Gait and Balance Assessment
Gait or walking is a coordinated action of the neuromuscular and musculoskeletal systems. The coordination of muscle contraction, joint movement, and sensory perception allows the human body to move in the environment. Individuals with neuromuscular and/or musculoskeletal involvement may have abnormal or inappropriate muscle activation, joint motion, or sensory perception. The result may be decreased mobility and function, and altered gait. Gait assessment is important to help identify areas of impairment. Once a reason for gait impairment is determined, a treatment plan can be developed. The goals of therapy are to minimize functional loss, restore mobility, and promote safety.
Balance is the ability to sit, stand, or walk safely without postural deviation, falling, or reaching for external items for support. Balance, like gait, is a coordinated response of the neuromuscular and musculoskeletal systems, as well as vision and sensory perception. Vestibular and cortico-cerebellar levels in the brain are also involved in maintaining stability. Balance assessment is used to evaluate the patient's ability to maintain appropriate posture during functional activities. It is usually evaluated statically and dynamically.
The goal of gait assessment is to evaluate walking in an effort to isolate dysfunction. Areas of impairment may include muscle weakness, loss of joint range, incoordination, or poor postural control.
During balance assessment, a patient's stability during activities is evaluated to identify areas of impairment, the reason for impairment, and the effect on function.
Both gait and balance evaluations are useful in identifying areas of impairment so that safe and proficient function and mobility can be restored.
During gait and balance assessment, individuals with impairment are at risk for further injury, especially from falls. Clinicians who evaluate patients with suspected gait and balance deficits must provide close supervision and ensure that the testing areas are safe.
Gait can be analyzed with a variety of techniques, involving a range of difficulty. One basic method is simply watching the patient walk and interact in the environment, noting any deviations or instability. More advanced techniques use motion analysis, force platform data, and electromyography in an effort to gain a global representation of joint motions, joint forces, and electrical activity of muscles during walking.
Balance is very complex and requires many systems to work at optimum levels. A problem or injury affecting strength, joint motion, vision, sensory perception, or vestibular apparati may lead to functional impairment. Balance needs to be evaluated both statically and dynamically, and if a deficit is present, further testing is indicated.
In a simple gait analysis, the patient is observed during standing (static testing) and walking (dynamic testing). Initially, the patient is examined in the standing position to evaluate posture as well as bone and soft tissue symmetry. The clinician evaluates the foot and ankle during standing to assess any deviation in the rear foot and forefoot. The patient is then asked to walk across the floor while the clinician evaluates the gait cycle. The clinician assesses joint range of motion, speed, and quality
of gait, and synchrony of all upper and lower extremity joints. The patient should be evaluated walking barefoot as well as while wearing normal walking shoes. The clinician should observe walking from the back, front, and side. In more complex gait assessments, videography is used to record patient movement and joint motion, and force plates and electromyography provide additional information. Unfortunately, the equipment used in complex analyses is expensive and thus cost-prohibitive to the average clinician. However, there are gait laboratories that have equipment specializing in instrumented gait analysis.
Various tests are used for balance assessment. Certain tests are specific to visual, cerebellar, muscular, or proprioceptive areas. Sensory integration tests and the Romberg test are used to try to isolate involvement of vision, sensation, and cerebellar integrity. Other tests commonly used are the Berg balance scale, the get-upand-go test, the functional reach test, and the Tinnetti balance tests. These tests provide quantitative data that allow the clinician to compare individual results with a normative group and document progress over time.
The treatment of an individual with a gait abnormality may include stretching, strengthening, joint mobilization, splinting or bracing, education, or a change in footwear. The treatment of an individual with a balance deficit may include stretching, strengthening, postural awareness exercises, various weight-shifting exercises, and increasing environmental stimuli in an effort to retrain proprioception. Treatment is individualized according to a patient's problem. For example, strengthening exercises are recommended for an identified muscle weakness.
A major concern is safety during a gait or balance assessment. If impaired balance or gait abnormalities increase the likelihood of falling, appropriate measures need to be taken, such as clear and safe pathways, adequate lighting, and good guarding techniques by staff members.
Gait or balance assessments are usually recommended for a decline in function, self-reported loss of balance, or unexplained falls. The patient may be fearful of falling, and restoring confidence often needs to be addressed. Ideally, areas of impairment are identified during the assessment so that appropriate treatments can be directed at the problem.
Health care team roles
Nursing and other allied health professionals in hospitals, outpatient clinics, diagnostic centers, skilled nursing facilities, and assisted living facilities need to be aware of their patients' gait, posture, and general mobility. When a patient is using an assistive device inappropriately, or gait and balance appear to have changed, it is the health care provider's role to address the problem to minimize the risk of falls. A request for further evaluation, such as a gait or balance assessment, may be an appropriate next step.
Berg balance scale—An assessment tool used to evaluate stability during functional activities. The patient is scored on 14 different tasks.
Cortico-cerebellar—Pertaining to the cerebellum and the cerebral cortex of the brain.
Dynamic—Movement such as walking that is due to muscles contracting.
Electromyography—An evaluation tool that detects electrical activity of muscles.
Force platform—A large plate, usually mounted in the floor, that records forces when an individual stands or walks on it.
Forefoot—The front portion of the foot from the ankle.
Functional reach test—A test that evaluates stability when reaching out beyond an individual's base of support. In this test the patient stands and tries to reach out with one hand as far as possible without losing balance. The reach is recorded in inches.
Get-up-and-go test—Evaluates balance during a functional activity. The test is scored based on the patient's ability to get up from a chair, walk forward about 10 feet (3 m), return to the chair and sit down. The test may be timed to monitor progress.
Motion analysis—Use of an instrumented system to record whole body and joint movement for later analysis.
Musculoskeletal system—Pertaining to the muscle and skeletal systems.
Neuromuscular—Pertaining to the nervous and muscle systems.
Normative—A group that is free from dysfunction compared to a group that has dysfunction. For example, in groups with and without knee osteoarthritis, the group without the osteoarthritis is the normative group.
Proprioception—The ability to sense movement and position of the body.
Rear foot—The back portion of the foot that includes the ankle and heel.
Sensory perception—The ability to perceive touch, pressure, pain, and joint position in the limbs and trunk.
Static—Without movement, i.e. standing still, with or without muscle contraction.
Tinnetti balance test—A battery of tests to assess balance and identify individuals at risk for falling.
Vestibular—Pertaining to the apparatus in the inner ear that senses orientation and movement of the body in space.
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Mark Damian Rossi, Ph.D, P.T., C.S.C.S.