Contents
Acknowledgments
About the Authors
Contributing Authors
Introduction
Section I Fundamentals
Chapter 1 Gait Cycle
Chapter 2 Phases of Gait
Chapter 3 Basic Functions
Section II Normal Gait
Chapter 4 Ankle-Foot Complex
Chapter 5 Knee
Chapter 6 Hip
Chapter 7 Head, Trunk, and Pelvis
Chapter 8 Arm
Chapter 9 Total Limb Function and Bilateral Synergistic Relationships
Section III Pathological Gait
Chapter 10 Pathological Mechanisms
Chapter 11 Ankle and Foot Gait Deviations
Chapter 12 Knee Gait Deviations
Chapter 13 Hip Gait Deviations
Chapter 14 Trunk and Pelvis Gait Deviations
Section IV Clinical Considerations
Chapter 15 Examples of Pathologic Gait
Chapter 16 Pediatric Gait Analysis
Henry G. Chambers, MD
Section V Advanced Locomotor Function
Chapter 17 Stair Negotiation
Chapter 18 Running
Marilyn M. Pink, PhD, PT
Section VI Quantified Gait Analysis
Chapter 19 Gait Analysis Systems
Chapter 20 Motion Analysis
Chapter 21 Muscle Control and Dynamic Electromyography
Chapter 22 Kinetics of Gait: Ground Reaction Forces, Vectors, Moments, Power, and Pressure
Chapter 23 Stride Analysis
Chapter 24 Energy Expenditure
Robert Waters, MD
Abbreviations and Acronyms
Glossary
Appendix A Normative Joint Motion
Index
Jacquelin Perry, MD’s interest in gait began in college
(UCLA). A major in physical education (1935-1940) introduced her to
anatomy and provided a strong background in kinesiology with
application to sports. Part of this experience was her attendance
at the Physical Therapy Clinic of the Los Angeles Children’s
Hospital where she began her exposure to disability. Subsequently,
she became a physical therapist (Walter Reed Army Hospital, 1941),
which expanded her knowledge of anatomy, kinesiology, and
disability. Her physical therapy experience in Army hospitals
during World War II provided a broad clinical experience
(1941-1945). In addition to working with a regular flow of trauma
patients, she spent 2 years at a center that had Army programs for
poliomyelitis and rheumatoid arthritis. All 3 clinical areas
involved a great deal of informal observational gait analysis as
one sought to improve the patient’s ability to walk. During most of
this time, she was also an instructor at two of the Army schools of
physical therapy (Hot Springs, AR and Denver, CO). There she taught
anatomy, kinesiology, and therapeutic exercise as well as the
modalities. Both normal and disabled gait were strong elements of
this program. After the war ended, she used her GI bill to go to
medical school (UC San Francisco, 1946-1950) for the specific
purpose of becoming an orthopaedic surgeon. Dr. Perry’s residency
in orthopaedic surgery (UCSF, 1951-1955) occurred during the period
when poliomyelitis and reconstructive surgery were strong clinical
programs. Observational gait analysis and experience in correcting
disabled gait became daily practice.
Her next move was to join the staff of the Rancho Los Amigos
National Rehabilitation Center. In 1955, poliomyelitis was the
entire focus of the rehabilitation program. Disability of lower
limbs, spine, and arms were all major concerns while bracing and
reconstructive surgery received equal emphasis. Working with this
program further expanded her knowledge of muscle function and gait
disability. In addition, her experience in observing polio
survivors exposed her to a number of different gait patterns as the
type of paralysis resulting from this disease varies from patient
to patient. Following introduction of the Salk vaccine, polio was
conquered so Dr. Perry and her colleagues redirected their
attention to other types of chronic impairments. This change was
the beginning of their intensive rehabilitation program for spinal
cord injury, hemiplegia, arthritis, and children’s disorders
(primarily muscular dystrophy, myelodysplasia and cerebral palsy).
Later, amputee and problem back services were added. At first, the
program was for general rehabilitation. Then as the patient groups
became large, they formed separate clinical categories with a ward
for each (1961). While continuing the polio spine surgery program,
Dr. Perry also developed a stroke unit. Responsibility for persons
disabled by a stroke forced her to expand her analysis process, as
the functional pathology of individuals with hemiplegia is much
more complex than that of polio. Because the standard clinical
examination findings correlated poorly with the gait dysfunctions,
a system of observational gait analysis was initiated. Developed in
conjunction with a group of knowledgeable and dedicated physical
therapists, the Rancho Los Amigos Observational Gait Analysis
System became highly organized. For the first time, there was a
means of cataloging the multiple dysfunctions that occur with the
various types of pathology. For the past 25 plus years, they have
taught this program nationwide. The organizational background of
this book is based on this program.
A second development was the gait laboratory (1968). Its initial
purpose was to document the improvement from reconstructive surgery
in patients who could not be returned to normal function based on
traditional rehabilitation therapy. This system was designed to
help ascertain whether surgery actually was the better alternative
for these patients. Out of this beginning was developed a
functional diagnostic system to be used for planning the
reconstructive surgery of patients with spasticity. The emphasis of
the program was, and still is, kinesiological electromyography
because the primary disability of patients with spasticity is
inappropriate muscle action (errors in timing and intensity).
Footswitches were developed to define the patient’s stride
characteristics, and an electrogoniometer to record joint motion
during gait also was developed. Clinical service and research have
had equal emphasis from the beginning. Another novel emphasis has
been on energy cost analysis of walking. An outdoor court was
designed where habitual gait could be studied (Dr. Robert Waters
spearheaded this). Today, the Pathokinesiology Laboratory at Rancho
Los Amigos National Rehabilitation Center is fully equipped with
automated motion analysis (CODA™), force plates and walking aids
instrumented with force transducers. All types of disability have
been studied over the years and continue to be seen as the clinical
need increases (cerebral palsy, hemiplegia, spinal cord injury,
post polio, arthritis, joint replacement, amputees, myelodysplasia,
and muscular dystrophy).
During her career, Dr. Perry has received numerous awards for her
pioneering work in many areas of gait and orthopaedics. She
received the Kappa Delta Award (Orthopedic Research Society, 1976)
for landmark work with dynamic electromyography to define muscle
function in cerebral palsy and the Isabelle and Leonard H. Goldson
Award in Technology (United Cerebral Palsy Research and Education
Foundation, 1981). She was a Shands Lecturer (American Orthopaedic
Association, 1988) and received the Shands Award (Orthopaedic
Research Society, 1999). Dr. Perry received Lifetime Achievement
Awards from the Gait and Clinical Movement Analysis Society (2000)
and The Scoliosis Research Society (2008). In December of 2008, the
University of Southern California dedicated the Jacquelin Perry
Musculoskeletal Biomechanics Laboratory in her honor. Dr. Perry
continues her lifelong dedication to the research and clinical
application of gait. This publication encompasses the extensive
work of Dr. Perry and her successful years as a therapist and a
surgeon renowned for her expertise in human gait.
Judith M. Burnfield, PhD, PT is a most welcome co-author.
She has excellent analytical skills and has an outstanding command
of words. In addition, her scientific preparation and professional
experience give her a unique perspective of impaired gait. Dr.
Burnfield’s interest in gait began during a clinical internship in
1986 on the Arthritis Service at Rancho Los Amigos National
Rehabilitation Center (Rancho). The analytic process encouraged
during weekly gait sessions (many led by Dr. Perry) tapped into her
investigative nature. Following graduation from the Physical
Therapy Program at the State University of New York at Buffalo
(1986), Dr. Burnfield accepted a position at Rancho Los Amigos
National Rehabilitation Center. Her initial work on the
Ortho-Diabetes Service further sparked her passion for
understanding gait. Differentiating the influence of human
impairments from prosthetic alignment factors was essential for
improving patient’s walking ability and helped her develop a
greater appreciation for the role alignment, forces, and moments
have on walking performance. During this period, Dr. Burnfield
started teaching a course on prosthetics and orthotics in the
Physical Therapist Assistant Program at Cerritos College (Norwalk,
CA). Gait was a central component of the course.
Subsequent work on the Stroke Service, Gerontology Service, and in
the Polio Clinic at Rancho expanded her knowledge related to the
profound impact of weakness on movement disorders. It also
highlighted the body’s exquisite versatility to compensate when
sensation and control mechanisms remained intact (eg, with polio).
Dr. Burnfield developed a strong appreciation for the role of lower
extremity orthoses in promoting independence, particularly when the
device’s capabilities were systematically matched to each patient’s
unique impairments. During this period, Dr. Burnfield engaged in
formal training to become a Rancho Gait Instructor. She then led
gait sessions at Rancho and started teaching workshops around the
country for therapists and physicians.
In 1996, Dr. Burnfield left her position as Director of Physical
Therapy at Rancho to commence graduate studies in Biokinesiology at
the University of Southern California (USC). Her doctoral research,
under the advisement of Dr. Christopher Powers, focused on human
and environmental factors contributing to slips and falls during
walking. She co-developed and taught the introductory and then
advanced observational gait analysis courses for students enrolled
in the clinical doctorate of physical therapy program at USC. At
the time of her enrollment in USC’s Biokinesiology program, she
also pursued a position as a research physical therapist working in
the Pathokinesiology Laboratory at Rancho due to her desire to
enhance her clinical research skills related to normal and
pathologic gait. Her work in the latter environment focused on
clinical and research studies quantifying gait abnormalities
through the analysis of kinematic (motion), kinetic (moment) and
electromyographic (muscle activity) data. The unique research and
teaching experiences in the two environments complimented each
other well and provided a framework for her role instructing
Biomechanics and subsequently Kinesiology in the Physical Therapy
Program at Mount St. Mary’s College in Los Angeles.
Following completion of her doctoral studies, Dr. Burnfield engaged
in a postdoctoral fellowship with Dr. Jacquelin Perry. This
mentorship had a profound influence on Dr. Burnfield’s professional
development for which she is most grateful. This focused period of
inquiry provided a strong foundation for their subsequent
collaboration on the second edition of this book. In October 2004,
Dr. Burnfield joined Madonna Rehabilitation Hospital in Lincoln,
Nebraska. She serves as Director of the Institute for
Rehabilitation Science and Engineering, Director of the Movement
and Neurosciences Center and the Clifton Chair in Physical Therapy
and Movement Sciences. Dr. Burnfield has developed a dynamic
research laboratory that capitalizes on the close proximity of
patients and clinicians, a strong network of research collaborators
internally as well as from universities and industry, and a diverse
group of undergraduate and graduate students willing and eager to
learn and contribute. Research efforts focus on developing and
studying new treatments and technologies to help individuals with
physical disabilities walk, exercise, and live more independently.
The fully instrumented Chapin Gait and Motion Laboratory within the
Movement and Neurosciences Center includes state-of-the art
technology and software for conducting biomechanical and
physiological analyses of movement function including a
twelve-camera infrared motion analysis system, 16-channel and
10-channel portable electromyography technology, four force
platforms, a footswitch system and plantar pressure mapping
technology, and a 30-meter walkway with an overhead safety support
track and full-body harness system. Dr. Burnfield holds adjunct
faculty appointments at Creighton University, University of
Nebraska– Lincoln, University of Nebraska Medical Center, and the
University of Southern California. In addition to a vigorous
research agenda, Dr. Burnfield continues to teach gait in the
academic setting and presents both nationally and internationally
on gait and rehabilitation related topics.
This textbook will remain a staple in the educational setting for
both student and teacher. If an O&P student needs one book on
gait, this is that book. For practitioners, the textbook is a ready
reference that can augment existing knowledge and inform clinical
practice.- Bryan Malas, MHPE, CO;
""The greatest strength of the new edition lies in its logical,
reorganized content presentation, which seamlessly interweaves the
old and new into a single comprehensive text the practitioner will
find valuable in both its breadth and currency. As with the first
edition, this textbook will remain a staple in the educational
setting for both student and teacher alike. If an O&P student
needed one book on gait, this would be that book. For
practitioners, the textbook is a ready reference that can augment
existing knowledge and inform clinical practice.""- Bryan Malas,
MHPE, CO, American Academy of Orthotists & Prosthetists;
""...in summary, this second edition includes several excellent
additions to a classic textbook which should be on the book shelf
of ever postgraduate student studying human gait, and every
physiotherapist with a specific interest in gait analysis.""-
Marietta van der Linden, Physiotherapy;
""This is a first-class publication on a very important subject not
discussed as commonly as other issues in orthopedics. The authors
are well-known experts and the book is the result of vast clinical
and research experience. This is the best book available on gait
analysis.""- Riad Barmada, MD, University of Illinois at Chicago
College of Medicine, Doody Enterprises, Inc.;
""Gait Analysis: Normal and Pathological Function is a
comprehensive text for basic gait analysis, systematically covering
the fundamental components of normal and pathological gait. The
clinical focus of this text makes it a useful resource for
clinicians and students of all levels.""- Dr. Vivienne
Chuter,University of Newcastle, New South Wales, Australia,
Physical Therapy Reviews;
""Their excellent and subtle changes have enhanced the book’s
value, both as a primer and as an encyclopedic reference on gait.
The authors allude to what the observer ""sees."" New methods of
gait analysis have more accurately characterized various parts of
the gait cycle. Chapter 9 is really a summary chapter of the first
part of the book, which covers normal gait. Valuably, it sums up
the parts and puts them together. This chapter integrates the total
limb function at each phase of gait, elevating observation to a
more sophisticated understanding. The use of clinical photographs
continues and helps readers relate the illustrated point to a
patient or series of patients being treated- an especially valuable
feature. The chapters on kinetics, running, and stride are updated
and valuable. The chapter on dynamic EMGs has been expanded to
discuss the relation of muscle control to the various aspects of
gait, both normal and abnormal—an essential concept. Reading the
first part of Gait Analysis: Normal and Pathological Function will
add dimension to observing gait and will be ideal for providing
readers having an advanced interest with a more complete and clear
technical understanding. In either instance, reading this text and
comprehending the data make this text clinically pragmatic and
worthwhile.""- Alfred D. Grant, MD, NYU Hospital for Joint
Diseases, New York, NY, JAMA
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