AUSTRALASIAN FACULTY OF REHABILITATION MEDICINE

The Royal Australasian College of Physicians

Musculoskeletal Medicine
Training Module
Workbook 2

Gait Analysis
 Copyright for this publication rests with
The Australasian Faculty of Rehabilitation Medicine (Royal Australasian College of Physicians)

1st Edition 2003

145 Macquarie Street

SYDNEY NSW 2000
AUSTRALIA

PHONE: (02) 9256 5402

FAX NO: (02) 9251 7476
E-MAIL: afrm@racp.edu.au

Acknowledgement

The AFRM would like to acknowledge the contribution made by Dr Susan Inglis, FAFRM, in
the development of this workbook.

Allergan Australia Pty Ltd is an ongoing sponsor of the AFRM Vocational Training Program.
 CONTENTS

Introduction 1

Learning Objectives 2

Knowledge 2

Skills 2

Learning Opportunities 3

Checklist for gait analysis 4

Evaluation 5

Clinical Scenarios 6

Suggested Learning Resources 10

Journal Abstracts 10

ATTACHMENTS

1. Workbook Evaluation Form

 Introduction

The purpose of the workbook is to help guide you through a self-directed learning
program on musculoskeletal (MSK) rehabilitation, in this case gait analysis.

The learning objectives are designed to make clear what is expected from you. A
deep approach to learning will hopefully enable you to transfer your knowledge and
skills into the clinical situation and provide expert care for patients with
musculoskeletal problems. How well you understand this “topic” will ultimately
affect them.

You can choose to work in small groups or on your own. The clinical scenarios will
help guide your research as each one covers different topics of the curriculum in
MSK. The skills you need to acquire are also in the learning objectives.

Musculoskeletal Medicine Training Module: Gait Analysis 1

 Learning objectives

Knowledge

 Describe the biomechanics and physiology of normal gait (kinetics and

kinematics).

 Describe the biomechanics and physiology of abnormal gait (kinetics and

kinematics).

 Describe the biomechanical effects of walking aids on gait patterns (orthotics,

prosthetics, canes, crutches, frames).

Skills

 Demonstrate ability to interpret X Ray, CT, MRI, EMG, NCS in relation to

gait abnormalities

 Demonstrate ability to formulate a physical program that addresses abnormal

biomechanics and physiology of gait

 Demonstrate ability to educate/ inform patients of the reasoning behind the

rehabilitation program

 Demonstrate ability to plan and participate in education sessions on gait

analysis that is appropriate to the participants’ level of training

Musculoskeletal Medicine Training Module: Gait Analysis 2

 Learning Opportunities

 Attend prosthetic and orthotic clinics

 Attend a gait analysis laboratory

 Attend EMG and NCS laboratory (private or public)

 Attend Radiology meetings

 Faculty State Branch training sessions

 Peer training sessions (for you to arrange)

 Independent workshops/ courses

 Library resources / texts/ journals/ videos

 Describe the gait pattern of all patients that you admit

 Prepare videotapes of patients with different gait patterns (patients’ written

consent must be obtained first)

Musculoskeletal Medicine Training Module: Gait Analysis 3

 Checklist for Gait Analysis

Introduced self to the patient □

Adequate exposure of patient □
Observed and described gait from

front □
side □
behind □
Asked patient to perform functional tasks

Squat □
Tiptoe □
Heelwalk □
Described components of the gait cycle

Symmetry □
Heel strike □
Step length □
Proportional time in stance/swing □
Cadence □
Described ROM at

Hip □
Knee □
Ankle □
If applicable

Described walking aids and effect on biomechanics □

Described orthosis/ orthotics and effect on biomechanics □
Described prosthetic device and effect on biomechanics □
Musculoskeletal Medicine Training Module: Gait Analysis 4
 Evaluation

Always start with self-evaluation because ultimately you will be the one evaluating
your own independent practice in future years.

Self
 Videotape or use a cassette to record yourself describing
gait.
 Have you addressed all the points on the checklist?
 Did you miss anything?
 Do you consistently miss the same point?
 How can you change this?

Peer
 Practice describing normal and abnormal gait patterns
 Use the checklist for consistency

Consultant
When you feel ready ask your Consultant to evaluate your
skills. Show them the checklist and ask them to use it.
Ask for what you did well and what you need to improve on.

You should attempt this process every few weeks to receive feedback on your
performance. (Formative feedback)

Supervisor This may be the same person as above.

Include your MSK (in this case gait) learning objectives and be
sure your supervisor is aware of your efforts. Repeat
evaluations as many times as necessary until you consistently
reach the standard required. There is no limit to how many
times you try.

You should attempt this process at least twice per term to receive feedback on your
performance. (Formative feedback)

Formal Examinations
This process formally tests your knowledge, skills and
attitudes. The checklists will be provided for examiners to use
in the assessment process. (Summative assessment)

Musculoskeletal Medicine Training Module: Gait Analysis 5

 Clinical Scenarios

These scenarios are suggested as they cover the main clinical areas of gait. They are
designed to be starting points for discussion with peers, supervisors, and team
members and to encourage further reading around each topic. They have no set or
right answers and are based on “real” patients.

To get the most out of these exercises it would be helpful to:

 Practise taking a history

 Practise examination technique
 Spend time viewing and interpreting the investigations
 Consider the underlying pathology and how it gives rise to symptoms
 Practise talking to patients about all of the above
 Examine the current evidence for treatment options

Working in small groups at Faculty State Branch training sessions or on your own
consider the following clinical scenarios:

1. Arthritis

A 70-year-old man has had a painful knee (OA) over the last three months and has
been mainly sitting in an attempt to minimise his pain symptoms. He now has a hip
contracture of 20 degrees and a knee contracture of 5 degrees. He walks leaning
towards the painful side.

a) Describe the altered biomechanics and underlying pathophysiology of this

man’s gait.

b) Describe the physical program you would recommend for this man and
provide current evidence from the literature to support/ refute your plan.

c) This man asks you if a hip replacement would help him. How do you
reply? (Give evidence for your comments).

d) Would your plan be different if this man was 86 years old? Why?

2. Amputation

An 80-year-old man tells you he “wants to walk” again. He had undergone a

transfemoral amputation 4 weeks earlier because of peripheral vascular disease. He
has mild cardiac disease, IDDM and minor memory impairment.

a) What additional information do you need from this man’s medical history
to enable you to make a decision on prosthetic use?

Musculoskeletal Medicine Training Module: Gait Analysis 6

 b) Would you order any investigations or tests? Why?

c) Who else may assist you in reaching a decision about the use of a
prosthesis?

d) How and when will you approach discussion of prognosis with this
patient?

3. Hemiparetic gait

A 54-year-old woman had ischaemic stroke three weeks ago. She has a left
hemiparesis with motor and sensory loss. She is mobilising with the assistance of one
person on your ward. She previously worked full time in the city as an accountant.
She is married with two teenage children.

a) Describe her probable gait pattern with reference to altered biomechanics

and physiology and explain the impact these changes will have on her
chances to return to living in her own home.

b) What other body impairments or altered function may have an impact on

her gait pattern and how will these alter your management plan?

c) What physical program will you recommend for this person?

(Include short, medium and long term plans with current evidence to
support/ refute each phase)

d) How will approach discussion on prognosis with this patient?

3. Post polio

A 55-year-old woman, who had polio as a child, attends your outpatients complaining
that her right leg seems weaker over the last twelve months. She tells you she has
difficulty walking even short distances and cannot use public transport now. She uses
one stick and a caliper to assist her walking.

a) Describe this woman’s likely gait pattern (with and without the caliper/
stick) and explain the underlying abnormalities in physiology and
biomechanics.

b) What is the likely energy cost of using a caliper and how does this impact
on this patient now and in the future?

c) What (if any) exercise program will you suggest for this patient? Why?
(Include the current evidence for your choices).

Musculoskeletal Medicine Training Module: Gait Analysis 7

4. Ataxic gait

A young patient of yours has recently been discharged from a rehabilitation unit. He
had survived a suicide attempt with carbon monoxide but had been left with an ataxic
gait. He is concerned over the appearance of his walking.

a) How will the ataxia affect the kinetics and kinematics of his gait?

b) What physical program (if any) will you suggest for him? Why?
(Include evidence for/ against your program).

c) How will you approach the discussion of prognosis with this young man?

5. Parkinson’s disease

You have been attending an 82-year-old man for the last 10 years and have been
concerned over the number of falls he has experienced in the last 4 months. His use
of medications has been optimised and he walks with a rollator frame. He and his wife
attend the appointment. They receive assistance from community nurses and home
care and are only just coping.

a) How does Parkinson’s disease affect this man’s gait pattern in terms of
altered biomechanics and physiology? (With and without aids)

b) Described what effects therapy/ rehabilitation programs will have on the

determinants of gait in this man. (Incorporate current evidence into your
answer).

c) Who are the other professionals that can assist you in the assessment of
this man and explain their role in his management?

d) Explain how you will approach discussion of prognosis with this family.

6. Paraplegia

A 17-year-old youth is admitted to the spinal unit with complete T6 paraplegia. He

has grade 2-3 muscle strength in his lower extremity muscles. He is eight weeks post
injury and wants to “walk” out of the rehabilitation unit on discharge in three weeks
time.

a) What orthotic aid/s could you use to assist this man in his goal of walking
and what training will the patient need to use this/ these aid/s?

b) Describe the gait pattern he might achieve both with orthotic aid/s and
without them.

c) What is the estimated energy cost of this gait pattern be and how will this
impact upon the patient?
Musculoskeletal Medicine Training Module: Gait Analysis 8
 d) What will you advise this patient about his goal to walk again?
e) (Include your approach, timing and current evidence form your Formatted: Bullets and Numbering
information and communication approach).

7. Orthopaedic

A 74-year-old woman fell down three stairs and sustained fractures to both her ankles.
She required open reduction and internal fixation (ORIF); both ankles have plaster of
paris applied. She is non-weight bearing and mobilising with a wheelchair.

a) What is your initial physical program for this patient and will you
recommend rehabilitation on your ward?

b) Her surgeon allows her to weight bear as tolerated (WBAT) with Canadian
crutches. Describe the biomechanics and pathophysiology of her altered
gait pattern.

c) Although she has a supportive family, they all work and she will be alone
during the day when you discharge her. When will you recommend
discharge and what safeguards will you suggest?

8. Professional Role / Teaching

The local clinical school has asked you the “teach” second year medical students
about gait analysis.

a) How will you approach this?

(Include learning objectives, content, presentation/ teaching style and
method of evaluation of your teaching).

b)You are asked to present the same topic to Advanced Training Rehabilitation Formatted: Bullets and Numbering
Registrars.

b) How will your presentation differ?

(Include learning objectives, content, presentation/ teaching style and
method of evaluation of your teaching).

You will need to refer to the education literature to effectively answer these questions.

Musculoskeletal Medicine Training Module: Gait Analysis 9

 Suggested Learning Resources

Journal Abstracts

1. Clin Biochem (Bristol,Avon) 2001 Jul;16

The biomechanics and motor control of gait in Parkinson disease.

Morris ME, Huxham F, McGinley J, Dodd K, lansek R.

School of Physiotherapy, La Trobe University, 3086, Bundoora,Australia

Parkinson disease is a progressive neurological condition characterised by hypokinesia

(reduced movement), akinesia (absent movement), tremor, rigidity and postural
instability. These movement disorders are associated with a slow short-stepped, shuffling
gait pattern. Analysis of the biomechanics of gait in response to medication, visual cues,
attentional strategies and neurosurgery provides insight into the nature of the motor
control deficit in Parkinson disease and the efficacy of current therapeutic
interventions. In this article we supplement a critical evaluation of the Parkinson
disease gait literature with two case examples. The first case describes the kinematic
gait response of an individual with Parkinson disease to visual cues in the "off' phase
of the levodopa medication cycle. The second case investigates the biomechanics and
motor control of turning during walking in a patient with Parkinson disease compared
with elderly and young control subjects. The results are interpreted in light of the need
for gait analysis to investigate complex functional walking tasks rather than confining
assessment to straight line walking, which has been the trend to date.

2. J Rehabil Res Dev 1995 Feb;32(1):25-31

Gait parameters following stroke: a practical assessment.

von Schroeder HP, Coutts RD, Lyden PD, Billings E Jr, Nickel VL.

Department of Orthopaedics and Rehabilitation, University of California, San Diego

92103-1190, USA.

Mechanical methods of quantifying gait are more sensitive to change than is direct clinical
inspection. To assess gait parameters and patterns of patients with stroke, and the
temporal changes of these parameters, a foot-switch gait analyzer was used to test 49
ambulatory patients with stroke and 24 controls. Patients walked significantly slower than
controls, with decreased cadence, increased gait cycle, and increased time in double limb
support. Patients' hemiplegic limbs spent more time in swing and stance when compared
to controls; their unaffected limbs spent significantly more time in stance and single limb
support compared to control s. Patients' hemiplegic side, when compared with the
unaffected side, spent less time in stance and more time in swing. A flatfoot pattern was
typically noted on the affected side. General gait parameters improved over time, with the
largest changes occurring in the first 12 months. However, the percentage of time spent in

Musculoskeletal Medicine Training Module: Gait Analysis 10

double and single limb support, stance and swing, parameters which describe the
asymmetrical pattern of gait, did not change over time. Abnormal gait was due to
difficulty in moving the body over an unstable limb. Gait analysis can be of importance in
documenting abnormalities and determining the effects of therapeutic modalities.
3: Arch Phys Med Rehabil 1983 Sep;64(9):402-7

Plastic ankle-foot orthoses: evaluation of function.

Lehmann JF, Esselman PC, Ko MJ, Smith JC, deLateur BJ, Dralle AJ.

Plastic ankle-foot orthoses (PAFOs) are worn by persons with hemiplegia to correct gait
abnormalities such as foot drop during swing and insufficient pushoff during stance. A
PAFO should resist plantarflexion sufficiently to provide toe clearance during the swing
phase of gait without excessively increasing the knee bending moment during heelstrike.
It should resist dorsiflexion during late stance to raise the heel to simulate
gastrocnemiussoleus muscle group function. Five PAFOs were evaluated as to the amount
of plantarflexion-dorsiflexion resistance that was provided when worn by hemiplegic and
able-bodied subjects. A self-aligning goniometer measured ankle angle as the subject
walked, and a gait event marker system recorded occurrences of gait events. The Seattle
design polypropylene orthosis which enclosed the malleoli was the least flexible; it
provided the greatest plantarflexion resistance to ensure against toe drag during swing for
patients with severe plantarflexion spasticity. It offered the greatest dorsiflexion
resistance to provide a good substitute for the gastrocnemiussoleus during the latter part
of stance as required by patients with flaccid plantarflexors and full ankle range of
motion. Progressive trimming of the Seattle design polypropylene orthosis made it more
flexible and comparable in function to the commercially available Engen and Teufel
orthoses. The latter 2 orthoses did not provide a pushoff substitute as well as the Seattle
design orthosis which enclosed the malleoli, but they did provide an adequate amount of
toe clearance during swing. The more flexible orthoses would be appropriate for subjects
with mild to moderate plantarflexor spasticity.

4. Arch Phys Med Rehabil 1999 Jul;80(7):777-

Hemiplegic gait of stroke patients: the effect of using a cane.

Kuan TS, Tsou JY, Su FC.

Department of Physical Medicine and Rehabilitation, National Cheng Kung University

Hospital, Tainan, Taiwan.

OBJECTIVE. To assess the effects of cane use on the hermiplegic gait of stroke patients,
focusing on the temporal, spatial, and kinematic variables. DESIGN: Case-control study
comparing the effect of walking with and without a cane using a six-camera computerized
motion analysis system. SETTING: Stroke clinic of a tertiary care hospital.
PARTICIPANTS: Fifteen ambulatory stroke patients were analyzed, including 10 men
and 5 women (mean age, 56.9 years; mean time since stroke, 9.8 weeks). Nine
age-matched healthy elderly subjects were recruited as a control group. RESULTS:
Stroke patients walking with a cane showed significantly increased stride period, stride
length, and affected side step length, as well as decreased cadence and step width (p <.05)
in comparison with those who walked without a cane. There were no significant
differences in the gait phases and the five gait events of hemiplegic gait walking with or
Musculoskeletal Medicine Training Module: Gait Analysis 11
without a cane. Cane use thus may have more effect on spatial variables than on temporal
variables. The affected side kinematics of hemiplegic gait with a cane showed increased
pelvic obliquity, hip abduction, and ankle eversion during terminal stance phase;
increased hip extension, knee extension, and ankle plantar-flexion during preswing phase;
and increased hip adduction, knee flexion, and ankle dorsiflexion during swing phase as
compared with hemiplegic gait without a cane. A cane thus improved the hemiplegic gait
by assisting the affected limb to smoothly shift the center of body mass toward the sound
limb and to enhance push off during preswing phase. It also improved circumduction gait
during swing phase. CONCLUSION: Stroke patients walking with a cane demonstrated
more normal spatial variables and joint motion than did those without a cane.

Musculoskeletal Medicine Training Module: Gait Analysis 12

 Attachment 1

The Royal Australasian College of Physicians

THE AUSTRALASIAN FACULTY OF REHABILITATION MEDICINE

Evaluation of Musculoskeletal Rehabilitation Training Workbook

Gait Analysis
Please take a few moments to complete this evaluation form. Your thoughtful comments will
be reviewed by the Vocational Training Committee and will assist the Committee in the
planning and development of future training resources.

1. Was the workbook helpful in your learning of this topic? (i.e. Did it clarify what
knowledge attitude and skills you needed to reach competency in this area?)

2)2. Did you find the clinical scenarios and references helpful? Formatted: Bullets and Numbering

3)3. Do you feel your skills have improved as a result of using the workbook? Formatted: Bullets and Numbering
Have you used your improved skills in the clinical setting?

4. If you have not used your new skills, what has prevented you from doing so?
 Attachment 1

5. What further questions about this topic remain in your mind remain in your mind?

6. Please give any additional comments about other aspects of the workbook, including
requests for future workbook topics (or improvement on the existing book).

7)7. What other support do you feel the Faculty could provide to assist or facilitate your Formatted: Bullets and Numbering
learning in Musculoskeletal Medicine?

Name ______________________ date ___________ signature_________________

Thank you for your assistance.

The Vocational Training Committee
Please return completed evaluation forms to: AFRM, 145 Macquarie Street, Sydney NSW 2000