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III

EXPLORACIN NEUROLGICA

III

EXPLORACIN NEUROLGICA

MA FERNANDA RODRGUEZ SANZ

SECCIN DE NEUROLOGA

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I-EXAMEN DEL SISTEMA MOTOR

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Es

importante para poder entender la exploracin motora repasar los siguientes conceptos:

-Motilidad es la

capacidad de desplazar en el espacio parte o todo el organismo mediante la

contraccin de los msculos actuando sobre las placas seas, puede ser voluntaria o refleja.

-Los impulsos que rigen la movilidad nacen en la corteza y para llegar a los msculos efectores
tienen que atravesar las vas piramidal y la terminal comn.
La

va piramidal (primera motoneurona o neurona superior) esta integrada por las neuronas de

la corteza motora y sus cilindroejes.

La va

terminal comn (segunda motoneurona o inferior) esta formada por las

motoneuronas

que estn en el asta anterior, los cilindroejes de estas neuronas que forman parte, sucesivamente, de las
races anteriores, de los plexos

y de los nervios perifricos y terminan en las fibras musculares, mediante

las placas motoras. Se entiende por unidad motora el conjunto de una motoneurona y las miofibrillas
ineruadas por ella. Sobre ella existe un control suprasegmentario de centros superiores propios de la
mdula espinal (p.ej. interneuronas de Rensaw), del tronco enceflico (ncleos vestibulares, sustancia
reticular) y de la corteza cerebral (va piramidal).
-Desde el punto de vista fisiopatologico podemos identificar:

l-Sndrome Piramidal o Corticoespinal: alteracin de la va piramidal desde su origen en

la

corteza hasta su terminacin en las astas anteriores de la mdula.

2-Sindrome de Motoneurona inferior o Segunda Neurona: alteracin de las motoneuronas


del asta anterior o del cilindroeje entre la mdula y su terminacin en la placa motora de los msculos. La

tabla 1 muestra

los patrones caractersticos de cada sndrome:

Tabla 1 Cracterstica de las parlisis en los Sndromes Piramidales y de Segunda Neurona

Sndrome Piramidal

Sndrome de Segunda Neurona

Tono

Aumentado (Espasticidad)

Disminuido

Reflejos musculotendinosos

Exaltados

Disminuido o Abolidos

Reflejos superficiales

Abolidos

Abolidos

Clonus

Presente

Ausente

Reflejo patolgicos

Presente

Ausente

Atrofia

Discreta (por desuso)

lntensa

EXAMEN MOTOR
La valoracin del sistema motor incluye la exploracin de la masa muscular, el tono y la fueaa.

I-MASA MUSCULAR
El tamao de los msculos vara mucho con la edad, el sexo, la constitucin corporal,

la

profesin, el estado nutricional y el entrenamiento.


El examinador evala el volumen del msculo mediante la inspeccin, palpacin

de con otros msculos.

y la comparacin

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En la exploracin de la masa muscular podemos encontrar:

1)

ATROFIA MUSCUI-AR o perdida de volumen


Se produce atrofia muscular especialmente en las enfermedades de la neurona motora inferior

o del propio msculo y se asocia a debilidad importante.


En las enfermedades osteoarticulares, en las personas ancianas, desnutridas o inactivas, hay
un erto grado de atrofia pero la fuerza suele estar conservada (salvo casos extremos).
Su aparicin asimtrica ocurre en lesiones de nervio y races. Los patrones simtricos proximales
suelen corresponder a miopatas y los distales a neuropatas (excepto Steinert)

2) HIPERTROFIA o un aumento del tamao del msculo

Se observa en individuos que realizan entrenamiento atltico en casos raros de miotona


congnita o por denervacin.

2-TONO MUSCULAR es la resistencia a la movilizacin pasiva.


El tono se mantiene mediante el arco reflejo miottico medular

y est influenciado por la va

piramidal, extrapiramidal y cerebelo.

El tono de cualquier grupo muscular depende de su localizacin, la posicin del individuo

la

capacidad de relajar los msculos de manera voluntaria.

La determinacin del tono es una cuestin de experiencia personal

y resulta difi:il de

evaluar

cuantitatvamente.
Las variaciones respecto al tono muscular normal da lugar:

I-HIPERTONIA o aumento del tono


Hay tres formas de hipeftona:

A- Espasticidad: hay un aumento de tono sobre todo al inicio del movimiento.


Con desplazamientos rpidos y pasivos la resistencia del msculo aparece y se vence de golpe'Yenmeno

de la navaja de muelle". Si es muy intensa puede producir contracturas permanentes. Predomina en los
msculos antigravitatorios flexores

de miembros superiores (MMSS)

los extensores de miembros

inferiores (MMII) produce por lesiones de la va piramidal.

B- Rigidez: se produce por contractura mantenida de flexores y extensores y


en ella la resstencia que se encuentra al hacer movimientos pasivos es uniforme desde el inicio hasta el
final dando la impresin de que se esta "moldeando cera" o "doblando un tubo de plomo". Afecta por igual

a todos los

msculos. Tambin se observa el "fenmeno de rueda dentada" porque

a la hipertona

se

suma el temblor de en la Enfermedad de Parkinson. Se produce en las lesiones de la via extrapiramidal.


C- Paratona: aumento de tono constante. Exste oposicionismo al movimiento

en cualquier direccin, se relaciona con lesiones del lbulo frontal y es frecuente verla en fases avanzadas
de la demencia.

2-HIPOTONIA es una prdida del tono normal en la que los msculos estn flcidos y
blandos y ofrecen una disminucin de la resistencia al movimiento pasivo de la extremidad. Se observa en

las lesiones del arco reflejo miottico (n sensitivo, races posteriores, asta anterior, races anteriores y
nervios motores), en las lesiones que afectan
cerebelo y en la falta de uso muscular.

a las regiones con influencias facilitadoras como es el

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-En reposo:
Si hay espaticidad las extremidades adoptan una postura fija que puede ser hiperextensin o con

ms frecuencia en aumento de la flexin. En la hipotona la extremidad adopta una posicin que viene
dada por la gravedad.
-Resistencia a la movilizacin pasiva:

I-Se pide al paciente que este relajado, que deje extremidades "flojas"

y que

permita al

examinador moverla libremente.

2-El examinador mueve cada extremidad en sus distintas articulaciones con movimientos de
rotacin,

fl

exin, extensin.

3-Si la rigidez es leve se puede incrementar con la realizacin de movimiento de facilitacin como
son los movmentos repetitivos con la mano que no esta siendo explorada.

4-La hipotonia se identifica por la mayor facilidad para la realizacin de los movimientos pasivos y
cuando se agita la extremidad se produce aleteo de las partes distales.

3- FUERZA
La fueza la podemos cuantificar de acuerdo con la escala de fueza muscular propuesta por el
Medical Research Council (MRC) descrita en la siguiente tabla2

Tabla 2 Escala de fueaa muscular del MRC britnico

FUNCION MOTORA
No contraccin

Cntraccin que no desplaza articulacin

Desplazamiento articular sobre plano

Desplazamiento articular contra gravedad

Movimiento contra resistencia

Fueza normal

En el examen motor consideramos la:

I-EXPLORACIN DE LA FUERZA GLOBAL que se realiza con las llamadas Maniobras de pequea
paresia o claudicacin piramidal: Maniobras de Barr y de Mingazzini:

se le pide al sujeto que separe al mximo los dedos colocado una mano
enfrentada a la otra por sus superficies palmares sin entrar en contacto, manteniendo un
meique frente al otro. Los dedos se separan y se extienden menos en el lado partico; la
MMSS

palma de la mano esta por dicho motivo mas excavada. (Maniobras de Barr)

MMII enfermo en decbito supino con los muslos perpendiculares al lecho

y las piernas

formando un ngulo recto con ellas. El segmento del lado afecto cae antes (Maniobras
Mingazzini):

de

III

EXPLORACION NEUROLOGICA

2-EXPLORACION DE LA FUERZA SEGMENTARIA


l-En primer lugar exploraremos grupos proximales y distales de las extremidades comparndolos
entre s y con las extremidades contralaterales
a. Parte proximal de las extrernidades zuperiores.

Indicar al paciente que cierre sus ojos y extienda sus bmzos con las palmas hacia aniba .

En

forma normal deben quedar elevadas. En caso de debilidad, el brazo afectado descende
lentamente y adoptara la posicin prona.

b. Parte distal de las exemidades superiores.

Pedir al paciente que oprima el dedo ndice del examinador tan fuerte corro sea posible. B
e<aminador debe tener algo de difiorltad para

retirar el dedo.

c. Parte proximal de las extremidades inferiores.


Pedir al paciente que se coloque de pie y al misrno empo doble ligemmente una piema.
d. Parte dstal de las extremidades inferiores.

Para valorar flexin plantar pedir

al paciente que camine de

puntillas

para valorar

flexin pedir al paciente que camine de blones.

2- En segundo lugar se realiza una exploracin ms detallada, observando la accin de

cada

msculo dependiendo de la debilidad que aqueja el paciente.

II-REFLEJOS

Los reflejos son respuestas involuntarias

estmulos

nos proporciona informacin de

la

integridad del sistema nervioso.


Los reflejos se agrupan por cuestin prctica y didctica en:

l-Reflejos normales son reflejos

segmentarios simples y estan presentes en individuos sanos y

pueden ser: a- Reflejos profundos. b- Reflejo superficiales.

2-Reflejos patolgicos son provocados tambin por estmulos de distensin muscular o


superficiales pero se diferencian en que no pueden ser provocados en individuos normales

y son ms

complejos que el reflejo segmentario simple.

I-REFLEOS NORMALES

l-Reflejos profundos o de estiramento muscular o miotticos


-Incorrectamente denominados osteotendinosos

REM

ROT ya que se originan en

el

estiramiento

de huso neuromuscular y el hueso y tendn son meros trasmisores de tensin.

-Su arco reflejo es el mismo que el que mantiene el tono, tienen una aferencia desde el huso
neuromuscular por el nervio sensitivo hasta la mdula y dede esta, a travs de una sinapsis modulada,

a la raz motora y el nervio efector hasta las unidades motoras. Este largo recorrido comprende una
amplia zona del sistema neryioso y el defecto del reflejo traduce varios posibles lugares anatmicos.
la modulacin suprasegmentaria es la responsable de la abolicin del reflejo asociada a la
debilidad en la fase aguda de la lesin de motoneurona superior que evoluciona con el tempo a su
Adems

exageracin patolgica, al perderse la modulacin inhibitoria del arco reflejo miottico que conduce las
fibras parapiramidales de la va corticorreticuloespinal.
-Tcnica para realizar la exploracin de los REM:

-Se precisa la colaboracin del paciente que debe de estar relajado; en ocasiones es necesario
conversar con el paciente para distraer su atencin o pedirle que mire a otro lado.

las piernas se pueden


-En ocasiones se debe intentar reforzar los reflejos. Los reflejos de
las manos que se mantienen unidas con
refozar mediante un esfuezo intenso y sostenido de separar
de las extremidades superiores puede
los dedos flexionados (maniobra de lendrassik). Los reflejos
con fueaa y cerrando el puo con la mano
refoaarse apretando los dientes, juntando las rodillas
contralateral.

motora como se recoge en la Tabla


-Los REM se gradan segn la intensidad de la respuesta

3:
Tabla 3 Escala de graduacin de los REM

intensidad de resPuesta motora


No respuesta

Respuesta ligeramente disminuida

Ll+

Normal

2l ++

Respuesta

intensa

de lo

normal

o 3

/+++

aumento del rea reflexgena


Exaltados; suele encontrarse clonus

4l++++

todos los msculos


-Aunque los reflejos de distensin muscular pueden obtenerse de casi
distintos de
una utilidad importante la valoracin de los reflejos de msculos

Reflejo

Nivel

Bicipital

c5-c6

Estiloradial

C6

Tricipital

C7

Rotuliano

t34

Adductor

L23 4
S1

Clonus:

Se valora si los reflejos de las extremidades inferiores estn hiperactivos. Se

puede

desencdenenar al mantener una tensin sobrc el tendn de Aquiles, para ello se realiza de forma rpida

una dorsiflexin del pie y se ejerce una ligera presin. En condiciones normales, el pie puede mostrar
flexin plantar una o dos veces. Ms de dos sacudidas indican reflejos hiperactivog aunque no siempre
esto es patologico.

III

EXPLORACIN NEUROLGICA

2-Reflejos sperficiales o cutneos


El estmulo no acta sobre el huso neuromuscular sino sobre la piel. El arco reflejo es ms
complicado que el de los profundos

y son multisegmentarios y

polisinpticos. La integridad de la va

piramidal es condicin sine qua non.

l-Reflejos abdominales superficiales.


a. Inervacin.
1)Porcin superior del abdomen, T8-10'

2)Porcin inferior del abdomen, T10-12.


b. Colocar al paciente en posicin supina.

c. Emplear un alfiler o un aplicador con punta de algodn.


1) Frotar la piel en los cuatro cuadrantes.

2) Hacer el movimiento de la periferia hacia el ombligo.

d. En condiciones normales el ombligo se desplazar ligeramente hacia el lado estimulado.


Esta respuesta puede estar disminuida en pacientes de edad avanzada, obesos o en
multparas.

cremastrio (L1,2)
Con el paciente de pie, frotar suavemente hacia aniba la cara intema del mudo, cerca
del escroto, @n un alfiler. Realizar la maniobra se observar ligera elevacin del testculo
2-Refl ejo

ipsilateral.

3-Respuesta plantar.

Se requiere un objeto moderamente romo para el e$mulo. Emplear una llave, un


depresor de lengua roto, una pluma con tapa, un palillo, etc. Sostener el tobillo del paciente y
frotar la superficie plantar. Iniciar en el lado extemo del taln y continuar hacia arriba en direccin
de la cara plantar de la cabeza de los metatarsianos. Hacer una curva en direccin interna de la
cam plantar del primer dedo. En condiciones normales se observa una ligera y breve flexin de
todos los dedos de los pies.
2-REFLEJOS PATOLGICOS

Son aquellos reflejos que solo pueden ser despertados en condiciones anormales

cuya

presencia indica la existencia de una interferencia orgnica en la funcin del sistema nervioso.

l-Signo de Babinski.
La estimulacin de la planta del pie extiende el dedo gordo, generalmente asociado a un

movimiento de abanico de los dems dedos (abduccin y ligera flexin). No siempre es obvio, es decir, a
veces la respuesta es ambigua o indiferente. En su expresin ms patolgica se produce la triple retirada:

extensin del 10 dedo, flexin de rodilla y flexin de cadera. Si no se obene. una respuesta, intentar
otms maniobras.

1)

De "Chaddock": se estimula la cara lateral del dorso del pie, desplazando

el estmulo debajo del maleolo extemo y hacia los dedos de los pies.

2)

De

"Oppenheimel: Deslizar hacia abajo los nudillos o los dedos ndice y

pulgar juntos, sobre el borde anterior de la tibia.

3)

De

"Gordon": oprimir firmemente los msculos

de la pantonilla.

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4)

De

"Schaeffer": oprimir firmemente el tendn de Aquiles.

2-Reflejos involutivos o de liberacin frontal

Se trata de reflejos primitivos presentes en el neonato que desaparecen con la maduracin y

pueden aparecer

de nuevo en caso de enfermedad cerebral difusa, sobre todo de los

lbulos

frontales. Se exploran cuando se encuentra demencia o alteraciones neurolgicas diseminadas.

l.Reflejo de parpadeo
a. Con un maftillo de reflejos golpear en forma suave

repetida entre los ojos del paciente. Al

principio el paciente parpadean pero pronto se habr adaptado.

b Con "liberacin frontal" (perdida de la inhibicin normal del bbulo frontal), d parpadeo

persiste

sin que ocurra adaptacin.

2. Reflejo de hociqueo

a. Golpear con suavidad encima de los labios. Habitualmente la respuesLa es mnima o no

la

hay.

b. Con libencin frontal:

1) Los labios se fruncirn con cada golpe.

2) En caso extremo el paciente har muecas.

3.Reflejo de succin
a. Con un depresor de lengua frotar con suavidad los labbs. Normalmente no hay respuesta-

b. @n liberacin fronhl, el paciente presentara movimientos de succin, de labios, lengua, y


maxilar inferior. Tambn puede seguir el depresor de lengua al igual que lo hara un recin nacido.

4.Reflejo de prcnsin o grasping.


El estmulo de la palma de la mano produce el cierre de los dedos
explorador.

5.Retrejo Pa I momentonia no.

Al rascar la eminencia tenar se contrae el mentn ipsilateral.

y la prensin de los dedos

del

III-EXPLORACION SENSORIAL
Se trata de la parte ms subjetiva del examen neurolgico, lo que unido a la variabilidad de los

territorios de inervacin, a la superposicin de los mismos, a la ocasional afectacin incompleta y a los


fenmenos reflejos sensoriales en la enfermedad de vsceras internas (zonas de Head) hace su examen
difcil y a veces poco rentable. Por estos motivos debemos ser cautos en su interpretacin.

I-PRUEBAS QUE VALORAN LA SENSTBTLTDAD SUPERFTCTAL Y PROFUNDA


Los tipos de sensibilidad que se exploran en la clnica y por tanto que tienen interes fisiopatolgico
son las siguientes:

Tctil que informa del contacto fino


Trmica que informa del calor y del fro
Dolorosa que capta estmulos nociceptivos
Posicin de las afticulaciones o cinestesica

Vibratoria o palestsica
La fatiga da lugar a falta de precisin en las pruebas sensitivas por ello debemos posponer
esta pafte de la exploracin si el mlico o el paciente se encuentran excesivamente cansados.

l
mapa-

distribucin de una rdida sensitiva puede establecerse sobre la piel

-a

manera de un

segn los nervios perifrios o raquCeos que se disffibuyen en dicha regin.

1)

Dichas regiones reciben el nombre de "dermatomas."

2)Solo algunos dermatomas que corresponden

a nervios raqudeos se

exploran

de manera sistemtica.
( a ) En la

mano: C6, C7, y C8.

( b ) En el tronco: C3,T4, T10 y T12.


(c)r bpitrnas: 13, L4,6,yS1
Debe valorerse la modalidad sensitiva al menos en estos dermatomas seleccionados.

Tcnica:
1. Cuando se exploran las sensaciones del paciente debe tener sus ojos cerrados.

2. Incrementar la intensidad del estmulo conforme sea necesario para que el paciente lo
perciba. Recordar que en forma normal la piel engrosada es menos sensible.

4. Comparar en los dos lados.

5. Si se encuentra un rea con cambios sensitivos intentar definir si la sensacin


aumentada, disminuida, o ausente y si la transicin de normal a anormal es abrupta o gradual.

esta

III

EXPLORACIN NEUROLGICA

I- Exploracin de la sensibilidad superficial


1-La sensibilidad dolorosa se e<plon con un alfiler y se valom en cada uno de los dermatomas
descritos con anterioridad, en cabeza, brazos, trax y piernas.

tempentura se emplean tubos de ensayo llenos con agua caliente y fra.


3-La exploracin de la sensibilidad tctl fna se emplea un algodn, y se indica al paciente
2-En la exploracin de la

que diga s o no, cuando perciba la sensacin o deje de hacerlo.

II-

Exploracin de la sensibilidad profunda o propioceptiva

1- La sensibilidad vibratoria se valora mediante un diapason de baja intensidad,

de

preferencia el de 128 Hz.

1-Se sostiene el instrumento cerca de su base, y se activa golpendolo contra el canto de la mano y
se hace presin, siempre sobre una prominencia sea.

a. Preguntar al paciente si siente la vibracin y cuando deja de sentirla. Si el explorador


puede percibir la vibracin cuando el paciente ya no la siente, ello indica prdida sensitiva.

b.

Para hacer mas objetiva

la

prueba, detener de forma ocasional el diapason de forma

prematura, parc asegurarse de que el paciente responda con precision.

c. Debido a que con la edad es normal que disrninuya el sentido vibratorio, buscar si hay
asimetas de derecha a izquierda. La prdida senstiva unilateral tiene mayor significado (la
perdida bilateral difusa tambin puede ser causada por polineuropatia perfia).

2- Se debe iniciar en la articulacin ms distal y el orden para realizar la prueba en la extremidad


superior es: ajculacin interfalangica distal o mehcarpofalangica de los dedos, mueca (apofisis estiktdes
dd radio o dd orbib), odo, estemn. Mientas que el orden para exploracin de esta sensacin en la
e<Uernidad inferior es: aftio.lacn inErfalngica

dd dedo gordo dd pie, tobillo (en el maleolo), rcdilla, cresta

iliaca.

2-La sensibilidad posicional puede ser explorada de diversas formas:


1-Colocando pasivamente los dedos

en diversas posiciones y solicitando del paciente que

las

identifique con los ojos cerrados.


2-Clocando una extremidad o segmento de ella en una posicin determinada para que el paciente,
siempre con los ojos cerrados adopte la misma posicin simtrica.

z-PRUEBAS DE DISCRIMINACIN SENSITIVA.


Con estos exmenes se valora la capacidad de la corteza cerebral contralateral (sobre todo el

lbulo parietal) para analizar

interpretar sensaciones. Necesibn funcionamiento sensivo intacto, en

parttular en los aordones poderiores de la medula (que transmiten la sensacin de posicin y brac6n) y se
o<pbm de fornn egeafica:

1-Estereognosia
Capacidad de identificar objetos mediante el tacto. Se emplea como prueba de seleccin para

este grupo y si la respuesta es anormal se emplean las dems pruebas. Consi$e en que el paciente
mantiene sus ojos cerrados, mientras el examinador

coloca un objeb que sea conocido por todo el

mundo, como son: llave, moneda, sujetador de papeles o lpiz. En condiciones normales el paciente ser
capaz de identificarlo en forma correcta. Hay que hacerlo de forma simtrica. Probar en cada lado.

10

III

EXPLORACION NEU ROLOGICA

2-Grafestesia
Capacidad para identificar objetos dibujados

cuando no

se puede efectuar

en la piel. Esta prueba es especialmente

til

la prueba para estereognosia por la presencia de parlisis. Se usa el

extremo romo de un lpiz o una pluma y se dibuja algn numero del 0 al 9 en la palma aunque tambin
se puede hacer en la espalda y en la planb del pie. El paciente ser capaz de idenficarlo en fornn orrecta.

3-Discriminacin ctil entre dos puntos.


Se emplea dos alfileres, un sujebdor de papel desdoblado pam formar una U, o un comps sin

filo.
Se indicara al paciente lo que es uno y dos puntos. Explorar ambos lados, las extremidades
superiores e inferiores. Iniciar siempre en sendo distal. Luego obsenar la disbncia mnima a la que el
paciente percibe los dos puntos.
1)

Verificr que los dos puntos hagan ontacto en la piel al mismo tiempo.

2) Iniciar en las yemas de los dedos.


3) Realizar la e<ploracn en forma altema al azdr, con uno y dos puntos
4)Las distancias mnimas promedio en que se perciben los dos puntos son:

i.
ii.
iii.
iv.
v.
vi.

Lengua, 1 mm.
Yema de los dedos, 2 a 3 mm.
Dedos de los pies, 3 a 8 mm.
Palma, 1cm.
Antebrazo o trax, 4 cm

Espalda,4aT cm.

4-iLoc:lizacin tctil.
Se pide al paciente que cierre sus ojos, y se toca la piel con un alfiler o una torunda. Explorar
ambos lados en cara, brazos

y piernas. E

paciente debe ser capaz de indicar casi con exactitud (en un

radio de 2 a 3 cm) la localizacin del estmulo. Cuando hay disfuncin del lbulo pariehl contralateral,
el paciente describe el toque mucho ms proximal de lo que fue.

5-Extincin.
Se realiza en forma similar a la localizacin tctil, pero el toque se hace de manea simultnea en

ambos lados. El paciente debe ser capaz de sentir en ambos lados. Cuando hay extincin, el paciente
solo percibe un lado.

FORMAS DE LESIN SENSITIVA


El anlsis de los trastornos sensitivos fundamentales atendiendo a su distribucin

a la combinacin de modalidades afectadas y

an

un alfilery

conseruadas (disociacin) permite localizar las lesiones.

Distinguimos tres niveles fundamentales:

rrr ExPLoRAcrn neu Ro-crcr


Nervio perifrico

ra2. Se produce la prdida sensitiva de acuerdo a la

distribucin

cutnea correspondiente siendo de ayuda los mapas de sensibilidad cutneos. En principio se afectan
todas las modalidades sensitivas.

En la mdula esoinal distinguimos varios patrones: La seccin medular completa en la


que se produce una abolicin de todas las modalidadel sensoriales por debajo del nivel de lesin.
Sndrome de afectacin centromedular o sindrome siringomilico en el que se produce una
anestesia disociada con prdida de la sensibilidad trmica y dolorosa y conservacin de la sensibilidad
tctil, posiconal y vibratoria que se extiende a lo largo de varios dermatomas en uno o en ambos lados

del cuerpo 'rea de anestesia

su

" o un nivel suspendido.

El sndrome tabtico cursa con

abolicin de la sensibilidad profunda manteniendo intacta la sensibilidad superficial.

Cerebro

v tronco enceflico:

Patrones de perdida hemicorporal. Casos especiales son los

sndromes sensitivos alternos por lesin a nivel bulbo con dficit sensorial en una hemicara y en la
mitad corporal contralateral. Rara vez la afectacin de la corteza sensitiva primaria produce patrones
que remedan alteracin de nervio perifrico.

t2

It
CHAPTtrR B

Gait Analysis
D. Casey Kerrigan, Michael Schaufele, and Marco N. Wen

Gait, referring in humans to walking and running, is one of


the most fundamental actions in life. Rehabilitation clinicians can especially appreciate the complexity of gait in the
face of irnpailment or functional lirnitation. Often, an individual has difficulty walking, and for somc, gait may be
functionally impossible. It is the physiatrist's task to determine the specific causes of why a person cannot walk well,
not only at lhe pathophysiology level, but also at the impairment and functional limitation levels as well. The effectiveness of any physiatric treatrnent relies heavily on the ability

to accurately determine these

causes.

NOMENCLATURE
An understanding of gait analysis first requires familiarization with the currentiy acceptcd terminology. Because gait

is habitual in nature, we often focus our analysis on

the

lunctional unit ofgait, called the gait cycle, or stride. Various


temporal and functional parameters within the gait cycle.
presented by Peny and colleagues (1) (Fig. 8-l), fbrm a
frame of reference to discuss both nondisabled and disabled
gait. This standard classification divides the gait cycle into
the stance and swing periods. Similarly. the gait cycle is
divided into three basic functional tasks. Weight acceptance
and single limb support are the funconal tasks occuning
during stance, whereas limb advancement is the functional
task primarily occun'ing during swing. These functional
tasks are further boken down into eight phases during the
gait cycle. The phases of initial contact and loading response
comprise the functional task of weight acceptance. The
phases of mid-stance and terminal stance comprise single

swing). The terms "heel strike" and "toe-off," conesponding to initial contact and preswing, respectively, may be inapplopriate and inaccurate in many atypical gait patterns.
Gait velocity refers simply to the speed of gait. Stride
tirne is defined fom the time of initial contact of one limb
to the next initial contact of the same limb. Step me is
defined fi'om the time of inial contact of one limb to the
time of initial contact of the contralateral limb. Stride length
and step length ale the distances covered during their respective time frames. The cadence of gait can be expressed in
either strides per minute or steps per minute. At an average
walking velocity, the stance period comprises about 6O7o of
the gait cycle, whereas the swing period comprises 407o. In
walking, at least one foot is on the ground at all tirnes. During
the stance period, there are two time intervals when both
feet are on the ground, telmed double limb support. One of
these time intcrvals occurs from initial contact into loading
l'esponse and the other during preswing. Single limb support
refers to the time interval in stance when the opposite limb
is in swing. At an average walking speed, each double limb
support time comprises approximately 10o/o of the gait cycle,
whereas single limb suppoft comprises abouf 40Vo. Typical
values (1) for tempolal gait parameters in adult nondisabled
subjects, walking comfortably on a level surface, ar summarized in Table 8-1. At slower walking velocities, the double
limb support times arc greater. Conversely, with increasing
walking speeds, the double limb support time intervals decrease. Walking becomes running when there is no longer
an interval of time in which both limbs are in contact on the
ground.

limb support. Limb advancement begins in the final phase

of stance (preswing) and thcn continucs through the thlee


phases

of swing (initial swing, midswing, and terminal

D. C. Kelrigan, M. Schaufele, and M. N. Wen: Department of


Physical Medicine and Rehabilitation, Harvard Medical School;
and Spaulding Rehabilitation Hospital, Boston. Massachusetts
02114.

ENERGY CONSERVATION AND THE


DETERMINANTS O}'GAIT
To the casual observer, nondisabled walking is a smooth
and almost effofiless task of locomotion. This elciency is
made possible by minimizing the displacement of the body's
center of mass (COM) during walkingQ,3). The COM, de-

Cait Cycle

Perircds:
Limb Advancement

Tosks:

Phoses:

Termina

Swing

FlG. 8-1. Periods of the gait cycle. The gait cycle s separated into two dstinct periods of stance and
swing. Functional tasks include weight acceptance and single limb support during stance and limb
advancement during swing. The stance period of the gait cycle includes nitial contact, loading response,
mdstance, terminal stance, and preswing. The swing period includes initial swing, midswing, and
terminal swing.

fined as the hypothecal point at which all mass can be


considered to be concentrated, is located just anterior to the
second sacral vertebrae in the average human lying in the
anatomic position (4). During walking, the COM normally
travels along a sinusoidal up-and-down and side-to-side path
with each step. It reaches its highest point during single limb
support and its lowest point duling double limb support.
With regard to cfficiency of walking, the vertical displacement of the COM is far more relevant an thc lateral displacement (5). The major mechanisms by which the body
minimizes the displacement of the COM during walking are
via a series of maneuvers described as the determinants of
gait by Saunders and colleagucs (6):

.
.
.
.

Pelvic rotation in the transverse plane


Pelvic obliquity in the coronal plane
Lateral displacement in the coronal plane
InLerchange between knee, ankle, and foot motion

The subsequent figures serve as simple models to illustrate


how each determinant contributcs to reducing the COM displacement. Figure 8-2 demonstrates a hypothetical "compass" that assumes what walking would be like without any
of these determinants (6). The legs are represented as rigid
levers without foot, ankle, or knee components, and articula-

TABLE 8-1. Typical temporal gait parameters for


comforlable walking on level surfaces n adult subject*
Temporal gait parameter
Velocity (m/mn)
Cadence (stepslmin)
Stride length (m)
Slance (percent of gait cycle)
Swing (percent of gait cycle)
Double support (percent per leg per
gait cycle)

Average value

-80
113
1.41

tions only at the hip joints. Normally, pelvic rotation in the


transverse plane reduces the drop in the COM during double
limb support (Fig. 8-3). A slight amount of pelvic obliquity
(i.e., Trendelenburg) reduces the peak of the COM during
single limb support (Fig. 8-a). Diminution of the lateral displacement of the pelvis are influenced by two factors. One,
the body is shifted toward the side of the stance limb during
loading. Two, the natural valgus between the femur and tibia
allow the feet to be closer togcther during forward progression (Fig. 8-5).
The intcrchange between knee, ankle, and foot motion is
a mechanism that further reduces the vertical displaccment
of the COM during walking and helps alter thc pattern of
COM motion from a series of arcs as in the hypothetical
compass gait situation t-o the actual characteristic smooth
sinusoidal appearance (Fig. 8-6). These joint motions are
described in detail in a later section. Relevant to this discus-

sion, the ankle moves into controlled plantarflexion from


initial contact into loading, and the knee flexes slightly to
reduce the peak of COM displacement in single limb support. Also during single limb support, there is progressive
ankle dorsiflexion that similarly cffectively reduces the peak
of COM displacement. Thc ankle plantarflexes again in double limb support, which effectively raises the COM's lowest
point. All of these actions occur gradually and in rhythm so
as to also smooth the curve of COM motion during gait.
If it were not for the combined action of the determinants
of gait, the average total vertical displacement of COM
would be about twice the value that it actually is (7,8). Many
impairments and functional limitations can interf'ere with
one or more of these determinants and thus incease the
COM displacement and energy cost of walking.

-60

-40

-10

normal and palhological function.


'From Perry J. Gait analysis:
Th^rfre N.l' Sl.k 1 qq2

ENERGY COST OF GAIT


At an average comfoftable walking velocity of 80 m/min
in nondisabled subjects, the energy expenditure is about four
fimes the hsl metholic

rqfe 15) Inteectinolr

fhc wlnnitrr

FlG. 8-2. Hypothetical ,,compass" gait


The pelvis is represented by singljbar

wilh a-small cuboid representig

the

body's COM. The legs are rigid barJarticulating only at the hip. No fot, ankle, dr
ne1j9in_tq are present. The parhway ol
the COM is a series of interconneciing
arcs. (Reprinted from Rose J, Gambl

JG. Human walking,2nd ed. Baltimore:


Williams & Wilkins, 1994, with permis_
sion.)

FlG. B-3. Effect of pelvic rotation in the


tranverse plane. The slight rotation of the
pelvis in the transverse plane during
double-limb support reduces the elevation needed by the COM when passing
over the weight-bearing leg during midstance. (Reprinted from Rose J, Gamble
JG. Human walkng,2nd ed. Baltimore:
Williams & Wilkins, 1994, with permission.)

FlG. 8-4. Pelvic obliquity during single.


limb support. A drop in the pelvis on th
non-weight-bearing side allows for a re,
duction in the peak height of the COIV
during mid-stance. (Reprinted from Rose
J, Gamble JG. Human walking,2nd ed
Baltimore:Williams & Wilkins, 1994, witl
nermiqqinn I

4
hat subjects choose as thel comrorlaole bpccu r
(9)'
distance
unit
per
energy
relocity that requires the least

metabWalking faster r running usually requires anaerobic


enexa
requires
slower
walking
hand,
the
other
n
:lism.
propelling
for
than
:rgy, probably for balance support, rather
energy exrft-UOy forward (10). Importantly, the rate of
across the
consistent
is
walking
pendediuring comfortable
person with
(5)'
A
populations
gait
disabled
and
nondisabled
person without
a gait disability tends to walk slorver than a
cxpenditure
energy
the
although
(tt).
fnut'
disability
a

lait

p", unit time ls consistent in subjects with gait disability'

energy expenditure per unit distance are comtheir


mon. For iostun", patients with hemiplegia affecting
comduring
per
time
energy
of
gait spend the same amount
iorrtUt" walking as subjects without gait disability' but they
energy
walk slower and spend 377o (12) to 62Vo (13) more

in"r.or", in

per unit distance.

be to
An important aim of impr-oving gait disability may
effectivethe
end'
this
To
walk'
to
required
energy
reduce thl
can be
ness of a particular type of rehabilitation trcatment
walking'
during
expended
assessed by evaluating the enel'gy
is via
The most iirect method to evaluate energy expended
This
walking'
during
consumed
is
that
oxygen
measuring the
is linked
involves uuiog tit" subject breathe into a mask that
oxyto a gas analyzer. The analyzer determines how much
energy
of
calculation
a
this,
gen is being used, and from
J*penditu." is given, based on the knowledge that about
+.ti tcat of energy is expended fbr every liter of oxygen
of energY expended

can be obtalncd by measuring heart rate before and durin


walking because the change in heart rate that occurs witt

walking is linearly correlated with oxygen consumptior


measufemcnls (14). An easier, although more indirect

method to evaluate the energy required to walk is to measure


the comfonable walking speed. This can be perlormed using
a stopwatch and a designated walking distance. This simple
measure rests on the fact noted above that subjects with gait

disability tend to walk at a consistent encrgy rate, just slower.


Thus, comfortable walking speed relates indirectly to the
energy required to walk. Unfortunately, all of these measures, including oxygen consumption, hcart rate, and comfortable walking speed, relate not only to biomechanical as_
pects of walking, but to cardiopulmonary conditioning and
psychological factors including mood as well.
euantitative
gait measures described in a later section, although useful
in determining e mechanisms of the gait impairment, are
insufficient in evaluating the cfficicncy of walking. A so_
:alled biomechanical efficiency quotient was proposed
i8,15) based on rhe concept of minimizing rhe COM dis_
:lacement through the determinants of gait. This measure
was introduced as a means to specifically evaluate biome_
:hanical walking efciency in subjects with gair disability,
ndependent of cardiopulmonary conditioning and psycho_
ogical factors. The quotient is the measured vertical disrlacement of thc COM divided by the predicted vertical disrlacement, the lattcr being a function of the subject's average
;tride length and height of the pclvis from rhe ground. paients with erif dis2hilifw rnd r h'\a hich-. ki^-^^L^-:^^r

urc drr uyLrtr \ru,r /.r. nr)wcvcr! tlDsefvauonat gllt analysls


also can provide irnpoftant qualitative kinematic information. Kinetics descibe the moments or torques and forces
that cause joint and limb motion, and these arc not intuitive

fronr observational gait analysis. Only quantitative gait analysis can provide kinetic infornlation. Similal'ly, the fir.ing
patterns of musclcs can be determined only with the aid of
dynamic electromyographic (EMG) rreasurement used in

quantitative gait analysis.


Broadly speaking, the study ofkinetics includes the study
of muscular activity as well as the study of forces, calculated
using physics, and providcs insight about the causes of the
observed kinematics. In quantitative gait analysis, we are
often interested in computing the net moments acring on
muscles, tendons, and ligamcnts. A moment about a joint
occurs when a force is acting at a distance from the joint

FlG. 8-5. Effect of narrowing the walking base. A shift in the


position of the body over the stance limb, combined with the
natural valgus between the femur and tibia allow for a reduction n the lateral displacement of the pelvis. Reduction in the
width of the gait cycle reduces the dsplacement of the COM.
(Reprinted from Rose J, Gamble JG. Human walking, 2nd
ed. Baltimore: Williams & Wilkins, 1994, with permission.)

efficiency quotients than subjects without gait disability and


treatments such as an ankle-foot-orthosis tend to reducc thc
biomechanical efficiency quotient (15).

CONCEPTS FOR UNDERSTANDING

GAIT EVENTS
Inasmuch as the determinants of gait result in a more effi,
cient method of human locomotion, they make human walking a raer complex concept to understand. In order to
evaluate the mechanisms of a gait disability and therefore
to identify individualized therapcutic interventions, a basic
knowledge of the events during a normal gait cycle is neceslary. Kinematics describe the spatial motions of .joints and
limb segments. Quantitative gait analysis, described in a larer
rection, can be used to quantitate normal kinemacs during

through a lever, causing acceleration of the joint angle. For


instance, an externally applied cxtensor moment about the
elbow is produced when a weight is placed in rhe hand. In
this case, the lever is the forearm and the elbow will tend
to accelerate uncontrrrllably into cxtension. The cxternal moment can be mathematically calculated as tlre product of the
weight of the object and the length o[ the forearm. [n order
that a joint angle remains stable, all re moments acting
about the joint must sum to zero. An internal force from the
biceps humerus acting through its forearm lever can provide
a resisting intemal flexor moment such that thc elhow joinr
is stabilized. Depending on the magnitude of the force
through the biceps. the elbow joint angle will extend in a
controlled fashion (eccentric contraction), stay the same (isometric contraction), or flex (concentric contraction). These
concepts are applied repeatedly in gait analysis. At each
point in the gait cycle, the hip, knee, and ankle joints are
stabilized, such that all the moments about a particular joint
arc in a statc of cquilibrium. The externally applied moments
from gravity, inertia, and the ground are counteLed by internal joint mornents generated by muscle activity and/or soft
tissuc. During the swing period of the gait cycle, most of
the external moments occurring about the lower limb ioints
are a result of gravitational and inertial forres flom the individual limb scgmcnts. Fur instance, during swing. both the
weight of the foot and the inertral force fom the swinging
lower leg will generate an external plantarflexor moment that
needs to be restraincd by an internal dorsiflexion moment.
provided by the ankle dorsiflexors in order ro prevent foot
drop.
During the stancc period of the gait cycle, most of the
external moments occurring about the hip. knee, and ankle
joints ale produced from the ground reaction force (GRF).
In quiet standing, thc body wcight pushcs againsr the grounrl.
The ground reacts with an equal and opposite GRF, rhe vector of which passes through the base of support (the feet)
up toward the COM of the body. When we walk, thc GRF
is essentially a result of both the weight of the body and the
body's accelerations and decelerations as our COM moves
up and down. Knowing whee the line of the GRF lies with

172

Rrur ..tr.,rrlot Motc;tNIi: PnrNcrpLrs \ND p&\crlcE

FlG. 8-6' Sinusoidal pathway of the COM. The combined interaction of the knee, ankle, and foot allows
for the reduclion and smoothing out of the dsplacement of the COM. (Reprinted from iiose J, Gamble
JG. Human walking,2nd ed. Baltimore: Williams & Wilkins, 1994, with permssion.)

respect to the hip, knee, and anklejoints gives us a reasonable approximation of the external moments occurring about
each of these joints. The GRF can be dir-ectly measured with
a forcc plate, described later in the quantitative gait analysis
section. A more exact estimation of the external moments
during the stance period, which includes the additional effects of gravitational and inertial forces, is ordinarily performed with quantitative gait analysis. These additional
gravitafional and inertial forces are small during stance at
slow and normal walking speeds and thus can be ignored for
norv in understanding normal gait function ( I 8). Visualizing
where the GRF lies with respect to a joint provides a means
to understand what'intelnal moments must be generated in
order to stabilize that joint. For instance, if the GRF line lies

posterior to the knee, an external knee flexor moment is


produced that is the product of the GRF multiplied by the
distancc of the GRF line fiom the knee joint. In order to
maintain stability so that the knee does not collapse uncontrollably into'flexion, an internal knee extensor moment lnust
occur. This mornent, provided by the knee extensors, is equal

in magnitude to te external flexor moment.


The concept ofjoint stabilization and the importance of

knowing where the GRF lies in relation to the joints

are

best exemplified during quier sranding. In quiet standing, the


GRF extends from the ground through the mid-foot, passing
aterior to the ankle and kneejoints and posterior to the hip

joints (Fig. 8-7). At the hip, the external exrensor momenr


is countered passively by the iliofemoral ligaments. Similarly, at the knee, the external knee extensor moment is countered passively by the posterior capsule and ligaments at the
knee. At the ankle, e extemal dorsiflexion moment can
be countered with an internal ankle plantarflexor moment
provided by the ankle plantarflexors (or alternatively rvith
an ankle-foot-orthosis with a dorsiflexion stop equivalent).
Thus, the only lower extremity muscles that need to be con-

FlG.

8-7. Quiet standing. The GRF, represented by the so/ld

affow, is located anterior to the knee and ankfe


and posterior to the hp. The soleus muscle is active to stabilize the lower limb.
/rne with an

Looding

Pre-swing

Response Midstonce

lnitiolSwing

Mid-Swing

TerminolStonce

TerminolSwing

8-8. The eight phases of the gait cycle include initial contact, loading response, midstance, termnal
stance, preswing, initial swing, midswing, and terminal swing. The GRF vector is represented by a solid
/rne with an arrow. The active muscles are shown during each phase of the gait cycle. The uninvolved
limb is shown as a dotted line.
FlG.

sistently active during quiet standing are the ankle plantarflexors.

During walking, the GRF line moves in a posterioranterior direction as the body progresses forward (Fig. 88). During loading response, the vector is anterior to the
hip and posterior to the knee and ankle. In mid-stance,
the vector passes through the hip and knee joints and is
anterior to the ankle. During terminal stance, the vector
moves postelior to the hip, anterior to the knee joint, and
maximally anteriol to the ankle. With these dynamics in
mind, normal gait function is easier to interpret. The muscles fire in response to the need for joint stability. Furthermore, whether the muscle is firing concentrically or cccentrically depends on the corresponding joint motion at
that time. In quantitative gait analysis, whether a muscle
group is firing concentrically or eccentrically can be determined by measuring the joint power that is mathematically
the product of the joint moment and the joint angular
velocity. A positive joint power implies that the muscle
group is firing concentrically, whereas a negative joint
power implies at the muscle group is firing eccentrically.
Interestingly, most of the muscle activity that occurs in

walking is eccentric. Also, it is interesting to note that


each muscle group undergocs a phasc of stletching and
or eccenIic colltraction before each concentric contraction.

NORMAL KINEMATICS, KINETICS, AND


MUSCLE FUNCTION
The lbllowing descriptions of nonnal kinematics, kinetics,
and muscle acvity are based on data collected from the
Spaulding Rehabilitation Hospital Gait Laboratory and are
similar to those reportcd clscwhcrc. The following general

pattems of movement are fairly representative in nondisabled subjects across most ages after the age of 3 year.s
( r 9,20).

Sagittal Plane Motion


For each phase, the kinematics, kinctics, and muscle activities ale described. Figure 8-8 illustrates the chief actions
occurring in each phase with a visual representation of the
limb and joint positions, the GRF line, and thc musclcs thar
are active during that phase. lt also may be useful to refer

to Figure 8-12, later in this chapter, which


gr.aphically dem_
onstrate the joint motion, moments, and poweis
throughout
the gait cyclc.

Initinl

Contact

Initial contacr with the ground typically occurs rvith


the
l::t i" nondisablecl gair. The trip is maximally flexed at

30", the knce is fully extended, and the ankle


is n a neutral
position. Because e GRF is anterior ro
the hip, the hip
extensors (gluteus maximus and hamstrings
are firing to
maintain hip stability. Ar rhe knee, the GRF lreares
an exrenso moment, which is countcrcd by hamstring
activily. The
foot is supported in a neutral position by th"e
ankle dorsi_

:ountered passively by the iliofernoral ligarnents. The hip is


row maximally extended at 10'. At e knee, the GRF moves
:rom an anterior to a slightly posterior position. As the heel
'ises from the ground, the GRF becomes increasingly ante-ior to the ankle joint, and this dorsiflexion mornenr
continres to be stabilized by ankle plantarflexor activity. During
Jris phase, the ankle is plantarflexing; thus, the action ofthe
mkle plantarflexors has switched lrom eccentric to concen-

ric.
?reswing

The purpose of preswing is to begin propelling the limb


:orward into swing. This second interval of double limb suprort is occul'ring as the contralateral limb now advances
.hrough initial contact and loading response. From maximal

rip extension, the hip now begins flexing and will continue

lexing throughout the swing period. The hip flexors (comrined activation of the iliopsoas, hip adductors, and rectus
:emoris) are concentrically active. The knee swiftly flexes

nto 40o of flexion as the GRF progresses lapidly posterior to


flexion may be conolled by lectus femoris

.he knee. Knee

rctivity. Thus, the rectus femoris is simultaneously acting


:oncentrically at the hip and eccentrically at the knee. The
inkle continues plantarflexing to approximately 20" with
rontinued concentdc activity of the ankle plantarflexors.

flexion and control knee extenslon. Ihe ankle dorsllexors remain active to ensue a neutral ankle position at
Ite hip

nitial contact.

loronal and Transverse Plane Motion


Most lower extremity motion during gait occurs in the
ragittal planes. The joint motions and kinctics about the hip
n thc transverse plane and about the knee and ankle in both
he coronal and transverse plancs are normally quite small.
\lthough significant motion and associated moments occur
n these planes in various gait disabilities, it is difficult to
eliably measure these parameters with current quantitative
ait analysis techniques. However, significant coronal plane
notion and kinetics do occur about the hip (and pelvis) nornally and can be accurately evaluated with quantitative analsis. At initial contact both the pelvis and hip are in neutlal
rositions in the coronal plane. During loading response, GRF
tasses medially to the hip joint center as the opposite limb
s unloading. This medial GRF causes an external adductor
noment, which tends to allow the contralateral side of the
relvis to drop slightly (the slight Trendelenburg noted previrusly as one of the determinants of gait). This motion is
:onolled by eccentric contraction of the hip abductors. Durrng mid-stance and terminal stance, the GRF is still medial
|o the hip; however, now the contralateral side of the pelvis is
lifted concentrically by the hip abductors. During preswing,
lnloading of the limb causes the ipsilateral side of the pelvis
ro drop again.

GENERAL APPROACH TO EVALUATING A


PATIENT WITH AN ATYPICAL GAIT PATTERN
Although a number of atypical gait pattems have been
described, each patient has a unique set of impairments,
functional limitations, and associated compensations causing these pattems. Examples of atypical gait patterns associated with distinct diagnoses are described in the following
sections. Especially in the casc of upper motor neuron
(UMN) pathology, a stereotypical descriplion of the gait par
tern may be sufficicnt for an initial classification but is too
imprecise for determining the rnechanisms in an individual
patient. It is important to determine these mechanisms in
individual patients bccause they are the basis for directing
optimal rebabilitation treatment.

It should be noted that an atypical gait pattern may or


may not be functionally signilicant and thus may or may not

be considered a true gait disability. Thus, the atypical gait


pattem first should be evaluated with respect to each of the

fbllowing:

.
.
.
.

Energy requirement

Risk of falling
Biomechanical injury
Cosmesis

Treatment to change the gait pattern should be prescribed

lour crrtena. hor lnstance, me pattern ol Knee recu


(or hyperextension) can be functionally significant if it increases the energy required to walk by not allowing the peak
of the COM to be minimized during single limb support.
Alternatively, knee recurvatum may or may not be associated rvith increased forces across thc posterior capsule and
ligaments of the knee (21), which would predisposc to bitlmechanical injury. Another example is equinus during the
swing period, which may or may not predispose to falling
depending on the associated compensations. To this end,
the as"^ociated compensatory gait patterns also need to bc
evaluated with respect to these four criteria. In the case of
equinus in swing, a compensation at the pelvis such as hip
hiking would interfere with the pelvic obliquity determinant
and thus increase the energy required to walk. Finally, an
atypical gait pattem should be evaluated with respect to
cosmesis. For this assessment, the patient's own perceptions
are far morc important than the clinician's perceptions.
From the examples above, it is cleal that a detailed evalution of the patient is required. Thc summary of the patient's
history and musculoskeletal examination, observational gait
analysis, and information from a quantitative gait analysis
assist in determining thc functional significance of the gait
patterns and help identify specific causes ftrr each pattem.
Based on these results, a detailed treatment plan can be prcscribed.

STATIC EVALUATION
History
The initial part of a comprchensive gait evaluation should
include a focused history and physical examination. Based
on this cvaluation, e underlying diagnosis (or diagnoses)
can be classified as a UMN pathology, lower motor neuron
(LMN) pathology, orthopedic disordcr, amputation (the
evaluation ofwhich is described in anoer chaptcr), cerebellar or basal ganglia related disoder, or psychogenic cause,
to name a few. It is helpful to anticipate certain gait patterns
associated with these diagnoses as well as to anticipate the
need for various components of a quantitative gait analysis.
F-or example, the use of dynamic EMG is particularly useful
in detecting inappropriate firing patterns in patients with
UMN pathology but may not be necessary for every patient
with one of the other mentioned diagnostic categories. The
reason for refenal should be identified, and the patient's
chief complaint with regard to walking should be considered.
Any prcvious medications, neurolytic procedurcs, or surgcries affecting the lower cxtremities should be noted. Also,
a detailed history of strengthening and stretching exercises
previously and currently being performed should be ascertained. Finally, the use of assistive devices and/or orthotics
should be recorded.

Physical Examination
The physical examination should focus on the neurologic

176

Rsuu.lmrroN Mnnlcn: Pri.nlclpr.r,s,rNu Pnrcrrt;

of the patient's strength, joint range of motion, tone, and


proprioception. Although static evaluation is a routine part
of a gait consultation and should be included in the assessment ofevery patient with an atypical gait pattern, it is generally agreed upon that, especially in the case of an UMN
pathology, the static evaluation has limited usefulness in
determining the underiying mechanisms responsible for the
atypical gait pattern (22-24). Thus, olten the results from
the static evaluation need to be combined with those obtained
trom quantitative gait analysis to provide dynamically relevant information on which to base treatment.
Strength
Classic evaluation of strength involves quantitative manual muscle testing about each joint. It requires the ability
of the patient to cooperate with resistive movement of the
examiner (25), which often is difficult in patients presenting
with a UMN pathology. The patient wi a UMN parhology
has impaired voluntary muscle control in the affected limbs
so that selectively activating an agonist while simultaneously

relaxing the antagonist may be impossible. Thus, the result


is a limited relationship betwcen static strength performance
and dynamic strengt} associated with gait. For example, a
patient with hemiplegia affecng his or hcr gait may not be
able to dorsiflex the foot during static examination, yet when
walking may be able to actively dorsiflex during the swing
period ofthe gait cycle (26,27), presumably under the control
of primitive reflexes. Conversely, a patient with normal dorsiflexion strength of the ankle during static evaluation may
demonstrate an equinus gait during the swing period of gait.
Range of Motinn

Determining f.he passive range of motion at each joint is


the traditional method to assess soft tissue contracture and
should be performed in at least the lower extremities in all
patients presenting with a gait disability. However, it is important to note that this static testing is somewhat limited,
particularly in the case of UMN pathology. Difl'erentiating
between contracture of a one-joint and a two-joint muscle
is difficult in patients with a UMN pathology, undoubtedly
because of impailed sclective control of these muscles. Furthermore, there seems to be a limited relationship between
static range of motion observed with passive ranging and
the dynamic range of motion that occurs during gait.
Three clinical tests are commonly performed in patients
with UMN pathology to screen for contractures of a rwo
joint muscle. The Duncan-Ely-test differentiates between a
rectus femois and a iliopsoas contractule given that the rectus femoris is both a hip flexol and knee extensor. [n this
test, the patient is placed in a prone position and the knee
is rapidly flexed. With a conftacture of the rectus femoris,
the hips will flex and the buttocks will rise off the table.
Although this test is somewhat useful, EMG studies have
demonstrated that this test induces activity not only in the

rectus femoris, but also in the iliopsoas in some patients with


cerebral palsy affecting their gait (28). The Silverskiold test
is used to differentiate between a contracture of the soleus
and the gastrocnemius muscle. Whereas the soleus is a onejoint muscle, thc gastrocnemius is both a knee flexor and

ankle plantar'flexor. With the patient in the sitting position,


the knee is flexed at 90o and the foot is brought to maximal
dorsiflexion. With a gastrocnemius contracture, some of the
ankle dorsiflexion will be lost when the knee is extended.
It has been shown that this test is not always clinically reliable (29). The Phelps test differentiates a contracture of the
gracilis from the other hip abductors, given that the gracilis
is the only hip adductor t.hat crosses the hip and the knee.
Wi the patient in a prone position, the knees are flexed
and the hips are brought into an abductcd position. A gracilis
contracture is present when the hip adducts when one knee

is extended.
Structural deformities also may contribute to reduced
range of motion and gait. If indicated, further clinical tests
and x-rays arc helpful to docurnent common problems such
as femoral auteversion, knee valgus and varus, tibial torsion,
and foot abnormalities. These structural problems al'e solnetimes associated with other underlying diagnoses and impairments and can have significant impact on the patient's
walking.
Tone

Tone in all muscle groups should be assessed in each


patient presenting with a gait disability. Clinical examination
of tone involves testing for resistance by passively moving
a joint through its range of motion. This assessment is fairly
subjective and is dependent on time of day, temperature, and
limb position. Thus, as in the other static tests, there is often
a limited association between what is obscwed statically and
what actually occurs during gait.

Proprioception
Joint sense position should be evaluated in all patients in
whom a neurologic diagnosis is suspecred. If this is impaied,
it is important to also cvaluate the degree of impairment by
evaluating joint position sense nor only at the geat toe, but
at the ankle, knee, and hip as wcll.

OBSERVATIONAL GAIT ANALYSIS


Observational gait analysis is common practice lor physiatrists. The observer describes e gait after watching the
patient walk without the aid of any electronic devices. However, it is often difficult to appreciate all limb segment and
joint motions throughout the different phases of gait because
of the difficulty in concurrcntly observing the mulriple body
segmcnts and

joint motion (30). Videotaping

can be an im-

portant part of observational gait analysis because it allows


repeated viewing of the patient's gait pattern without causing

Inoue pallent l atlBue. I f tc Pautrrrt sllultlu us vu)trr vEu rwu


he side and forn behind. Stride and step length, width, and
;ymmctry should be noted. By concentrating on one joint at
r time, including hip, knee, and ankle, atypical motions may
re easier to identify. Having the patient walk at faster speed
;ometimes exaggerates an atypical motion. Observational
gait analysis can identily obvious atypical gait patterns' such
ls excessive ankle plantarflexion or reduced knee flexion in
swing. However, in certain cases this approach may not show
all atypical patterns. For example, an incleased lumbal lor-

iosis ol anterior pelvic tilt due to a hip flexion contracture


may be apparent only via quantitative analysis. MoLeover,
quantitative gait analysis can be quite helpful in delineating
the specific causes for each atypical pattern and thus help
direct the appropriate treatnlent.
A number of terms are commonly used to chanacterize
various atypical gait patterns that are obvious from observational assessment alone. For instance, antalgic gait has been
described as a pattern common to patients with pain in one
lower extremity. In this pattern, gait is modified to reduce
weight bearing on the involved side. The uninvolved limb
is rapidly advanced to shoflen stance on the affected side.
Gait is often slow and steps are short in otder to lirnit the
weight bearing period. Steppage gait is a corpensator] gait
pattern used to describe excessive hip and knee flexion to
assist a "functionally loug" lowet leg to clear the ground
in swing. Festinating gait have been described as a characteristic pattern of Parkinson's disease, in which there is a tendency to take short accelerating steps. Shutfling gait is also
common in Parkiuson's disease and refers to the feet shuffling during swing. Ataxic gait, associated with cerebellar
pathologies, peripheral neuropathies, and dorsal colutnn pathologies, is a broad ter m used to describe a pattern of apparent poor balance, a wide base of support, and variable motions flom stride to stride.
Various gait pattenls associated with the use of assistive
gait devices are easily noted with observational analysis. The
specific indications and use of each of these type of devices
are described in detail in another chapter. A cane essentially
increases the base of support by providing an additional point
of contact with the ground. When pathology, impairment,
and functional lirnitation involve bilateral extlemities, two
canes or crutches aLe occasionally used. In this situation, an
alternating two-point gait is comrnonly used in which one
cane and opposite lower limb are in contact with the ground
alternating with the opposite cane and lower limb in each
successive stcp. In three-point gait, contact with one limb
that f'ully bears weight onto the ground alternates with full
weight-bearing through two crutches that make simultaneous contact with the ground. In four-point gait, which provides maximal stability and base of suppolt (at the cost of
reduced speed of locornotion), there is always three points
of support on the ground at all tirnes. It is initial-ecl by forward
movement by an upper extremity crutch, followed by forward movement of the contralateral lower limb, then forwrd

ment of the other lower limb-

QUANTITATIVE GAIT EVALUATION


Modern-day quantitative gait analysis systems typicaily
include measurement of three primary components: kinematics, kinetics, and muscle activity. Quantitative gait analysis also can include other components such as footswitches
and oxygen consumption monitoring to measul'e overall energy expenditure. To measure these valioLls cotnponents' a

variety of equipment is used, including optoelectronic motion analysis systems to measure kinematics. force plates to
help measure kinetics, and a multi-channel dynarnic EMG
apparatus to measure electrical muscle activity in multiple
muscles during gait. Given the previously described linitations of static evaluations and of observational gait analyss,
quantitative gait analysis can be a particularly useful clinical
tool for developing a tleatrnent plan.
Modern quantitative gait analysis is clearly recognized as
useful in outlining an ef'fective orthopedic sulgical tleatment
plan in patients with spastic paretic gait from cereblal palsy
(23,31-33). Children with cereblal palsy often undergo tendon lengthening or tlansfer procedurcs to itnprove range of
motion in the lower extremities in an effort to improve gait
disability. The esults from a detailed quantitative gait analysis can help determine the best surgical pian (i.e., which
tendons should be lengthened or transfened) to provide the
rnost optimal gait. In thc same way that quantitative gat
analysis is helpful in orthopedic decision making in patients
with UMN pathology, it should be similarly useful in directing these patients' rehabilitation management. Many physiatric treatments, as described in other chapters, include intramuscular neurolytic techniques, strengthening, bracing,
functional electlical stimulation, stretching, rnodalities, and
many other management techniques aimed at (a) strengthening ol compeDsating fbr weakness, (b) stretching a contracture, and/or (c) reducing tone in a spastic muscle' The
outcome of these treatments ultimately rely on the proper
determination of the specific underlying impairment or flnctional timitation causing the gait disability. In sorne instances, rehabilitation tleatments are aimed at irnproving
motor control through, for exarnple, EMG biofeedback or
neufomuscular re-education. In these instances, quantitative
gait analysis is especially helpful in determining which specific muscle groups are firing at inappropriate times.
Unfbrtunately, skepticism still pcrsists about the vaiue of
quantitative gait analysis in defining a physiatric therapeutic
plan because there have been few reports about the value
of quantitative gait analysis as a useful evaluation tool in
rehabilitation. Human gait is cornplex. Quantitative analysis
offers a clinical tool to better ullderstand these complexities
and thus prescribe an optimal rehabilitation treatmcnt program (34). Some of the reluctance in using quantitative gait
analysis may be due to the heavy time commitment necessary to understand and interpret the data and the necessity

tTU

Rln,tnu.lrr'roN Ml:ul<;rNri:

Pnrx<;pr.ri.s AND PR

for teamwork between ntany disciplines, including nedicine


and engineering. The cost for gait analysis systems is declining, and the technology required for acquiling atrd analyzing
the data is continually improving. A rapid expansion of computer and optoelectronic technology has brought dramatic
changes in irnage-based motion analysis in the past

It

l0

years.

will soon bccome a routine clinical evaluation, much like electrodiis anticipated that quantitative gait analysis

agnosis has become a routiue clinical extension of our physi-

in quantitative gait
analysis, which is already a mandatory part ol our physiatric
residency cuniculum, is likely to become the norrn.
atric examination. Formal training

Syslems to Evaluate 'l'emporal Parameters of Gait

Corunon tempolal parameters such as velocity, cadence,


and stride length can be measured to monitor a patient's
progress outside of a sophisticated gait laboratory. As noted
previously, velocity can be measured sinrply with a stopwatch as a patient traverses a designated distance. Sirnilarly,
step and stride length can bc measuLed without sophisticated
equipment if thc walkway is sprinkled with talcum powder.
Computerized stride analyzers may provide this same information in a more automated fashion (35,36). They usually
consist of instrumented insoles with footswitches (i.e., pressure sensitive transducers), typically attached to fhe heel,
toe, and occasionally thc metatarsal region. They are connected to data boxes wom by the patient either around the
waist or the ankle. These sensols measule the duration of

floor contact via opening and closing switches. After acquisition, data transfer and analysis are typically performed
using a personal computer.
Footswitches are also commonly used in gait laboratorics
to help determine the beginning and end of the stance period,
allowing calculation of temporal gait parameters such as the
duration of the stance and swing periods, single and double
support time, and cadence. These palamcters are useful jn
interpreting the tempolal relationships of kinematic, kinetic,

\c,r,r(li
mellitus ol other underlying vascular and peripheral neuropathy disordels.

Kinematics
Electrogonometers
Electrogoniorneters are computelized versions of simple
goniometers, which are commonly used in clinical pl'actice
to assess joint range of motion. An electrogoniometer consists of one or more potentiometels placed between two bal s,
with one bal strapped to the ploximal limb segment and the
other strapped to the distal limb segment (Fig. 8-9). The
potentiometer, which is placed over the joint, provides a
varying electrical impulse, depending on the instantaneous
angle between the two limb segments. This electrical impulse infonlation is then interfaced to an analog-to-digital
convcrter in a personal computer to plot joint angle infor-mation over time. A combination of three potenolneters allows
for measuring threc rotations between limb segments (37).
A rnajor disadvantage of cun'ent electrogoniometers is relatively poor accuracy because they are difficult to apply, par.ticularly abont the hip and ankle. Unfbrtunately, even in the
case of good accuracy, the results obtained from electrogonion'leters provide only relative joint angle information, not
absolute positions of the joins of limb segments. Because
of these limitations, electrogoniometers cannot be used in
conjunction with force plate data to evaluate joint kinetic
data.

Cinemafography

Historically, gait analysis was perlormed using sequential


photographs or motion pictules. Markers placed over various
anatomic landmzu'ks can be used to help identify the location

of limb segments and joints. The iocation of markers can

and particulally dynarnic EMG data. Alrhough this same


information can be obtained directly from fbrce plate data,
footswitches are particularly helpful in the gait laboratory
when force plate data cannot be obtained.
Foot Pressure Systems
l.-oot pressure systems are electronic instruments to mea,
sure pressure distributions in the soles of the feet. Tbe systems work via a large number of capacitive or forcc sensitive
sensors in lbot insoles or platforms and are linked to a com-

:\

,t:.

.--

.: -.--+

puter by either cable or radiowave telemetry. Several commercial systems are available and used clinically and for
research. These systems rnay help direct appropriate shoe

wear and orthotic prescriptions by providing information


about abnormal pressure distributions, particularly in patients with structural foot deformities or in patients at risk for
developing skin ulccrations in the feet because of diabctes

FlG. 8-9. Electrogoniometer. A potentiometer placed at the


joint center records varying electrical impulses depending on
the relative position of the proximal and distal segments.

'narker position in two ditnensions can be determined. In


roth cinematographic and optoelectronic systenrs, a single
:arnera provides two-dimcnsional infonnation. By using two
:ameras, triangulation can be pertitrmcd kl deterrnine the
hrcc-dimensional position of each markcr'. Although thc cirematographic system is theoletically as accurate as what

:an be obtained with modern-day optoclcctronic systems,


.hc timc necessary to manually digitize and process the data
s

of such great magnitude that it makes this procedure

;ible for routine clinical

lptoelectrordc

evaluation.

unt'ea-

Motio, Analysis

Modern-day quantitative gait analysis typically involves


sophisticated computerized video camera apparatus, re'er'ed t<-r as an optoelectronic motion analysis system. These

vidual marker in a manner similar to that in cinematography,


but with far greater ease and speed. .lhe system automati_
cally digitizes the position of each markel. frorn each vicleo
carncra and then automatically tr.iangulates the information
to pr.ovide a three-clinensigal posiiion of each rnarker. at
each frame. A layout of a typical laboratory space that in_
cludes an optoelectronic rnotion analysis system is illustrated
in Figure g-10. Typically, an optoelectronic systcm can detect the true three-dimensional position of a marker within
a few millimeters in each of the thrce axes. The specific type
of camera or lenses that are used, the algorithms used to
digitize or identify mat'kers, the size of the markers, and
the laboratory environment are all factors that deter.mine e
spccific accuracy of any given system. Marker position is
typically determined at cvery l/50, l/100, or l/200 ofa second, depending on the speed of the calleras uscd. Multiple

marters are alllxed to the skln of the pelvts and the lower
:xtremities in relationship to bony landnalks. Similar to the

power; thus, lrlultlple wlres connected to a powef source


need to be attached to the patient, which tend to encumber

rinematographic method, two cameras ale necessary to visualiz-e each markcr to obtain its three-dimcnsiotral position.
Cften a camera cannot visualizc a rrratkcr duling a palticular
part of a movement bccause of linrb rotation or because
another lirnb segment gets in the rvay. For this reason. solne-

the patient's gait. In contrast. passive markct'systems requit'e


only that a small infi'aled rellcclive piece of material be
placed over each anatomic landmark. Although passive

limcs a laboratory uses rnote than two calnetas to ensure


lhat at every given frame of tnovement, at least two cameras
can visualize each of the rnarkers. In the case where tht'ee
or more cameras visualize a marker, an algorithm must bc
used to determine the true position of the marker because
there is invariably some etlor such that not all cameras converge on the identical thlee-dimensional position. Other laboratories strategically position the markers so that the same
two camcras can visualize a particular marker throughout
the movement.
Currently, there are two different types of optoelectronic

systems used for quantitative gait evaluation: (a) acf.ive


marter systems, u,here the malkers are actively illuminated
by a computer', and (b) passive marker systems. A built-in
advantage of an active marker systctn is that the computet
knows in advance which maker it is illuminating at any
given fr-ame so that the markers are automatically identified
as the lateral femolal epicondyle marker, the lateral malleolus marker, etc. The main disadvantage of current active
rnarker systems, however, is that the illuminators require

markels do not encumber the patient, lhcy do require some


additional tyre of systern to detemine which markcr is
which. Forlunately, sophisticated comprter softr.vare ptograms have been developed that automate this procedure.
Thus, passive marker optoelectronic systems have beconre
the prefcred systems for routine clinical practice and are
readily cornnrercially available with all necessary software
programs.

In older to obtain cstimates of joint motion, the optoeiectronic systern is coupled to a biomechanical or rnathematical
model that defires where on the body the markers are optimally placed (Fig. 8-l l). A simple model to measure knee
rnotion might involve placenrent of one marker over thc
greater trochanter. onc marker over the lateral femoral epi-

condyle. and one over the lateral rnalleolus. The angle


formed between the line connccting the greater trochantcr
with the lateral femoral cpicondyle and the line corrnecting
the lateral femoral epicondyle and the lateral malleolus
would represent knee flexion. However, this modei would
be too simplistic in that knee varus or valgus could easily
be misread as true knee flexion. To accutately dene sagittal
motions such as knee flexion, geometry dictates that three

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i,t

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FlG. 8-'l 1. An example of marker arrangement. Markers are placed on a variety of


anatomic landmarks allowing forthe collection of three markers or marker equivalents
aa,

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FlG. 8-12. Kinetics and kinematics at the hp, knee, and ankle. Sagittal joint motion, moments, and
powers are shown.

markers (or marker equivalents) be placed on each limb segment, assumed to be rigid, to define the thrce-dimensional
coordinate system for that segment (Fig. 8-12). A marker
eguivalent could be some imaginaly anatomic point calculated on the basis of the position of real makers. For instance, three markers could be used to define a plane in the
pelvis. Fiom this and the known gcometly of the pelvis. the
location of the hip joint center can be calculated. The hip
joint center then becomes an imaginary marker equivalent
and can be used in defining the thigh segmenr coordinate
system. Marker locations are often chosen in order to facilitate estimating joint centers as well as to cnsure that the
markerc can be visualized by the camera system.
Typically, markers are placed ovcr bony landmarks to
ensure consistent applications as well as to reducc skin
movement artifact. With three markers or marker equivalents
for cach body segment, the segment can be reprcscnted in
the form of a local coordinate system whose orientation is
determined with respect to a global coordinate system. 'fhe
local coordinatc system is defined by three mutually perpendicular vectors. Joint angle information then can be ascer-

tained from the proximal and distal limb segment local coor.dinate systems. Several mcthods exist for determining.joint
angle information. Commonly, one axis is chosen kl be parallel to the pltrximal segrnent local coordinate system axis,
and a second axis is chosen to be parallel to the distal segmcnt local coordinate system axis (38). In this way, a medial/
lateral axis is selected from the proximal segment local coordinate system and is considered to bc the axis about which
joint flexion/extension occurs. A longitudinal axis chosen
from the distal scgment local cooldinate system represents
the axis about which intemal/extelnal rotation occurs. Finally, an axis folrned mutually perpendicular to these two
axes is considerecl the axis about which abduction/adduction
occuls ([ig.8-13).

Kinetics
Joint moments and power are comrnonly measurerl with
quantitative gait analysis. The concept of a joint moment
has already been described. A joint power, also refened to
previously, rcpresents the net rate of generating or absorbing

182

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the plate

without interference from the other foot or an assis_


tive device. Also, to feasibly assess joint kinetics, kinematic
measurements must be collected synchronously with force
plate data. The locations of the force plates are predeter_
mined within a calibrated volume where the kinematic data
are measured. A combination of vaious measurements taken
on the patient arc used in conjunction with look-up tables,

Proximol Segmeni

\.L

Soglltol

Plore

based on cadaver data, to estimate body segment masses and

'\

onwerse
Plore

/-'
Abducfion
Adduction
Axis

/ "tt.

{\J\),'...

Dtstotsegmsnt

lnternol/Externol

moments of inertia (4,39). Clinical gait laboratories r.eport


moments as either external or internal. An external
moment refers to the net external load applied to the joint
measured via inverse dynamic techniques. The internal mo_
ment, which is equal and opposite in sign to the external
moment is the presumed molnent due to the muscle activity
and/or soft tissues to fulfrll the r-equirement that the joint is in
equilibrium. For exarnple, an external dorsiflexion moment
about the ankle during the stance period of a gait cycle im_
plies that an equal and opposite internal moment provided
by the ankle plantarflexors or heel cord is present to maintain
joint stability. Similar.ly, an external flexo moment_ about
the hip during the stance implies that the hip extensors must
be active in order to maintain stability. The typical kinetics

joint

'\l-

Roloflon Axis

FlG, 8-13. Determination of axes of rotation. Flexion/extension, abducton/adduction, and internal/external rotation axes
are determined based on the proximal and distal segments,
local coordinate systems.

cnergy and is the mathematical product of the joint moment


and joint angular velocity. A positive joint power implies
that the muscle contractiotl is concentr.ic because the joint
angular velocity and moments are in the same direction. A
negative power implies that the muscle contraction is eccen_
tric because angular velocity and joint moments are in oppo_
site directions. Joint kinetics ar-e calculated in part using
inverse dynamic techniques according to Newton's second
law of motion, which essentially calculate the joint moments
based on the motion and mass characteristics of the limb
segments. Although theoretically the kinetics could be calcu_
iaed from the kinematic data alone, these calculations would
be extremely complicated and prone to e.or. Kinetics are
thereforc typically calculated using a combination of GRF
data along with inverse dynamic techniques. Thus, kinetic
calculations are usually based on (a) knowledge of the posi_
tion of the joint in relationship to the GRF, (b) estimates
of body segment masses and moments of inertia, and (c)
knowledge of the body segment positions, velocities, and
acceleration.
GRFs are measured using force plates that are comprised
of piezoelectric or strain-gauge transducers. One or more
force plates ale imbedded in the ground of the walkway (see
Fig. 8-10). As the patient walks, he or.she steps on the for.ce
plate. To obtain useful GRF data, only one foot must str.ike

and kinematics at the hip, knee, and ankle are shown in


Figure 8-12. This type of graphic formar is typically used
for reporting quantitative kinetic and kinernatic gait informa_
tion in the clinical setting.

Dynamic Electromyography
Quantitative gait analysis also includes measurements of
muscle activity during walking obtained using dynamic
EMG measurement. When combined with kinematic and
kinetic data, dynamic EMG provides useful information
about whether a muscle is firing appropr.iately and if not,
how this nonphasic activity impacts on gait, particularly in
patients with spastic paretic gait. Because muscle activity
does not linearly relate to the rnagnitude of force generated,
quantifying the amplitude of activity is not pracrical in pa_
tients. However, r'elative norrnalization to the peak level ac_
tivity over the gait cycle or the peak level activity, whether
it occurs during strength testing or during walking, improves
the clinical usefuiness of the EMG data (l).
Muscle activity is measured using either surface clec_
trodes affixed to the skin or fine-wir-e electrodes inserted
in e muscles. Surface electrodcs are adequate in studying
activity in large superficial muscle groups. In addition to the
fact that surface electr-odes are less invasive than fine-wire
electlodes, a major advantage of surface electrodes is thar
the data obtained ale more easily replicated. This latter ad_
vantage is undoubtedly due to the fact that surface elec_
trodes. as compared with fine-wire electrodes, sample data
from an inordinately greater number of muscle fibers, repr-e_
senting a fal greater number of motor units. Because of this
same fact, fine-wile electrodes are not as prone as superficial
electrodes to interference or "cross-talk" from nearby mus_
cles. Surface electrodes are commonly used for many large

[odes are necessary fbr analyz.ing activity flom srnallcr,

strvurl L[rBUrres. prcilraLUru o[sct., ucraycu oltset, cultalle0


period, plolonged, absent, out of phase, or continuous (40).

posteriol tibialis.

Although thcse categorizations at'e useful in describing ac-

ln addition, fine-wire electlodes are usefirl 1br differentiating


activity frour overlapping ntuscles suclr as the lectts fenroris
and vastus internrcdius.
Surface IIMG is typically recorded using disposablc.
gclled clectrodes attached to the patient's skin overlying the
muscle to be sarrplcd. t.lsually, bipolal electrodes aLe used
and the signal recorded is the potential difference betwcen
the two electrodes. Fine-wire EMC is often lecorded usin,e
a wire bipolar electlode consisting of two thin, insulated
wires with bared tips. The r,ires are placed thlough thc shafi
of a 25-gauge needle with the two ends bent over the needle
and the baled tips staggered so rs to avoid contact between
them. The needle is inserted through the skin into the musclc.
and then quickly rerroved, leaving tlre fine-wire in place.
When in place, the bend in lhe wires providcs a rneans fbr'
Lhc electrodes to "catch" on the muscle fascicles. Again,
the signal recorcled is lhe potential clifference between the
two eiectrode ends. At the end of the study, thc wircs are
rcmoved with a gentle pull.

tivity in each rnuscle, it is inrportant to note that thcy do not


ncccssalily inrply pathology about that particular musclc.
In some instalrccs, nruscle rctivity differs froln that ol a

:uPsrlllldl

tllu)tIg)

ut trv uwut cAuultilty.

Ceeper nrusclcs, such as the iliopsoas and

t-ltg-wll

nondisablcd sub.ject becruse of compensatory actions, As an


cxarnplc, plolongation of quadliceps activity into the mid-

tertrinal stance phascs would be con'rpensatory in a patient with an excessive external kee flexor moment. Thus,
nrusclc firing pattelns are optimally assessed in conjunction
with the kinetics to help clissociate ir.npailrnent from comand

pensatoly action.

Overall Gait Analysis


'I'he overall gait laboratory anall,sls procedurcs takes approxirnately 2 hours for data acquisition and an additional
2 hours lbr analysis and interpretation. The majority of the
acquisition time is spcnt applying and confilrning placement
of the rnultiple rarkers and EMG electrodes. The paticnt is
typically cvaluated under several cotrditions, i.e., barefoot,
with shoes, and with and without an or-thosis ol assi.stive

Preamplified EMG signals, eithcr from fine-wire eleclrodes or surface electrodes, can be transmitted by cable
or radjowave telemetry to a receiver that is connected to a
computer system. The EMG signals are usually filteled to
remove artifacts created by the mechanical movemcnt. The
signals are displayed and the gait cycle events identified.
Some labolatories report raw EMG signals, whereas others
report rectified and smooth EMG activity as well. The tirning
of the activity is typically what is irnportrnt in the assessment. The normal tirnings of activity of major muscle groups
alc summarized in Figure 8-14. Muscle timing errors in palients with UMN pathology traditionally ale classified into

t0
Tibiolis

20

30

device.

EXAMPLES OI' EVALUATION APPROACH TO


SPECIFIC ATYPICA, GAIT PATTERNS
Gait Patterns Associated with UMN Pathologr

A nurnbel ol atypical gait patterns can be observed in


patients with hemipalctic, paraparetic or diplegic impairrnents aff'ecting their gait, regardless of the underlying

Percent of Goit Cycle

40

50

60

70

80

Anterior

Vosti, Long
Homstrings, ond
Hip Extensors
Rectus Femoris

Ankle
Plontorflexors
Hip Flexors

Indi.u,.s that a muscle or muscle groups

UMN

pathology (41 45). These atypical patterns include bu1 are

are active

FlG.8-14. General muscle group activity as a percentage of the gait cycle.

90

t00

rot limited to reduced knee flexion in swing, also refened


o as stiff-legged gait, excessive knee flcxion in stance reerred to as crouched gait, equinus or excessive ankle planarflexion occurring during one or ntore phases in either
tance anor srving, and knee hypercxtension oL r-ecurvatum
rccurring in one or more phases of stance. Also common
rre presumably compensatory atypical gait pattems, includng hip hiking, circunrduction, and steppage gait. The imporant point to remember is that the causes of each of thesc
rtypical gait patterns ale not necessarily thc same from indi,idual to individual and thus often necessitate a detailed
:valuation including quantitative gait analysis.

ipastic Paretic StiffLegged Ga't


Spastic paretic stiff-legged is a classic atypical gait pattern

in patients with UMN pathology. StifT-legged gait


:an be functionally significant from several views. From an
:nergy standpoint, a lack of knee fiexion in swing creates a
arge moment of inertia that signicantly increases the en:rgy r-equired to initiate the swing period of the gait cycle.
\dditionally, associated compensatory actions to clear the
fiff limb such as vaulting on the unaffected side and exces;ive pelvic motion can increase the vertical COM displace>bserved

nent, thereby increasing energy expenditure. From a biome:hanical standpoint, these same compensatory actions could
rlace the unaffccted knee at risk for posterior capsule damige or the lower back to injury. Finally, lack ofknee flexion
nay cause toe drag during swing, which could increase the

:isk of falling.
C)ne cause of stiff-legged gait is inappropriate activity in
)ne or more heads of the quadriceps during the pre- and/ol
nitial swing phases of gait (46*49). Reduced knee flexion
rlso may be caused by weak hip flexors, inappropriate harn;tring activity, and/or insufficient ankle plantarflexor muscle
rction (49). For many patients with spastic paretic stiff-

Legged

gait who undergo a quantitative gait analysis, the

:ause of the stiff-legged gait is not at all obvious from the


itatic ol observational gait evaluations. Fol instance, patients
with increased knee extensor tone often can be found to have
quiescent quadriceps EMG activity during preswing and ini:ial swing. Conversely, a patient with normal knee extensor
:one can have inappropriate activity during these phascs in
lne or mo'e heads of the quadriceps. In the latter case, if
Jrc inappropriate activity is limited to just one head, an inuamuscular neurolytic procedure would be a reasonable treatment to implove the gait patten. On the other hand, quantita:ive gait analysis may point to dynamically significant weak
nip flexors, indicated by slow progression into hip flexion
lnd poor hip power generation in preswing. These findings
:ommonly are not correlatetl with hip flexion strength evaluated by static testing. In this case, hip flexion strengthening
would be the optimal prescription. In another scenario, a
reduced extemal ankle dorsiflexion moment during stance
would impiy insufficient ankle plantarflexor muscle action,

might be the most appropriate treatment. A quantitative gait


analysis also can help provide inlormation about the functional significance of the atypical gait pattern. For instance,
the lisk for injury to the postelior capsule and ligaments of
thc unaffected knee can be assessed by rneasuring the extensol moment during that limb's stance period. Finally, a follow-up quantitative gait assessment rnay be useful in quantifying the improvement in knec flexion as well as ascertaining
that the treatment itsclf did not cause any new problems.

Dynamic Knee Recurvafunt


Hyperextension of the knee during the stance period. referred to as dynamic knee rccurvatum, is a common observation in patients with UMN pathology. This atypical gait pat-

tern may be caused by one or more

of the following

impairments: quadriceps weakness or spasticity, ankle plan-

tarflexor weakness or spasticity, dorsiflexor weakness, and


heel cord contracture (1,50). A primary functional concern
for patients with dynamic knee recurvatum is that the hyperextension may produce an abnormal external extensor moment across the knee, placing the capsular and ligamentous
structures of the posterior aspect of the knee at risk for injury.
Injury to these issues may cause pain, ligamentous laxity,
ol bony deformity. Not all paticnts have an abnormal knee
external moment, however, in which case the risk for injury

is probably less (21). Knee recurvatum is also ilnportant


flom the standpoint of energy expenditure. The lack of knee
flexion can cause a greater displacement of the COM because of the lack of knee flexion during the stance period.
Alough multiple factors may contribute to knee recurvatum. it is useful to determine the primary cause in each patient so as to prescribe an optimal treatrnent plan. In some
cases, dynamic recurvatum may be advantageous by

provid-

ing a control mechanism for an otherwise unstable limb during thc stance period of the gait cycle. If the associated knee
extensor moment is small, then attempts to improve this
atypical pattern may not be the appropriate treatment plan.
Thus, quantitative gait analysis provides information that
can help assess the functional significance of the atypical
gait pattem as rvell as informaon that can help delineate
the pattern's underlying impairment(s).

Dip

le gic-C ro uc hed

Gait

Crouched gait is defined as excessive knee flexion during


the stancc period of the gait cycle and is most commonly
descdbed in diplegic gait specific to cerebral palsy (51-53).
Associated gait patterns are adduction and internal rotation
at the hips, as well as equinus and forefoot abduction during
stance. Reduced knec flexion in swing is also common. Dynamically, hamstring spasticity has been implicated as the
principal cause ofexcessivc knee flexion in stance (51-53).
However, clinical experience suggests that dynamically tight
hip flexors, plantarflexor weakness, and heel cord con-

)est evatuateo usurg ure


rom static evaluation and observational and quantitative gait
rnalysis.

iquinus Gait
Excessive ankle plantarflexion or equinus occurring in
,ither stance or swing is common in patients with neurologic

esions. The differential cause for this pattem is inapprorriate soleus, gastrocnemius or posterior tibialis activity,
reel cord conhacture, or weakness of the ankle dorsiflexors.
\s in the other atypical gait patterns described, the functional
rignificance of the pattern needs to be determined. For inrtance, excessive plantarflexion during stance may inhibit
ibial advancement, thereby interfering with forward proression necessary for efficient ambulation. During swing,
:xcessive plantarflexion may place the patient at increased
isk for tripping and falls. Dynamic EMG is useful in identiying the presence of inappropriate soleus, gastrocnemius,
rr posterior tibialis activity as a cause of the excessive planarflexion. For equinus in swing, the lack of ankle planarflexor activity suggests either a heel cord contracture or
reak ankle dorsiflexors as a cause. Each patient also should
re evaluated for functionally significant compensatory
nechanisms as well as increased hip flexion and hip hiking
n swing. Finally, it is important to consider the possibility
hat the excessive ankle plantarflexion itself is a compensaory response for some other impairment or functional limiration such as weakness. This scenario has been rerorted to
rccur in muscular dystrophy (5a) and is likely to also occur
n patients with weakness from UMN. Thus, a reduction in
;he peak knee flexor moment in a particular patient wi
:xcessive ankle plantarflexion during stance may indicate
:hat the ankle plantarflexion is occurring as a compensation
ior weak knee extensors. Again, because of the complexities
rf gait, these possibilities are best assessed using quantitative
3ait analysis including kinetics.

Gait Patterns Associated with LMN


md Orthopedic Disorders
Unlike in most patients with UMN pathology, the atypical
gait patterns associated with specific peripheral nerve inju:ies cause discrete patterns of muscle weakness and associted characteristic atypical gait patterns- The following ex-

lmples illustrate atypical gait patterns that arise from


weakness of one specific functional muscle group. Unlike
patients with UMN pathology, in order to determine the
rnderlying impairment and functional limitation responsible
lor the atypical gait pattern, static evaluation and observaiional analysis are usually adequate. Kinetic assessment is
ften useful, however, in helping to determine the functional
;ignificance of an atypical gait pattern.
Ln

Gait Associnted wifh Femoral Neuropathy


Selected quadriceps weakness, which can occur in femoral
neuropathy in diabetes. femoral nerve entrapment, or polio-

IIrJEu5, rfl llrdll5 wgrBllr-us4rruB ]rdurrrLy uurrrrB Jtdlt

quadriceps eccentrically contract to control the rate of knee


flexion during the loading response of the limb. With weakness, the knee would tend to "buckle." The effective cornpensatory action is to position the lower extremity such that
the GRF lies anterior to e knee joint, imparting an extension moment during stance phases. This is first achieved
during initial contact by plantarflexing the ankle. Contraction of the hip extensors also can help to hold the knee in
hyperextension. As noted previously, quantitative gait analysis may be useful in evaiuating the associated knee extensor
moment, which, if excessive, could place the posterior capsule and ligamentous structures at risk f<lr injury.

Atypical Gait Patterns Associated with Weak Ankle


Dorsiflexian
Dorsiflexion weakness also has a characteristic gait pattern. Clinical conditions in which this is seen is peroneal
nerve palsy occurring as a result of entrapment at the fibular
head or more proximaiiy as an injury to a branch of the
sciatic nerve, or in an L5 radiculopathy. If the ankle dorsiflexors have a grade of 3 or 415, tbe characteristic clinical
sign is "foot slap" occurring soon after initial contact, due
to the inability of the ankle dorsiflexors to eccentrically control the rate of plantarflexion after normal heel contact. If
the ankle dorsiflexors have less than 3i5 strength, toe drag
and/or a steppage gait pattern with excessive hip flexion in
swing is iikely. The cause of these patterns can usually be
determined with a careful history, physical examination, and
standard electrodiagnostic procedures (as opposed to a dynamic EMG assessment).

Atypeal Gait Patterns Associated with Generalized

LMN Lesians
More generalized LMN lesions commonly involve variable weakness patterns and thus often have unpr-edictable
and often complex associated gait patterns. Poliomyelitis and
Guillain-Barr syndrome are examples. For these diagnoses,
kinetic asscssment can be particularly useful in determining
excessive joint moments, implying excessive soft-tissue
strain or the need for increased compensatory muscle action

in another muscle group.


Trenilelenburg Gait
Trendelenburg gait (gluteus medius gait), describes a pat-

tem of either excessive pelvic obliquity during the stance


period of the affected side (so-called uncompensated Trendelenburg gait) and/or excessive lateral truncal lean during
the slance period ofthe affected side (so-calied compensated
Trendelenburg gait). Weakness or reluctance to use the gluteus medius can cause this atypical gait pattem. The most
common cause of Trendelenburg gait is osteoarthritis of the
hip. In this case, the gait pattem (regardless of whether it is

)ompensated or uncotnpensated) occurs as a compensatoly


'esponse to reduce the overall forces across the hip during

in the external hip


rdductor moment, which ordinarily occurs in the stance pe;tance. This can be secn as a rcduction
'iod.

Itypical Gait Pqents Associated with Orthopedc


londitiotts

In

cases

of specific orthopedic conditions, the atypical

ait pattern is fairly predictable and the cause directly relates


o the structural abnormality. For instancc, the cause of ab;ent knee flexion during gait may simply be the result of a
mee fusion. Studies about the diagnostic use of quantitative
ait analysis in structural abnormalities are scant. Nevertheess, quantitative analysis rnay be useful in evaluating com-

llex orthopedic conditions involving multiple joints and in


:valuating the functional relevance of associated gait paterns. Fror instance, one study demonstrated that kinematic
rnd kinetic measurements were helpful in directing and docrmenting the effects of gait training in patients with sympomatic knee hyperextension due to posterolateral ligament
:omplex injury (55)- Other studies have reported the usefulrcss of quantitative gait assessments to identify abnormal
oint forces in patients with anterior cruciate ligament-defi:ient knees and osteoadu'itis of the knee, which may help
o identify patients with risk of fufhcr deterioration (56,57).

\CKNOWLEDGMENT
We thank Mary K. Todd and Thomas A. Ribaudo tbr their
rssistance in preparing gures fol this chapter. The work in

his chapter was supported in part by National Institutes of


{ealth Grant HDOl07l-03 from the Public Health Service
rnd by the Ellison Foundation.
R.EFERENCBS

l. Pmy

J. Gait anolsis: nornnl ond ptrhologicol function. 'fhorofare,

NJ: Slack, 1992.

2. Inmm VT. Conservaon o[ energy in ambu]atior. Arch Ph.ts


Rehobil

1961 :

3. Klopsteg

Mecl

47:484-488.

PE, Wilson PD, eds. Huntan lintbs qnd rheir srbstitutes. New.

York: Ivlccraw-Hill,

basis of relwbilitaliur metlicite- Stoneham, MA: Buterworth-Heinemann, 1994;413-446.


Saunders JBD, lnlnan VT, Elerhart HD. The major determinanrs in
normal and pathological gait. J Bone Joint Surg [Ant] 1953 35:

543-558.

7. Innlan VT,

Ralston HJ, Todd F. Hunan l-oconrotion. In: Rosc J, Garnble JG, cds. Huntan u'alking. Baltiloe : Williams & Wilkins, 1994;

3-22.

8. Kerrigan DC. Virarnon(es llE, Corcoran PJ, et al. Measued vcrsus


predicted venical displacement of the sacrum during gait as a tool to
rneasure biornechanical gait rerformance. Am

Pltts Med Rehalil

3'19.

l.

Corcoran PJ. Energy cxpenditure during arnbulation. In: Downey JA,


Darling RD. cds. P h'si o l o gica l bo s i s of re hab i l iro t i ott nedic fu e. Philadelphia: WD Saunders, 1971; 185-198.
12. Bard B- Energy expenditurc of herniplegic subjects during walking.
Arch Pht's Med Rehabl 1963;44:368-310.
I 3. Corcorm PJ, Jcbsen RH, Brengclnlann GL. Effects of plastic and metal
leg bmces on speed and energy cost of hcmiparetic ambulation. zlrc
Ph's Med Rehabil l97O:, 5l69-17.
14. Astrand PO, Rodahl K. Te.rtbook on y'ork physiolog. New York:

McGraw-Hill, 197015. Kenigan DC, Thirunarayan MA, Sheffler LR, et al. A tool to assess
biomechanical gait efficiency: a preliminary clinical srudy. Atn J Ph-s
Med Rehabil 1996; 75:3-8,
16. Murray MP, Drought AB, Kory RC. Walking partems of normal mcu.
J Bone Jottt Surg [Ant] 1964; 46:335-360.
17. Kadaba MP, Ramakishnan HK, Wootten ME. Measurement of lower
extrcrnity kinmatics during level walking. J Onhop Res 19901 8:
383,392.
18. Wells RP. The prcjection of the ground reaction force as a piedictor'
of internal joint moments. Eull Prosthet Rs 1981; l8:15,.l9I

9.

Sutherland DH, Olshen RA, Biden EN, et al. I


ualking. Philadelpbia, Mac Keith Press, 1988.

velopme nt of rrcture

20. Muffay MP, Kory RC, Clarkson BH. Walking pattems in healthy old
Aen. J Gctantol 1969;24:169-178.
21. Kerrigan DC, Derning LC, Holden MK. Knre recurvatum in gait: a
study of associated knee biomechanics- Arch Phss Med Rehabil 19961'

77:645 650.
22- Gage lR. Cait unal,sis in cerebral pals'. Philadclphia: Mac Keith
Press,1991.

23. t-ee EH, Nather A, Goh J, et al. Gait analysis in cerebal palsy. ,4nn
Acad Med Singapore.1985; l4:37 -43.
24. Deluca PA. Gait analysis n the irearmcnt of the ambulatory child wilh
cerebral palsy. CIin Orthop 1991;264:65-75.
25. Brain Edirorial Committee for the Gutrantors of Brain. Aids to the
e.xamination ofthe peripheral nen,our s).srm. Oxford, England: AldenI 986.
26. Peny J, Giovan P, IIaris LI, et al. The deteminants of muscle acrion
in the herniparetic lower extremity (and their effect on the exalnination

procedure). Clin Orthop 1978; l3l:71-89.


27. Peny J, Mulroy SJ, Renwick SE. The relaaionship of lower extrernity
strength and gait parameters ir patients with post-polio syndrome. Arclr

Phts Med Rehabil 1993;74:165-169.


28. Peny J, Hoffer MM, Artonelli D, et al. Electromyography beforc and
after surgery for hip deformity in children with cercbral palsy. A comparison of clinical and electromyographic findings. J Bone Joint Surg
JAml 1976:58:201-208.
29. I'eny J, Hoffer MM, Giovan P, er al. Gait analysis of the triceps surae
in cerebral palsy. A prcopremtive and posroperative clinical and electromyographic study. J Bone Joirt Sur6 [Am] 1974'5:5ll-520.
30. Saleh M, Murdoch G. In defence of gait analysis. Obseruation and
neasurernerrt in gait assessment- J Bone Joint Surger [Br] 1985.,67:
231

Space requirenents of the seated operator. An A|borMI: University of Michigan, 1955.


Gonzalez EG, Corcoran PJ. Erergy expendirure during ambulation. In:
Downev JA, Myers SJ, Gonzalez EG, ct al., eds. Tlte physiologicul.

1995l.74:3-8.

Rehabil 1996; 75:375


I

1954.

4. Dempster WT.
5.

Il: Expenditure on walking related to weight. sex, lreight, speed.


and gradierrt. Nutr Absr Ret 196l:31:739-762.
10. Duff-Rtffaele M, Kenigan DC, Corcoran PJ, et al. The proponional
work of lifting the center of rnass during walking. Anr J Phys Med
I'art

3I

-241.

Gage JR. Cait analysis for decision-making in cerebral palsy.

Bdl llosp

Joint Dis Orthot Inst 1983:43:147-163.


32. Gage JR. Gait analysis: an essential tml in the rreatment of cerebral
palsy. C/,? Onhop 1993; 288:126- 134.
33. Ire EH, Goh JC, Bose K. Value of gait analysis in lhe assessment of
srrrgery in cerebral palsy. Arclt Phls Med Rehabil 1992.,73:642-6a6.
34. Kenigan DC, Glenn MB. An illustraion of clinical gair laborarory use
to improve rehabilitation management. Am J Phys Meil Rehabit 1994.,
13:421-421.
35. Turnbull Gl, Wall JC. The development of a system for the clinical
asscssment of gait following a stroke. Pltl,sqtrtp 1985; 7l:
294,298.
-16. Hausdorff JM , Ladin 7,, Wei JY. Footswitch system for measuremenr
of the temporal pararnetcrs of gait. J Biomech 1995;28:347-351.
37, Chao EYS. Jusrification of tliaxial gonometer for thc measuremenr of
joint rotation. J Biotnech 1980; l3:989-100.

Crlltrnr

8: G,u'r'AN,r-vsls 187

trarsfer versus proximal lecturi rclease.

Pedian' Orthot

l99O l0l.

433-441.
t9. Kerrigan DC, Gronley J, Perry J. Stiff-legged gait in spastic paresis:
a study of qua<lriceps and harnstrings nruscle activity. Am

Ph1's

Med

Rehabil 1991, 70:294-300.


t0. Sirnon SR. Dctrtsch SD, Nuzzo RM, et al. Genr recurvalurn in spastic
cercbral palsy. Report on findings by gait analysis. J Bone Joinr Surg

il

[Ant ] 1918', 60:882-894.


Gage JR, Peny J, Hicks RR. et al. Rec(us femoris lransfer to jmprove
knee function of cbildrcn with cercbral palsy. Del Med Chiltl Nurol

198'1:, z9:159-166.
i2 Sutherlmd DH, Cooper L. The pathornechanics of progressive crouch
gat in spastic diplegia. Onhop Cln Nortlt Am 1978,9:143-154.
i3 Thometz J, Simon S. Rosenthal R. 'lhe effect on gait of lengtheling
of the medil hamstrings in cerebal palsy. J Bone Joint Surg lAml
1989;71:345-353.
t4 Johnson EW, Walter J. Zeiter lectur: pathokinesiology of Duchenne

rnuscular dystrophy: implications for management. A,'ch Plt's Med Re-

hqbil 1977:58:4-7.

L, Andriacchi T, et al. Knee hyperextension; gait


abnormalities in unstable knees. An J Sports Med 1996; 24:35-45.
Noyes FR. Schipplein OD, Andriacchi TP, et al. The anterior cruciate
ligarnent-deficient knee with varus alignment: an analysis of gait adaptations and dynamic joint loadings. Anr J Sports Med 1992t 20:

55. Noyes F, Dunworth


56_

'707

-7 t6.

K, Khoo BCC, Gait analysis study on patients with


valus osteoanhrosis of the knee. Clin Orthop 1993;294:223-231,

57. Goh JCH, Bose

scrrptlon oI thrce-drmensronal motrons: applrcatrons [o the Knee. J IJro.


,nech Eng 1983; 105:136-144.
39 Zatsiorsky VM, Seluyanov VN. The mass and inertia characteristic
of the main segments of the human body. In: Malsui H, Kobayashi K
eds. Human ilnetirs. Champaign, IL: 19831 ll52-1159Bekey GA, Chang CJP, et al. Pattern recognition of rnultiple EMC
signals applied to the description of human gait. Proc |EEE 1971 65
674-691_
Hirschberg GG, Nathanson M. Electromyographic recordings of mus
cular activity in normal and spastic gaits, Arc Phs Mad Rehabil 1941
33:217-224.
42 Peat M, Dubo HI, Winter DA, et al. Elecrornyographic temporal analy
sis of gait: herniplegic locomotion. Arch Pltl's Med Rehahil 1976',57
421

43

-425.

Knutsson E, Richards C, Different types ofdisturbed motor control ir


Sair of heniparetic parients. Brain. 19'19; 102:405-430.
Shiavi R, Bugle HJ, Limbird T. Electromyographic gait assessment
Part 2: Preliminary assessment of hemiparetic syneqy patterns. ../ R

lnbil

Res

Dev 1987:74:24-30.

45. Winrers TF Jr, Gage JR, Hicks R. Gait patterns in spastic hemiplegia ir
children and youn g ad\hs. J Bone Join.t Surg [Ant] 1987; 69:437 -441
46. Waters RL, Garland DE, Peny J, et al. Sff-legged gait iri hemiplegia
surgical conection. J Bone Jont Surg [Am] 1979:'61:927-933.
4',1. Treanor WJ. The role of physical medicine lreatment in stroke rhabili
tation. Cln Orthop 19691 63:14-22.
48. Sutherland DH, Santi M, Abel MF. Treatment of stiff-knee gait ir
L..

ioral

r^r,r.

f^;

ctNesroloeta De Lr
Dra- Marco San1, Carmen. Profesora Titular de Cinesiologa

OBJETIVOS OPERATIVOS

. Definir la marcha humana normal.


. Distinguir las fases y periodos del ciclo de marcha.
. Describir el paso y explicar sus parmetros cuantitativos.
. Conocer las transferencias de energa que se producen durante la marcha y los factores que influyen en el
gasto energtco.

As como las principales fuezas que intervienen desde el punto de vista cintico.

. Analizar las acciones musculares

articulares de las extremidades que se producen a lo largo de un ciclo

de marcha completo.

La marcha humana

es

un modo de locomocin bpeda con actividad alternada de los

miembros inferiores, que se caracteriza por una sucesin de doble apoyo y de apoyo unipodal, es
decir que durante la marcha el apoyo no deja nunca el suelo, mientras que en la carrera, como

en el salto, existen fases areas, en las que el cuerpo queda suspendido durante un instante.
Tambin se puede definir como un desequilibrio permanente hacia delante.
Desde una ptica dinmica, la marcha es una sucesin de impulsos y frenados, en los
que el motor o el impulso se sita a nivel del miembro inferior posterior y el frenado en el anterior.

Ms que el desarrollo de un reflejo innato, la marcha es una actividad aprendida.


Durante los primeros aos de su infancia el nio experimenta con su sistema neuromuscular y
esqueltico, hasta llegar a integrar esta actividad a nivel involuntario. Hasta los 7 u 8 aos no se
alcanza la marcha caracterstica que una persona muestra en la edad adulta. Aunque algunas
variables dependientes del crecimiento, como

la longitud del paso, continuan

evolucionando

hasta alcanzar los valores tpicos del adulto alrededor de los 15 aos. Pese al carcter individual

de este proceso, las semejanzas entre sujetos distintos son tales que puede hablarse de un
patrn caracterstico de marcha humana normal, patrn que vara con diferentes circunstancias
como el tipo de terreno, la velocidad, la pendiente,... y sobre todo bajo determinadas condiciones
patolgicas. Nos centraremos en este tema

en

la marcha humana normal, sobre suelo llano, en

lnea recta y a velocidad espontneamente adoptada.

Cinesiologa de la marcha humana normal. Marco Sanz, Carmen

Para su mejor descripcin conviene dividir la marcha en fases, ya que su anlisis


cinemtico comienza por la inspeccin visual de cada regin anatmica, en cada una de las fases

del ciclo de la marcha, mientras el individuo camina. Por ello, definiremos el ciclo de marcha y
sus fases.

El ciclo de marcha es
contacto de

un

la

secuencia de acontecimientos que tienen lugar desde el

taln con el suelo, hasta el siguiente contacto del mismo taln con el suelo.

Durante un ciclo de marcha completo, cada miembro inferior considerado pasa por

dos fases:

A) Fase de apoyo: en la cual el pie de referencia est en contacto con el suelo.


B) Fase de oscilacin: en la que el pie de referencia est suspendido en el aire.

La fase de apoyo constituye alrededor del 60% del ciclo


representa

el

40o/o restante.

y la fase de oscilacin

Las fases del ciclo de marcha, para facilitar su estudio suelen

dividirse, todava, en componentes ms pequeos o subfases, segn la siguiente secuencia: El


ciclo se inicia con el impacto de taln en el suelo; al 15% el antepi tambin contacta con el suelo,
por lo que esta subfase se denomina "pie plano sobre el suelo" o media; al 40% del ciclo, el taln
comienza a elevarse del suelo (subfase de despegue de taln o final), al 5oo/o, despega el antepi,
que culmina al 60% del ciclo con el despegue de los dedos, lo que indica tambin el comienzo de

la

fase de oscilacin.

La atribucin de percentiles en esta fase es algo imprecisa, pero en la

primera parte, se realiza el avance del miembro oscilante hasta alcanzar el miembro contralateral,

la extensin de rodilla completa el avance del miembro inferior. Al cumplirse el 100% del ciclo,

se produce de nuevo el impacto de taln, con el mismo pie. Autores como Perry dividen la fase

de apoyo en 4 subfases (inicial, media, final y preoscilacin) y la de oscilacin en 3 (inicial,


media y final).
El ciclo de marcha con sus porcentajes de duracin sucede exactamente igual para el

miembro contralateral, lo que revela, considerando los dos miembros inferiores, la existencia de

dos periodos de apoyo bipodal o doble apoyo,

que se caracterizan porque los dos pies

contactan con el suelo: uno esta iniciando el contacto de taln mientras que el otro, prximo a la
fase de despegue, se apoya por la cabeza del primer metatarsiano y el pulpejo del dedo gordo.
Estos periodos tienen un porcentaje de duracin de alrededor de un 10%, cada uno,

y,

tambien

hay durante un ciclo de marcha dos periodos de apoyo monopodal durante los cuales
slo un miembro inferior contacta con el suelo y sobre l recae el peso del cuerpo.

Cinesiologa de la marcha humana normal. Marco Sanz, Carmen

tan