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Gait analysis methodology

ARTICLE in HUMAN MOVEMENT SCIENCE · MARCH 1984

Impact Factor: 1.6 · DOI: 10.1016/0167-9457(84)90004-6

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Aurelio Cappozzo
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Human Movement Science3 (1984)27-50 27
North-Holland

GAIT ANAL YSIS METHODOLOGY *

Aurelio CAPPOZZO
Universitàdegli Studi' La Sapienza',Italy

Cappozzo, A., 1984. Gait analysis methodology. Human Movement

Science3, 27-50.

This paper reports a discussionon the heuristic and applicative objectivesof gait analysis and on
the experimentaland analytical methodsused in this context. In particular, the use of an effective
method of description of joint kinematics and kinetics i.e., joint function, as applied to the lower
limb joints during normal walking is reported. A methodological hypothesisfar the evaluation of
gait, as an integrated phenomenonis presentedand supported by experimental data concerning
normal and pathological walking and sportive gaits.

Introduction

Locomotion is the action with which the entire bulk of the animal's
body moves through aerial, aquatic, or terrestrial space.Locomotion is
achieved by coordinated movements of the body segmentsemploying
an interplay of internaI and external forces (Cappozzo et al. 1976).
Although locomotion is a very complex phenomenonwhich can only
be thoroughly describedthrough a multidisciplinary approach,the most
qualifying approach comes from the domain of classical mechanics,
that is to say that biomechanics has the greatest responsibility for
establishingthe relevant scientific knowledge.
The quantitative description of alI mechanical aspectsof walking is
commonly referred to as gait analysis.This paper intends to elaborate
on this definition and on the scientific and applicative objectivesof gait

* Some of the experiments referred to in this paper were carried out at Physical Support Italia
Ltd, Roma, where a VICON systemwas made available to the author. The collaboration of Dr.
Fabio Gazzani in the preparation of this manuscript is gratefully acknowledged.
Author's address: A. Cappozzo, Laboratory of Biomechanics, Istituto di Fisiologia Umana,
Università degli Studi 'La Sapienza',00100 Roma, Italy.

0167-9457/84/$3.00 <rJ1984, Elsevier Science Publishers S.V. (North-Holland)

Human Movement Science3 (1984)27-50 27
North-Holland

GAIT ANAL YSIS METHODOLOGY *

Aurelio CArrozza
Universitàdegli Studi' La Sapienza', Italy

Cappozzo, A., 1984. Gait analysis methodology. Human Movement

Science3, 27-50.

This paper reports a discussionon the heuristic and applicative objectivesof gait analysis and on
the experimentaland analytical methodsused in this context. In particular, the use of an effective
method of description of joint kinematics and kinetics i.e., joint function, as applied to the lower
limb joints during normal walking is reported. A methodological hypothesisfar the evaluation of
gait, as an integrated phenomenonis presentedand supported by experimental data concerning
normal and pathological walking and sportive gaits.

Introduction

Locomotion is the action with which the entire bulk of the animal's
body moves through aerial, aquatic, or terrestrial space.Locomotion is
achieved by coordinated movements of the body segmentsemploying
an interplay of internaI and external forces (Cappozzo et al. 1976).
Although locomotion is a very complex phenomenonwhich can only
be thoroughly describedthrough a multidisciplinary approach,the most
qualifying approach comes from the domain of classical mechanics,
that is to say that biomechanics has the greatest responsibility for
establishingthe relevant scientific knowledge.
The quantitative description of alI mechanical aspectsof walking is
commonly referred to as gait analysis.This paper intends to elaborate
on this definition and on the scientific and applicative objectivesof gait

* Some of the experiments referred to in this paper were carried out at Physical Support Italia
Ltd, Roma, where a VICON systemwas made available to the author. The collaboration of Dr.
Fabio Gazzani in the preparation of this manuscript is gratefully acknowledged.
Author's address: A. Cappozzo, Laboratory of Biomechanics, Istituto di Fisiologia Umana,
Università degli Studi 'La Sapienza',00100 Roma, Italy.

0167-9457/84/$3.00 CC>
1984, Elsevier SciencePublishersB.V. (North-Holland)
28 A. Cappozzo/ Gait analysismethodology

analysis. In addition to this, some crucial experimental and analytical

problems encounteredin analyzing gait will be discussed.

What is gait analysis?

An effective way of outlining the contents of a discipline is to describe

its historical developmentand its heuristic and applicative objectives.
Borelli (1680)was the first to apply Galileo's scientific method to the
study of locomotion. His treatise on walking has more than a fiere
historical value. His analysis may be regardedas correct far walking at
a very slow cadence. However, lack of proper instrumentation and
incomplete awarenessof the inertia principle probably mediated against
him abandoning what, today would be looked upon as a quasi-static
approach.
The leap tram a static to a dynamic approachwas facilitated by the
developmentof photography. Only then, could fast motions be stopped
and analyzed.Muybridge (1887) was the first to publish photographic
sequencesof animaI and human locomotor acts. These sequenceswere
obtained using a systematic method which permitted some detailed
observation of the phenomenon. However, measurementsin the strict
sensecould not be sufficiently accurate. Muybridge's work awakened
interest and produced results of great relevanceto the field of arts and
it also stimulated the use of photography in scientific research.
At about the sametime, in fact, and after having becomeacquainted
with Muybridge's work, Marey (1885)started to use photography in bis
lire movementstudies. Although Marey's experimental approachto the
problem was highly scientific and representeda fundamental enrich-
ment of man's sensorial capacity, the observation of the phenomenon
however stilI remained to a large extent qualitative.
The history of modern biomechanicsstarts in 1895 when Braune and
Fisher begin publishing their work. Two fundamental developments
pioneered by them merit their receiving the title of fathers of modero
biomechanics.Firstly, they perfected the processof idealization of the
natural phenomenonbeing studied -basic to any scientific methodol-
ogy -which allowed the use to full capacity of the instruments of
classicalmechanics.This permitted them to predict those aspectsof the
phenomenon which were not observable or were difficult to observe
directly. Secondly,and also by virtue of the above-mentionedidealiza-
 A. Cappozzò Gait analysismethodology 29

tion of the phenomenon, they could design experimental setups which

permitted proper measurements.In particular, Braune and Fisher were
the first to representhuman body segmentsusing a major stereotypeof
classicalmechanics:the rigid body. They also introduced into the study
of lire movementthe technique of stereometry,of stereophotogramme-
try in particular, which today is stilI the basic experimentaltechnique in
biomechanicsof human movement.
Stereometrypermits the three-dimensional (3-D) reconstruction of
the instantaneousposition of a moving point in a laboratory coordinate
system.li this is carried out for at least three noncollinear points fixed
in a body segment(supposedrigid) then the position of this segmentis
thoroughly defined. Several techniques use the basic concepts of
stereometry:(1) stereophotogrammetry(Braune and Fisher 1895; Bern-
stein 1967; Eberhart et al. 1947; Winter et al. 1972; Jarrett et al. 1974;
Lindholm 1974; Macellari 1983), (2) light scanning (Mitchelson 1975),
(3) stereosonicsystems(Brumbaugh et al. 1982).
Other techniquesused for the measurementof body segmentmotion
afe exoskeletallinkageand accelerographicmethods(Chao 1980; Hayes
et al. 1983).The former method permits the measurementof the gross
relative motion between adjacent body segments.The use of accelero-
metry poses several technical and computational problems, and does
noi therefore seem to be competitive with the methods discussed
previously. However, in those situations where body segments afe
subjected to external impulsive forces, as when the heel strikes the
ground during gait, this techniqueplays a fundamental role.
The problem of measuring the 3-D movement of human body
segments was thus already solved at the end of the last century.
Subsequentdevelopmentsbave led to such measurementsbecoming,
largely, automated.
A further problem posed by gait analysis concerns the forces that
cause the observed movement and the assessmentof their role within
the phenomenonbeing analyzed.The forces acting on the human body
during walking may be devided into two categories: internaI and
external. The external forces representalI physical interactions between
the body and the environment. These afe the gravitational and the
ground reaction forces. The internaI forces afe, among others, those
transmitted by body tissues as muscular forces, tension forces trans-
mitted by the ligaments and forces transmitted through joint contact
areas.
30 A. Cappozzo Gait analysismethodology

Generally, the only forces which can be measured afe the ground
reactions. This simply requires the use of a dynamometric platform
which occupies a portion of the floor on which the locomotor act is
performed. The first dynamometer of this type, although rather primi-
tive, was built by Amar (1916). Only in 1947 was a dynamometric
platform able to measurethe three forces and three moments necessary
to describe the interaction between foot and floor made available
(Eberhart et al. 1947).
The gravitational forces acting on each body segment can be
determined tram the relevant mass and location of the centre of masso
These quantities can be calculated, together with the segmentalmass
moments of inerti a, by means of prediction techniques tram anthropo-
morphic dimensions. Current methods for their in vivo experimental
assessmentafe complex and some of them may be harmful to the
subject's health. The prediction techniques can be divided into two
major methodological groups: (1) estimation through regressionequa-
tions (Dempster 1955; Clauser et al. 1969; Chandler et al. 1975;
Zatsiorsky and Seluyanov 1983); (2) geometrical approximation
(Hanavan 1964; Jensen1978; Hatze 1980b). The regressionequations
have beendetermined through statistical analysis of data obtained tram
sample populations of subjects. Most of the measurementshave been
made using cadaver specimens.The geometrical appro~imation tech-
nique entails that the irregular shapesof the different body segments
afe represented with standard geometric forms which admit simple
mathematicaldescription.
The measurementof internaI forces requires sophisticatedtechniques
which afe often invasive, and which afe difficult to use when dynamic
physical exercises,such as walking, afe analyzed. For these reasons,
analytical procedureshave beendevelopedfar estimatinginternaI forces.
This approachrequires data on the motions and the inertial properties
(mass,massmoments of inertia, and locations of the centres of gravity)
of the subject's body segments,and on the ground reactions. The
analysis then leads to the calculation of a set of internaI forces which
afe consistent with the observedmovement. Relevant analytical meth-
ods use classicalmechanicsand modelling approaches.
Using the equations of rigid body mechanics it is possible to de-
termine the intersegmental forces and couples, that is, the resultant
rocce actions transmitted across an imaginary surface which separates
two adjacent body segments (Bresler and Frankel 1950; Cappozzo
 A. Cappozzo/ Gait analysismethodology 31

1983). These forces and couples represent alI physical connections of

one body part with the other. They afe assumedto maintain both body
parts in the same dynamical state they had before their imaginary
separation. From this knowledge and from soft tissue anatomical and
functional information the prediction of internalloads occurring during
physical exercisemay be undertaken. This is achieved through modell-
ing techniques (Paul 1966; Seireg and Arvikar 1975; Hatze 1980a;
Carrozza 1984).
In several instances an effective way to describe the process of
walking is achievedby analyzing the function of energy; variables such
as force and displacement can then be reduced and used in a more
compact form of work or energy variation (Cappozzo et al. 1976).
When a mechanicalmodel of the human body is defined as a linkage of
physically-united rigid segmentstransmitting forces and couples, the
mechanicalenergyof thesesegmentsand the work dalle on them can be
calculated.
For mathematical tractability, the above-mentioned analytical ap-
proachesrequire the use of simplifying assumptionsabout the mechani-
cal structure and behaviour of the human body. Thus, the accuracyof
the analytical predictions dependsnot only on the quality of the input
data, but also on the validity of these simplifying assumptions. In
generaIit is necessaryto validate the estimatedquantities by comparing
them, or other related quantities, with empirical observations in a
number of selectedcases.For this purpose physiological measurement
techniques such as electromyography,intra-abdominal and intra-discal
pressuremeasurementsetc., afe often used.
The ensembleof the analytical and experimental procedures which
lead to the determination of the above-mentionedquantities is com-
monly referred to as gait analysis.
Walking is accomplishedthrough the summation of a certain number
of musculo-skeletal functions. An objective of gait analysis is the
quantitative assessmentand description of these functions, that is, of
the joint motions which concur to form the locomotor act and the
forces that contraI these motions. This analysis permits recognition of
the "how" a given individuaI walks.
The way the above-mentionedfunctions afe combined together with
the objectivesthat afe pursued through their combination pertain to the
motion strategy. A strategy is chosenamong those that afe consistent
with the functional and structural constraints associated with the
32 A. Cappozzo/ Gait analysismethodology

locomotor systembeing analyzed. It is reasonableto assumethat with

these different possible strategiesdifferent qualities of gait afe associ-
ated. Based on these considerations, it may be concluded that the
quality of the gait performed by a subject depends on two major
factors. ane is associatedwith the functional and structural constraints
imposed by the subject's locomotor systemand, given this locomotor
system,the second factor is associatedwith the subject's ability to put
into action an effective motion strategy.Assigninga value to the quality
of gait is another objective of gait analysis, usually called gait evalua-
tion. The discrimination between the two above-mentioned factors
influencing the quality of gait is yet another, and the most ambitious,
objective of gait analysis.

Function assessment

Musculo-skeletal function assessment entails the quantitative descrip-

tion of joint kinematics and kinetics. Basically, this requires the de-
termination of the relative motion between the opposing bones and of
the relevant inersegmental load actions. When diarthrodial joints afe
considered, the intersegmental couple may be calculated so as to be
assumed to equal the muscular moment acting about the joint therefore
yielding information about muscular function.
As was mentioned in a previous section, the experimental and
analytical determination of the above-mentioned m~chanical quantities
represents no difficulty from a theoretical point of view. A free-body
diagram of the portion of the human body under investigation is
defined which is a linkage of physically-united rigid segments. With this
mechanical model, positional and inertial properties afe associated.
The positional properties convey the information needed to locate, at
any instant in time, the position of any point in a segment relative to an
arbitrarily chosen reference observer. This is achieved by defining a
local coordinate system (o x y z) rigid with the segment and a global
coordinate system (O X Y Z) rigid with the observer. Given the
position vectorp of any point in the local coordinate system (l.c.s.), the
relevant position vector P in the global coordinate system (g.c.s.) is
given by:
 A. Cappozzo/ Gait ana/ysismethod%gy 33

p = Ajj + Po

where A is the transformation matrix and 1>0is the position vector of

the l.c.s. origin relative to the g.c.s. The columns of matrix A afe the
direction cosines of the l.c.s. axes with respectto the g.c.s. Hence, the
definition of the instantaneousposition of the moving segmentr~lative
to the fixed observerreducesto determining the position vector Po and
transformation matrix A, which therefore becomethe mechanicalmodel
positional properties.
Stereometric techniques permit the determination of the instanta-
neous position of points fixed in a moving segment and, therefore,
allow simple vector calculations of the segmenttransformation matrix
and position vector. AlI stereometric techniques entail that the target
points be representedby convenient skin markers the physical realiza-
tion of which depends on the particular technique used. Consequently
the target points afe selected according to the following practical
considerations:

(1) relative movement between markers and underlying bone due to

soft tissue deformation should be minimal in arder to be consistent
with the assumptionof rigidity of the body segment;
(2) the distance between markers should be sufficiently large so that
errar propagation from measured marker coordinates to the transfor-
mation matrix is minimal;
(3) sufficient measurementsshould be available on the markers from at
least two stereometricdetectors at anyone time (Woltring 1982).

The target points which meet the above requirements may not coincide
with anatomical landmarks. Consequently, the l.c.s. determined using
thesepoints may result in a thoroughly arbitrary geometric relationsliip
with respect to the relevant body segmentoThis poses some practical
problems which will be consideredbelow.
The inerti al properties associated with each model segment afe
representedby the following parametersof the relevant body segment:

(1) mass,
(2) position vector of the centre of mass in a given l.c.s.,
(3) principal axes of inertia defined relative to a given l.c.s. through a
transformation matrix and moments of inertia.
34 A. Cappozzo/ Gait analysismethodology

The position vector of the centre of mass and the principal axes of
inertia transformation matrix are given, in the previously cited litera-
luce, with respect to sets of axes passing through bony anatomical
landmarks. These"anatomical" axesare, in generaI,different tram the
local axes derived tram the markers mentioned above which in the
following will be referred to as technical markers. It follows, therefore,
that in arder to associatethe above-mentionedinerti a properties with a
model segment, information musi be acquired that would permit the
determination of the former tram the latter axes. This entails the
determination of the position vectors of selectedanatomicallandmarks
relative to the technical marker l.c.s.
The above positional and inertial properties thoroughly deCinethe
mechanicalmodel. Thereafter, analytical mechanicspermit the calcula-
tion of the relative motion between adjacent segments (i.e., joint
kinematics), and the intersegmentalfacceand couple vectors. However,
it should be emphasizedthat these objectives require the solution of
some important practical problems.
One problem relates to the description of joint kinematics. The
crucial difficulty here is the overcoming of the ever-existingdichotomy
between the language of the physicist and that of the biologist and
physician. The former language should be made to converge towards
the latter, however, without losing its properties of quantitative exacti-
tude. This is noi only to favour the use of this information in the
relevant applicative fields bui also becausethe language of biology is
more likely to be the most effective in describing biological functions.
In generaI, the motion which occurs at a joint is described by six
independentparameters: three rotations and three translations. Trans-
lations, however, in most circumstances,are of small magnitude and
noi accuratelydetectableusing the experimental techniquestypical of a
gait analysislaboratory. Therefore they will noi be consideredhere. As
far as rotations are concerned,they require the definition of a reference
system of axes. The so-called gyroscopic system seemsto match suc-
cessfully the requirements of both mechanicsand functional anatomy.
This systemis defined with one axis fixed to one segment,another axis
fixed to the secondsegment,and the third axis (the floating axis) is the
common perpendicular to the first two. This system of axes is noi
necessarilyorthogonal, bui has the characteristic that joint angular
position is described by three angles (Bryant or Cardan angles)inde-
pendent of the temporal arder in which the relevant rotations are
 A. Cappozzo/ Gait analysismethodology 35
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36 A. Cappozzo/ Gait analysismethodology

thought to occur (Chao 1980; Grood and Suntay 1983).

An exampIe of the application of the above procedure to the lower
limb is used in the author's laboratory. An optoelectronic stereophoto-
grammetric systemis used far the segmentmotion measurement.The
data presented bere were obtained with a VICON system (Oxford
Dynamics Ltd) equipped with three TV cameraspositioned as shown in
fig. la. The technical markers afe placed on the subject's pelvis, thigh,
shank and foot as shown in fig. 1b. These positions satisfactorily meet
the practical requirementslisted previously. The marker P3is affixed to
a stick in line with the posterior superior iliac spines and is held in
pIace by an elastic belt. The thigh markers and the shank marker S3afe
mounted on 5 cm sticks. In this way their relative distance is enlarged
and, as was said previously, measurementerrar propagation reduced. In
addition to this, marker visibility from the camerasis enhanced.The
markers SI' Pl, P2, Fl, and F2 afe placed on the following anatomical
landmarks: head of the fibula, anterior superior iliac spines, fifth and
first metatarsal bones. In addition to the above-mentioned technical
markers, other markers -referred to as anatomical markers -afe
placed on the following anatomical landmarks: lateral and mediaI
epicondylesof the femur, and lateral and mediaI malleoli.
The experimentalprotocol comprisesthree tests. During the first test,
the subjectassumesa relaxed upright pasture facing cameratwo so that
alI markers afe visible by at least two cameras.This test permits the
determination of the local position vectors of the Ce, Ci, Me' and Mi
anatomicallandmarks with respectto the axesdefined by the technical
markers. The test data afe also used far the determination of the joint
angular position during upright standing. After the above static test is
performed the anatomicallandmark markers afe removed. The second
test aims at the determination of the hip centre of rotation. The subject
performs a movementof abduction-adduction of the thigh followed by
a flexion-extension. Using the reconstructed 3-D trajectories of the
thigh markers it is possible, through a least-squaresmethod to estimate
the location of the centre of rotation of the above movements,that is,
of the hip centre both in the pelvis and in the femur l.c.s.'s. At this
stage, informatico is available far the determination of the following
anatomical systemsof reference(fig. 1b). For the pelvis, the technical
marker systemcoincides with the anatomical system.For the thigh, the
Xt-Zt pIane contains the anatomicallandmarks Ce, Ci, and H, and the Zt
axisjoins the midpoint (K) betweenCeand Ci and the hip centre. For
 A. Cappozzo/ Gait analysismethodology 37

the shank, the xs-zs pIane is defined by the anatomicallandmarks SI'

Me' and Mi. The Zs axis is defined by the orthogonal intersection
betweenthe xs-zs pIane and the bundle of planesdefined by S2and the
midpoint betweenthe malleoli. The Xsaxis is made to pass through the
Me landmark so as to approximate the ankle flexion-extension axis
more closely. The foot anatomical system of reference was defined
using the markers FI and F2 and the point A shown in fig. lb. The
anatomical axes defined above approximately bave the orientation of
axes of symmetry. As such they may be considered principal axes of
inertia, and the segmentalcentre of massmay be consideredas lying on
the z axes. These simplications afe justified by the magnitude of the
inaccuracywith which the above inertial parametersafe predicted. The
joint coordinate systemsand the relevant rotations afe defined as in
table 1. The third test is the actual dynamic test. In fig. 2A an example
of lower limb joint kinematics is depicted far a normal adult male
subject walking at a free cadence.
As far as joint kinetics is concerned,the following generaIremarks
afe worth of note. When calculating the intersegmental torce and
couple vectors a point of application must be chosen. Selecting an
approximate point is important since both the numerical value and the
functional significance of the couple vector depend upon its location.
This point should be defined either as the point through which the
resultant articular surface contact torce acts or, in the absence of
friction, could be taken as the joint centre of rotation. Thus, the
intersegmentalcouple is balanced by the moments of forces transmitted
only by the soft tissuesaround the joint, and in particular by muscles
and ligaments.The intersegmentalcouple vector will then be presented
in its scalar components which bave functional significance. It is
thought that the componentsalong the joint coordinate systemsdefined
above meetthis requirement.The intersegmentalcouple calculated with

Table 1
Joint rotation axes(for symbolsseefig. lb; f.a. = floating axis). For the foot internaI and external
rotations afe more commonly defined as eversion and inversion, respectively.

Hip Xp z,
Knee X,X. z,
Ankle zf
 38 A. Cappozzo/ Gait analysismethodology

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X
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al
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H H RTO RHS RTO
I 1 ,I
0 50 100
TIME [% cf cycleJ

(A) CB)
Fig. 2. (A) Lower limb joint kinematics during walking at 1.3 msec-J. Right limb of an adulI male
subject (body mass=63 kg, stature=1.73 m). Hip (-), knee ( ), ankle ( ).
Abscissesindicate anglesduring up-right standing.
(B) Lower limb joint intersegmentalcouple components along the joint coordinate systems.Same
test and li ne types as above.Abséissesindicate zero moments.
(RHS, LHS = righI and left heel strike; RTO, LTO = righI and left toe off).

respectto the points H, K, and A shown in fig. 1b, and resolved with
respectto the relevantjoint coordinate systems,afe given in fig. 2B as
obtained during the samewalking test as the data in fig. 2A. The points
H, K and A approximate the location of the instantaneous rotation
pivots of the relevantjoints. Similar kinetic data relative to the upper
trunk may be found in Cappozzo(1983).

~
~
./'"\-
 A. Cappozzo Gait analysismethodology 39

Gait evaluation

Gait evaluation should be approached in terms of both assessmentof

the resourcesthat the subject employs to accomplishthe locomotor act
and the quality of the result. In a previous section this was summarized
by the statement: "gait evaluationis the assessmentof the ability of the
subjectto move through spaceby ambulation". It may be assumedthat
this ability is directly related to the reliability of the locomotor act and
to its consistencywith the relevant aestheticcanons(the word "reliabil-
ity" is usedbere in the engineeringsense,that is, as the probability that
the function be performed satisfactorily under given circumstances).
This type of approach to gait evaluation carries with it an important
conceptual implication. Referenceto normality, which is always some-
what implicit in gait evaluation, does not entail the comparison of the
normal and abnormal mechanicalpatterns per se, nor does it entail the
comparison between single functions as would be the case if the
quantities describedin the previous sectionwere used.The emphasisis
placed on the overall strategy of the movement making allowance for
the often objective impossibility that the patient achievenormal motion
trajectories since bis neuro-muscular-skeletalsystemis, in some cases,
irreparably impaired. Nevertheless,the patient can achievea high level
of ability in walking relative to bis locomotor system.
Subsequentto the above considerations,a gait evaluation methodol-
ogy may be suggestedthat usesphysical quantities capable of describ-
ing the following aspectsof walking:

(1) symmetry and simplicity of the movement,

(2) maintenanceof balance,
(3) mechanicalload on tissues,and
(4) energyexpenditure,

the first aspectbeing related to the aestheticsof walking, the others to

the reliability of the locomotor act.
Gait aestheticsis mostly associatedwith the upper part of the body
motion. The symmetry and simplicity of this motion is well depicted
through the representationof the relevant displacementcomponents in
the frequency domain. This matter is discussedin full length in Cap-
pozzo et al. (1982), and Cappozzo (1981). As emphasized in these
papers,a "stereotype" pattern of movement of the upper body can be
 40 A. Cappozzo/ Gait analysismethodology

ANTERO-POSTERIOR AXIS
II HARH. III HARH. IV HARM

HEAD , , ,0,5

PELVIS , , ,5 , , , ,1,
'"'o O

HEAD

PELVIS

HEAD

,
PELVIS , , , , '~

Fig. 3. Vector representation of the harmonic components of the linear displacementsof the
longitudinal axis of the upper parI of the body at head and pelvislevel. The sectorsafe defined by
the phaseand amplitude rangesof the harmonic component vectors relative to sixteen testsof rive
normal subjectsin the speedrange 1.31-1.60 msec-l. The harmonic component vectors relative to
three testsof an above-kneeamputeewalking in the samespeedrange afe superimposed.Numbers
on the abscissesindicate mm/div.

r
 A. Cappozzo/ Gait analysismethodology 41

devised.This is characterizedby a perfect symmetry of eachelementary

displacement with respect to the anatomical planes. The stereotype
pattern of movementof the longitudinal axis of the trunk and head, far
instance, moves along the vertical (Z) and antero-posterior (X) axes
with a cycle period equal to one step, and along the latero-lateral (Y)
axis, with a cycle period equal to one stride and with mirror-image
symmetry with respectto the mid-sagittal pIane. Thus, in the frequency
domain, the displacement components along the X and Z axes afe
described by harmonics of even arder only, while along the Y axis by
odd arder harmonics only. Thesewere termed intrinsic harmonics..The
other harmonicswere termed extrinsic and were related to gait asymme-
tries. In a normal population the intrinsic harmonic coefficients were
found highly repeatable,while the extrinsic harmonic coefficients were
mostly of a random nature. In fig. 3 the significant intrinsic and
extrinsic harmonics afe depicted, respectively. They afe representedin
vectorial formo The sectorsafe defined by the phase range and ampli-
tude range of the harmonic vectors relative to a population of five
normal adult male subjects walking at a speed in the range 1.3:-1.6
msec-l. Superposedon thesenormative data, the harmonic vectors afe
shown far three walking trials in the samespeed-rangeof an adult male
above-kneeamputeewearing a single-axisprosthesis.The magnitude of
the relevant extrinsic harmonics may be used as a measure of the
movement asymmetry. In this amputee's gait, as opposed to normal
walking, the extrinsic harmonics afe repeatable; this suggeststhat they
afe associatedwith a specific locomotor system impairment and not
with random causes.The intrinsic harmonic vectors afe often close to
the relevant normal range (fig. 3). Whether this circumstance would
apply to other types of patients or not, and the meaning which can be
associated with it, afe matters that need further investigation. The
Lissajous'splots presentedin Cappozzo(1981) may also be an effective
way of representingthe symmetry and simplicity of the moverrient. In
fig. 4A, B, and C these plots afe given far a normal subject, the
above-kneeamputeereferred to above, and far an adolescentsuffering
from cerebral palsy. Theseplots bave a more qualitative character than
those in fig. 3, but they afe more immediately readable.
The other aspect of walking which is of interest in the present
context is the effectiveness with which balance is maintained. The
Lissajous's plots of fig. 4 may be able to supply some information
concerning this aspectas well. From those plots it would appear, far
42
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 A. Cappozzo/ Gait analysismethodology 43

instance, that the amputee is able to control balance more effectively

than the cerebral palsy patient. His head, in fact, has a more regular
trajectory than bis pelvis and this implies a compensatorymovementof
the upper trunk. The opposite occurs in the cerebral palsy patient, who
thus appears unable to optimally control the upright posture of the
trunk. Another way of looking into the effectivenessof postural control

HEAD o
X AXIS
PELVIS 6

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d l
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CI:
2.0 2.5 3.0 3.5 4.0
SPEED [m s -1]

CB)
 44 A. Cappozzo/ Gait analysismethodology

o
Z AXIS

'C

HEAD o
Z AXIS
PELVIS ~
15
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~ 5
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2.0 2.5 3.0 ::I.~ 4.0
SPEED Cm s -1]

(DJ
Fig. 5. Effective value of the linear accelerationof the upper body longitudinal axis at pelvis and
head level versus speed of progression. (A) Acceleration along the antero-posterior axis during
normal walking (empty symbols) and amputeewalking (full symbols).
(B) Acceleration along the antero-posterior axis during running (empty symbols) and during
race-walking(full symbols).
(C) As in (A) butalong the vertical axis.
(O) As in (B) but along the vertical axis.

..
.. ..
 A. Cappozzo/ Gail analysismelhodology 45

is through the analysis of upper body accelerationsboth in the time and

frequencydomains. The antero-posterior accelerationof the trunk and
head is bound to carry most of the relevant information. It is, in fact,
along this direction that, during locomotion, balance is "lost and
regained"; thus, contraI of this campanelli is more criticaI. The follow-
ing experimental results help in appreciating the relevance of this
accelerationcomponent. In fig. 5A, the effective value of antero-poste-
rior accelerationat pelvic and head levels is depicted, versus speed of
progression.This data refers to normal walking and amputee walking.
In fig. 5B the same data obtained during race-walking and running is
shown. From these plots it appears evident that the antero-posterior
component of head acceleration is well under contraI: whatever
locomotor act is performed normal or abnormal, the effective value of
this accelerationcomponent has always approximately the same rela-
tively small value. This is intriguing and suggeststhat this acceleration
component must be viewed as a figure of merit far the effectivenessof
the contraI of balance.This opinion is reinforced by the analysis of this
accelerationcomponentin the frequencydomain. In Cappozzo(1982) it
was seen that in normal subjects the upper trunk movement with
respect to the pelvis causesa sort of filtering of the high-frequency
accelerationcomponents present at the pelvic level. This was found to
occur in amputee-walking, in race-walking, and also in running. It is
thought that thesephenomenaafe associatedwith the optimization of
the effectiveness of the labyrinth Tale in controlling balance, and
possibly with the requirementsof vision as well..Of course,the hypothe-
sis that antero-posterior accelerationat the various levels of the upper
body may supply information on the effectivenessof postural contraI
remains to be validated. The analysis of neurological patients may be
helpful in tbis respect.
During walking, the mechanical loading of tissuesshould be main-
tained below a suitable threshold. This loading is essentially applied
along the cranio-caudal direction. Horizontal forces afe in fact ab-
sorbed by musclesthrough the yielding of somearticulation. An overall
assessmentof the mechanicalloading of upper body tissues,which afe
the most delicate, may be obtained through the analysis of the relevant
vertical acceleration. Tbis data is reported in figs. 5C and D with
referenceto the same test-trials as figs. 5A and B. As could be easily
foreseen, vertical acceleration increases with speed during normal
locomotion. The amputee, at bis maximal speed of progression -
46 A. Cappozzo/ Gait analysismethodology

approximately 1.5 msec-} -exhibits a vertical acceleration similar to

that of normal subjectsat their maximal speedsofprogression (fig. 5C). Ì'
After this observation, it may be asked whether the vertical acceleration
-and the mechanicalload associatedwith it -be ODeof the limits to
walking speed, both in normal and handicapped persons. However,
higher speedsof progressionmay be obtained by changing gait, as in
race-walking, for instance (fig. 5D). In this case, although speed of
progressionincreaseswith respectto normal walking, vertical accelera-
tion does noto Is it possible to infer, at this stage, that there exists a
limi t over which the vertical acceleration'seffective valùe should not
go? In running, even higher speedsof progressionafe howeveraccom-
plished. As shown in fig. 5D, the vertical accelerationduring running is
remarkably greater than during walking and race-walking. But, if this
accelerationcomponent is analyzed in the frequency domain, then the
following is found. The vertical acceleration amplitude spectrum for
walking is found to occupy the range 1-5 Hz with a dip at approxi-
mately 3 Hz (Cappozzo 1982). These characteristics fit very well the
biodynamical properties of the body in that no resonancesshould occur
in relevantorgans. During running, this accelerationspectrumremarka-
bly increasesin amplitude but most of it is damped out below 3 Hz.
Thus, it appearsas if it is permitted to increasethe effective value of the
vertical accelerationover a certain threshold -as occurs in running -
but at the same time most of the acceleration spectrum must be
compressedwithin a low frequencyrange so as to stay away from those
frequencieswhere resonancesof body parts occur.
The estimation of energyrequirementsis also relevant for the evalua-
tion of gait. Indirect calorimetry is the obvious technique to be used in
this case.Aiso heart rate is regarded as an indirect index of metabolic
energyexpenditure during the execution of physical exercises.The use
of mechanical quantities in this context poses several interpretative
problems. This is basically due to the complex and differentiated
relationships existing betweenmetabolic energyand kinetics of muscu-
lar contraction. In this context, the human body is often devided into
two sub-systems,the lower limbs and the upper body. The former
support and transport the latter. How this is done, in terms of mechani-
cal energyinvolved, is describedby Saunderset al. (1953), Ralston and
Lukin (1969) and Cappozzo et al. (1976), among others. ODe basic
aspect in this context is the following. During walking, at the com-
monly adopted speed,the potential and kinetic energiesof the upper
 ,.,.., ""pp"" UV"", ".."" "" , --
1_- 1. :~ -:-:-:---1 ,o

energy eXpenOllUre l~ mlmmlzt:U. l nt: tUtal mt:~nam~al t:nt:rgy a~~U~l-

ated with the upper body during walking in the range of speeds of
progression was assessed in the author's laboratory. This was carried
out through a 3-D analysis of the head, upper torso, and upper limbs
motion in rive normal adult male subjects who each performed four
walk-trials. From the mechanical energy function the positive work
done by the lower limbs on the upper body during a walking cycle was
determined. This quantity was then normalized with respect to cycle
duration and body weight. In fig. 6 the relevant regression curve is
represented. This may be considered as normative data. Superimposed
on it, the normalized positive work found during four walking trials of
an above-knee amputee and two walking trials of a patient with knee
ankylosis afe represented. In the amputee the positive work exchanged
between lower and upper body is larger than in normal walking. This
indicates that the lower limb muscles have to produce more mechanical
energy. The data of the other patients, on the contrary, is either within
or below normality. Although specific measurements were not made, it
is reasonable to exclude the hypothesis that this patient's gait could be!

[ [] []

Fi
W(
ative to twenty norma
L__- , ,

"',
~
48 A. Cappozzo/ Gait ana/ysismethod%gy

more economical than normal gait. In fact, this patient tip-toed with
the healthy leg in order to gain clearance from the ground for the
affected limbo It is therefore likely that extra metabolic energy is
required by the quasi-isometric contraction of the sound li mb ankle,
while the energyexchangebetweenlower and upper body is kept close
to normality. The above examples confirm the difficulty of drawing
correct information concerning metabolic energy requirements tram
mechanical energy data. However, mechanical energy analysis permits
the collection of information about energyflows tram different muscu-
lar districts to the body segments,and betweenbody segments(Winter
1979). This is opposed to metabolic energy expenditure assessment,
which is unavoidably a global assessment.

Conclusions

In this paper a brief accounthas been given of what gait analysisis and
what its objectives may be. Emphasis was placed on the distinction
betweenjoint function assessmentand gait evaluation. Experimental
and analytical methodologies have been described which permit the
accomplishmentof the above objectives.
As far as the clinical application of gait analysis is concerned, the
following is noteworthy. Once the "numbers" that describethe mecha-
nics of the patient's gait have been assessed,only the first step -
perhaps the least crucial step -has been accomplished. Following on
the analysis, based on the measurementsand calculations referred to
previously, a synthesisof the data must be made which will supply the
clinically relevant information. Since the phenomenonbeing dealt with
is very complex and multifaceted, it is unlikely that the process of
synthesiscan be completely carried out in numerical terms, that is, by
computer. Thus, the speculativeintervention of the clinician in a rather
early stage of the synthesiscan not be precluded. What message,both
in terms of content and form, should the computer provide the clini-
cian, and what methodology should the clinician employ in order to
deal with the messageso as to accomplish an objective gait evaluation?
Theseafe problems the solution of which biomechanicianshave, as yet,
not perfected. In this respectsomeideas have been put forward in this
paperoImplementation of such ideas is stilI at the experimental phase
 A. Cappozzo Gait analysismethodology 49

and the validation of the clinical orientation of the methodology

presented bere is stilI in the process of being substantiated.

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