROPRIOCEPTION IS LOST OR DEGRADED
• THE STANCE IN SUCH PATIENT IS DESTABILIZED
BY EYE CLOSURE

49. GAIT APRAXIA
• FRONTAL GAIT DISORDER
• WIDE BASE OF SUPPORT
• SHORT STRIDE
• SHUFFLING ALONG THE FLOOR
• DIFFULTY IN STARTING OR TURN

50. Thank you