Mrs. Smith shuffled out of my clinic, bending over her walker and clutching her daughter to remain upright. Another patient turned to me and said, “She looks so frail. Can you really do anything for her?” Of course we can! It may seem daunting, but there is a lot we can do for patients like Mrs. Smith. By choosing the right types of gait and balance assessments, we can establish realistic and functional goals with our patients in order to improve their safety and independence.
History
Obtaining a thorough history is crucial for guiding later assessments. Asking good questions early on can help the clinician focus the assessment later. For example, questions like: 1) Do you have dizziness or difficulty walking in crowds? (possibly indicating a vestibular disturbance) or 2) Do you have a history of diabetes? (possibly indicating a sensory disturbance) provide critical information that will influence the rest of the evaluation.
Gait analysis
Doing a gait analysis early in the assessment process can help the clinician choose the most relevant tests and measures later in the assessment. It is often possible to do a quick gait analysis immediately upon meeting the patient when he or she walks into the clinic from the waiting room. For example, when evaluating a patient with a shortened step and lack of functional hip extension during gait, the clinician knows to test hip flexor length, gluteal strength, and ability to perform single leg stance.
ROM
An examination of active and passive range of motion can narrow down why certain gait deviations occur. Evaluation of the foot, including ankle triplanar motion and toe extension are important, as foot mechanics can be easily overlooked but are crucial to proper gait mechanics.
MMT
Of course no physical therapy examination would be complete without analyzing lower extremity muscle strength. In addition to lower extremity musculature, the transversus abdominus (TA) muscle is also important in controlling trunk and pelvic motion during gait, so screening TA strength can provide valuable information about why abnormal movement patterns happen in these areas.
Sensory systems
Light touch and proprioception examinations are useful for patients presenting with abnormal gait, especially if they have a history of neuropathy or sensory disturbances caused by a neurological disorder. The modified CTSIB (mCTSIB) tests the 3 sensory systems that supply balance information (vision, proprioception, and vestibular) and helps identify any system that is over- or under-weighted.
Outcomes measures
Outcomes measures, like the Tinetti POMA, the Functional Gait Analysis, and the TUG add a quantitative aspect to the assessment. The Tinetti POMA identifies impairments even if the patient can only walk a short distance. The Functional Gait Analysis is an effective test of dynamic responses during gait for higher level patients. Slow gait speed is correlated with falls, so the TUG is a quick and easy measure to perform.
Functional motion testing
ROM, MMT, and the CTSIB are all useful for gathering isolated data about a patient’s impairments, but the only way to truly understand how all of these impairments fit together into a complete functional movement is by analyzing the entire movement.
Single leg stance and squats are useful functional movements that are helpful in evaluating ankle, knee, and hip stability and motion. These movements also allow us to assess trunk control and balance in a closed-chain activity, similar to the stance phase of gait.
Gait and balance assessments are the key to safety
Gait and balance assessments can be overwhelming, and it can be especially hard for a new graduate to identify which aspects of gait to evaluate when working with a patient who “seems to need so much help.” A thorough history and examination reveal the most relevant impairments and how these impairments impact the patient’s movement. Through careful analysis and thoughtful intervention, it is possible to help every patient become safer and more independent with gait and balance.
References
Franklin S, Grey MJ, Heneghan N, Bowen L, Li FX. Barefoot vs common footwear: A systematic review of the kinematic, kinetic and muscle activity differences during walking. Gait Posture. 2015;42(3):230-9.
Verheyden G, Vereeck L, Truijen S, et al. : Trunk performance after stroke and the relationship with balance, gait and functional ability. Clin Rehabil, 2006, 20: 451–458.
