Therapeutic Kinesiology:Musculoskeletal Systems, Palpation, and Body Mechanics

Therapeutic Kinesiology Instructor Manual: Ch08 p.1 TK INSTRUCTOR MANUAL: CHAPTER 8 Gait Chapter manuals include: Objectives Lecture Notes Suggested Classroom and Student Development Activities For other chapter-by-chapter resources, see: Key Term Quizzes Muscle Origin and Insertion Worksheets Muscle OIAs List by Chapter MyTest Test Bank For additional resources see “Teaching Tips and Tools”: 7 research-based learning principles for kinesiology courses in massage 5-step self-directed learning cycle for body mechanics courses Tools that build metacognitive skills: e.g., concept (mind) maps, grading rubrics, and self-assessments inventories OBJECTIVES Define gait and name another term for gait. Name and define the two phases of gait patterns and the subphases of each. Describe the difference between walking and running. Define step, stride, and step width and the average length of each one. Define cadence and describe three different levels of cadence in gait. Describe how the pelvis moves in each plane during a normal walking gait. Discuss the dynamics of contralateral motion in the limbs and trunk. Discuss the role of fall and recovery in gait. Describe the three functions of muscles in the lower limbs during gait. Define an antalgic gait and describe how it can be treated with massage and bodywork. List and describe five antalgic gait patterns. List four atypical gait patterns caused by joint dysfunctions and describe each one. Define an ataxic gait and describe two types of ataxic gait patterns. Describe different approaches to gait assessment. LECTURE NOTES COMPONENTS OF GAIT Gait (ambulation) mechanics underlie all movement patterns Postural patterns are carried into gait Gait influenced by psychology and emotional disposition Gait demonstrates habitual muscle and joint patterns Rolling through foot Weight rolls from heel to toes Weight follows curve pressure path Rolling through foot important For weight to load of arches To create elastic energy and rebound Stance phase occurs during 60% of walking Heel strike: Heel contacts ground Ankle flexes and toes hyperextend Brief moment of double limb support (20%) Foot flat: Whole foot contacts with ground Midstance: Body weight shifts over stance leg Heeloff: Heel lifts off the ground Pushoff (toe-off): Toes push off ground Swing phase occurs during 40% of walking Early swing (acceleration): Lower limb swings in downward arc Midswing: Lower limb swings under hip Late swing (deceleration) Lower limb swings in upward arc Knee extends in preparation for heel strike Step and stride length and width Step = Movement between right and left foot Averages 1518 inches Stride = Two steps Averages 3036 inches Stride = 1 gait cycle Step width Distance between right and left heel Averages 24 inches Foot angle Degree of toe-out Averages 57 degrees Cadence is the speed of gait Measured by number of steps per minute Slow cadence: 7090 steps Average walking cadence: 100120 steps Average running cadence: 180 steps Running gait Has float moment: When both feet are off ground Has three phases: stance (40%), swing (60%, float (20%) Joint motion in lower limbs during stance Heel strike: Hip flexes 30 degrees, ankle at 90 degrees Heel strike to foot flat: Ankle plantarflexes 5 degrees Foot flat to midstance: Body shifts over standing leg Extensor support moment: Both hip and knee extend Prevents lower limb from buckling Heeloff : Ankle dorsiflexes 510 degrees Pushoff: Toes extend, knee extends, hip hyperextends 1020 degrees Joint motion in lower limbs during swing Early swing: Hip and knee fall into flexion, knee flexes 30 degrees Swing phase: Hip, knee, and ankle flex Late swing: Hip flexes, knee extends, ankle dorsiflexes Pelvic movement in each plane Sagittal plane motion Pelvis tilts forward and back 5 degrees Pelvis shifts 2 inches up/over stance leg Frontal plane motion Pelvis makes lateral tilt about 1½ inches Stance leg adducts, swing leg abducts Horizontal plane motion Pelvis rotates forward with swing leg Rotation averages 8 degrees Trunk rotation and contralateral limb motion Upper body rotates opposite lower body Opposing arms and legs swing in opposition Rotation mediated by crossed extensor reflex A lightning-quick response Involves flexion of one leg /extension of other Reflexive movement cycles of fall and recovery Walking is a process of losing balance Catching oneself with a reflexive step MUSCLE ACTIVITY IN GAIT Function of each type of contraction Isometric contractions: Stabilize and support stance phase Concentric contractions: Accelerates lower limb motion Eccentric contractions: Decelerates lower limb motion In lower limb during stance phase Heel strike Concentric in hip flexors, knee extensors, dorsiflexors Eccentric in hip extensors, knee flexors, plantarflexors Foot flat Eccentric in dorsiflexors Concentric in knee flexors Midstance Isometric in hip abductors Isometric in knee extensors, plantarflexors Heeloff Concentric in plantarflexors Eccentric in hip, knee extensors Pushoff Concentric in hip extensors, plantarflexors, dorsiflexors Eccentric in hip flexors, ankle dorsiflexors In lower limb during swing phase Early swing Concentric in hip extensors, knee flexors, dorsiflexors Eccentric in hip flexors Midswing Concentric in knee flexors, dorsiflexors Eccentric in hip extensors Late swing Concentric in hip flexors, knee extensors In trunk and shoulders Postural muscles work isometrically to stabilize trunk. Obliques work concentrically and eccentrically Stabilize trunk during hip flexion Rotate trunk Transfer motion between upper and lower body Hip and shoulder flexors/extensors coordinate limb swing ATYPICAL GAIT PATTERNS Common atypical patterns Swinging arms sideways, holding shoulders still Taking extra wide or extra narrow steps Walking with pigeon-toed stride Walking with legs toed-out like ballerina Popping up on toes on each step Walking with exaggerated lateral hip swing Genu recurvatum gait: Stance knee locks in hyperextension Antalgic gait: Self-protective gait pattern to avoid painful range of motion For example: Occurs with plantar fasciitis or heel spurs From paresis: Partial muscle dysfunction or paralysis From plegia: Total muscle paralysis Muscle dysfunctions in gait Trendelenburg gait: gluteus medius lurch Gluteus maximus lurch Steppage gait (drop-foot gait) from dorsiflexor dysfunction Psoastic gait Limitations to joint range of motion Knee fusion results in: Circumducted gait or "paddling" Vaulting gait or "peg-legged" Neurological effects from damage to cerebellum causes ataxic gait Main characteristics of ataxic gaits Hypotonia (low muscle tone) Hypertonic muscles and spasticity Types of ataxic gaits Crouched gait Scissors gait Parkinsonian gait GAIT ASSESSMENT Benefits of gait assessment Effective way to study movement patterns Information from gait can guide bodywork applications Develops innate pattern-recognition skills Can be practiced in public Guideline for gait assessment Be discrete and respectful Self-study is recommended General gait assessment Observe overall quality of gait Notice where attention is drawn Notice underlying posture Notice energetic or emotional pattern Notice what moves and what holds Notice rhythm and cadence Notice symmetry or asymmetry Notice dimension and planes of gait aberrations Specific gait assessment Observe specific phases of gait Observe specific parts of body in gait Assess joint motion Assess muscle patterns Therapeutic applications for gait assessments To assess and improve overall body mechanics To assess and improve muscle and joint function SUGGESTED CLASSROOM AND STUDENT DEVELOPMENT ACTIVITIES PROVIDE AN OVERVIEW OF THE CLASS Before class, write a short schematic overview of the class on the board, then go over it at the beginning of class. For example: Today's class covers: Components of gait Muscle activity in gait Atypical gait patterns Gait assessment Activities: Review, lecture, gait lab, recap, and homework GOING OVER GUIDELINES EXERCISES Working with clients who have balance issues (p. 193) Intake of clients with antalgic gait patterns (p. 198) General gait assessments (p. 202) Specific gait assessments (p. 203) SELF-CARE EXERCISES Using a rocker base in massage (p. 186) Exercises for lower limb alignment (p. 190) Improving sagittal tracking of the lower limb (p. 197) GROUP DISCUSSION: About gait pattern recognition Lead a group discussion about how we sometimes recognize a friend at a distance by the way he or she walks. What is it about gait patterns that make a person recognizable? What does gait reflect? How does a person's emotional state affect gait? Ask for examples. How does posture carry into gait? Ask for demonstrations, perhaps of what they have noticed when watching people, in their practice clients, or in themselves. GAIT LAB Have students get into triads to practice gait assessments: one student walks, the second student observes the gait of the walker, and the third student fills out the gait assessment forms provided below. Have students complete three rounds so that each student has an opportunity to fill each of the three roles. Set ground rules for students to use when giving each other feedback about gait. Emphasis how everyone has something unique and personal about their gait pattern, how gait patterns are somatic (they reflect a person feelings, beliefs, and emotional states), and how important it is to respect the patterns and learn from them, rather than seeing them as a pathology or something to fix. GAIT OBSERVATION EXERCISE In class, ask several volunteers to write a paragraph describing the gait pattern they saw, then pick three random papers and have these students present their cases in class. Discuss how pain patterns affect gait (how people usually walk around a painful area rather than moving through it), causing people to limp, walk asymmetrically, and freeze painful area into holding pattern. Pick several key patterns to discuss: Whiplash creates rigidity in neck, shoulders, and spine. Sacroiliac pain causes the pelvis to move like a block. Restricted sacral movement (nutation and counternutation) results in increased rotation in waist, which can underlie lumbar spine instability and pain. Pain from plantarfasciitis will prevent rolling through foot. GENERAL GAIT ASSESSMENT NAME: _______________________________ PARTNER: _____________________________________ As you answer these assessment questions, be aware of when your answers are objective or subjective. An objective finding is some aspect of gait that two or more people could observe and agree on. A subjective answer is an intuitive impression or opinion. What is the overall quality of the gait (e.g., is it bouncy, fast, measured, confident, awkward, or tipsy)? _________________________________________________________________________________ What part of the body is your attention drawn to and why? _________________________________________________________________________________ What is the underlying posture of the gait? _________________________________________________________________________________ What is the energetic pattern of the gait (e.g., the energy could be heavy, light, bent, cautious, jumpy, guarded, internally focused, externally focused, sympathetic dominance, or parasympathetic dominance)? _________________________________________________________________________________ What moves and what holds as your partner walks? Does he or she tend to walk around a certain part of the body? __________________________________________________________________________________ What is the rhythm and cadence of the gait? __________________________________________________________________________________ Is the gait symmetrical? __________________________________________________________________________________ Does your partner lean back or does any part of the body move sideways? __________________________________________________________________________________ Does one part of the body arrive before another (e.g., in the head-forward posture, the face arrives first; in the posterior pelvic tilt, the hips tend to arrive first)? __________________________________________________________________________________ SPECIFIC GAIT ASSESSMENT NAME: _______________________________ PARTNER: _____________________________________ Feet Are your partner’s feet pigeon-toed or toed-out? Do your partner’s feet chronically supinate (which leads to high arches) or pronate (which leads to flat feet)? What is the foot angle? What degree do the toes point to the side? If your partner’s feet are misaligned, to what degree? Also, which muscles are adaptively shortened and stretch-weakened by the pattern? Does your partner roll through the entire foot into pushoff? Do your partner’s toes bend to 90 degrees on pushoff? What is your partner’s step width? Does the foot on the swing leg extend into heel strike? Is the heel strike on the front leg simultaneous with the pushoff on the back leg? Knee and Limb Alignment Are your partner’s feet, ankles, knees, and hips facing forward and moving along a sagittal track? If not, what direction does each joint move? Does your partner have a pattern of genu valgum (knock-kneed) or genu varum (bow-legged)? To what degree? Do your partner’s thighs swing under the pelvis in the sagittal plane? If not, in what direction do they move? Do your partner’s hip joints swing freely? What are the step and stride lengths? Are the steps symmetrical? If not, how are they asymmetrical and to what degree? Right after midstance, is there an extensor support moment where the knee, hip, and spine extend together? Pelvis Does your partner’s pelvis rock forward and backward in an anterior and posterior tilt? Is the tilt limited or exaggerated? If so, by how much? Does your partner’s pelvis rotate horizontally, moving forward with the swing leg? Is the rotation limited or exaggerated? If so, by how much? Does your partner’s pelvis make a lateral shift, swinging side to side? Is the shift limited or exaggerated? If so, by how much? Arms and Trunk Do your partner’s arms move in sagittal plane? If not, in what direction do they move? Do your partner’s arms swing freely at the shoulders? If not, how do they move? Do your partner’s arms swing in opposition to the legs? Do your partner’s pelvis and thorax counterrotate? Is there an ease of rotation in your partner’s thorax? Are your partner’s spine and ribs supple and responsive to the movement of the lower limbs? If not, are they held and rigid? Head and Neck Does your partner’s head ride over the thorax? Does your partner’s head move freely, subtly bobbing on top of the neck? Are your partner’s eyes looking out on the horizon? If not, where does he or she look while walking? Developing a Treatment Plan Based on Gait Assessment 1. What areas of the body have muscles appear adaptively shortened and need stretching? 2. What areas of the body have muscles appear stretch-weakened and need facilitation and strengthening? 3. Which joints appear hypermobile and need stabilization? 4. Which joints appear hypomobile and need an increased range of motion? 5. If this person were your client, how would you work with him or her in a bodywork session to improve overall gait? © 2013 by Education, Inc. Foster, Instructor Resources for Therapeutic Kinesiology