pemeriksaan gait, locomotion, and balance

8/12/2019 Pemeriksaan Gait, Locomotion, And Balance

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PEMERIKSAAN GAIT,

LOCOMOTION, AND BALANCE



DEFINISI

Gait (Pola jalan) – cara seseorang berjalan

– Dikarakteristikkan oleh ritme, irama, langkah, jaraklangkah, dan kecepatan

Locomotion (pindah tempat) – Kemampuan untuk bergerak dari satu tempat ke tempat

lain

Balance (keseimbangan) – Kemampuan untuk mempertahankan tubuh dalam

keseimbangan dengan gravitasi secara statik dandinamik



TUJUAN PEMERIKSAAN

Mengetahui adanya gangguan,

keterbatasan, dan ketidakmampuan

berjalan, berpindah, dan keseimbangan

Menentukan apakah perlu menggunakan

alat bantu, ortotik, prostetik.



INDIKASI KLINIS

Penyakit, gangguan, atau kondisi pada sistem :– Kardiovaskuler, respirasi, muskuloskeletal, neuromuskular

Impairment– Sirkulasi (klaudikasio intermitten)– Integritas dan mobilitas sendi (nyeri gerak hip)

– Fungsi motor (pola gerak abnormal)– Kinerja otot (penurunan kekuatan dan ketahanan otot)– ROM (lGS tak normal saat jalan)

Keterbatasan fungsi dalam kemampuan membentuk aksi,kerja, dan aktivitas yang meliputi :– Pemelihaaan diri (ketidakmampuan berpakaian krn

ketidaknormalan keseimbangan duduk)– Pengelolaan rumah tangga (ketidakmampuan melakukan aktivitas

berkebun krn menurunnya kekuatan otot)– dsb



Indikasi ….

Disability (ketidakmampuan atauketerbatasan kmampuan untuk membentukaksi, tugas, atau aktivitas sesuai dengan

aturan dalam konteks sosial budayaindividu

Faktor resiko

– Meningkatnya resiko jatuh KEbutuhan kesehatan, wellness, dan

kebugaran



OBSERVASI GAIT

Berjalan adalah berpindahnya tubuhdari satu titik, ketitik berikutnyadengan cara menggunakan kedua tungkai

(bipedal : posisi tubuh selalu tegakselama proses berlangsung). Polarepetisi daripada penumpuan beratbadan dari satu tungkai ketungkai yang

lain dengan heel–

toe striding adalahfenomena yang membedakan manusiadengan hominids yang lebih primitif (Napier, 1967).



Walking is a series of gait cycles

– A single gait cycle is known as a STRIDE



TUJUAN

untuk mengetahui ketidaknormalan gait yang disebabkan kelemahan otot,

keterbatasan mobilitas sendi, nyeri,atau ganggan kontrol motoris akibat lesisistem saraf

Analisa : dengan camera video danvideotape



Normal Walking Requirements

There are (4) major criteria essential to walking.

– Equilibrium

the ability to assume an upright postureand maintain balance.

– Locomotion

the ability to initiate and maintain rhythmic

stepping



Walking Requirements Cont’d

– Musculoskeletal Integrity

normal bone, joint, and muscle

function– Neurological Control,

must receive and send messagestelling the body how and when tomove. (visual, vestibular, auditory,sensorimotor input)



Siklus berjalan :

Satu cycle, dimulai dari heel strike,

sampai tungkai yang sama mulai heel

strike berikutnya. Interval antara dua steps bisa dihitung

jarak dan waktunya.



A Single Gait Cycle or Stride



Gait Flow Chart



SIKLUS GAIT NORMAL

Stance phase (40%) Swing Phase (60%)

Racho Konvensinal Racho Konvensional

Initial contact Heel strike Initial swing Acceleration

Loading

response

Foot flat Mid-swing Mid-Swing

Mid-stance Mid-stance Terminal

swing

Deceleration

Terminal

stance

Heel off

Pre swing Toe off



Komponent Gait Normal :

1). Weight Acceptance.

2). Single limb Support.

3). Limb Advancement.



Stance.

Initial Contact.

Loading Response (LR).

Mid Stance (MSt).

Terminal Stance (TSt).



Swing

Pre-swing (PSw).

Initial Swing (Isw)

Midswing (MSw)

Terminal Swing (TSw)



Stride length :

Adalah jarak antara dua jejak kaki, pada

kaki yang sama.

Pada orang dewasa pria jaraknyaantara 140 – 156,5 cm.



Stride duration :

Adalah waktu yang dibutuhkan untuk

jarak tersebut ( stride length ).



Step length :

Adalah jarak antara dua jejak

kaki , baik dari kanan kekiri atau

sebaliknya. Jarak rata2nya adalah 68 –

78cm.



Step duration :

Adalah waktu yang dibutuhkan

dari heel strike kaki yang satu ke

heel strike kaki yang lain.



Cadence :

Adalah jumlah steps permenit.

Dimana nilai rata2nya adalah 112

– 116 permenit.



Stance Phase of Gait

When the foot is

contact with the groundonly

Propulsion phase

Stance phase has 5parts:– Initial Contact (Heel

Strike) (1)

– Loading Response (FootFlat) (2)

– Midstance (2)

– Terminal Stance (3)

– Toe Off (Pre-Swing) (4)

(Missing Loading Response inpicture)



Motions during Stance Phase

Shoulder flexes

Pelvis rotates right (transverse plane)

Spine rotates left Hip extends, IRs

Knee flexes, extends

Ankle plantarflexes, dorsiflexes, plantarflexes

Foot pronates, supinates

Toes flex, extend, flex

I i i l C



Initial Contact

Phase 1 The moment when the

red foot just touches the

floor.

The heel (calcaneous) is

the first bone of the foot

to touch the ground.

Meanwhile, the blue legis at the end of terminal

stance.



Static Positions at Initial Contact

FREEZE FRAME POSITIONS Shoulder is extended

Pelvis is rotated left

Hip is flexed and externally rotated Knee is fully extended

Ankle is dorsiflexed

Foot is supinated Toes are slightly extended



Loading Response

Phase 2

The double stance periodbeginning

Body weight is transfered

onto the red leg. Phase 2 is important for

shock absorption, weight-

bearing, and forwardprogression.

The blue leg is in the pre-swing phase.



Static Positions at Loading

Response Shoulder is slightly extended


hip is flexed and slightly externally rotated

knee is slightly flexed

ankle is plantarflexing to neutral foot is neutral

Toes are neutral



Midstance

Phase 3

single limb support interval.

Begins with the lifting of

the blue foot and continuesuntil body weight is alignedover the red (supporting)foot.

The red leg advances overthe red foot The blue leg isin its mid-swing phase.



Static Positions at Midstance

Shoulder is in neutral

Pelvis is in neutral rotation

Hip is in neutral

Knee is fully extended

Ankle is relatively neutral

Foot is pronated Toes are neutral



Terminal Stance

Phase 4

Begins when the red heel rises and continues

until the heel of theblue foot hits theground.

Body weight progressesbeyond the red foot



Static Positions at Terminal Stance

Shoulder is slightly flexed


Hip is extended and internally rotated


Ankle is dorsiflexed

Foot is slightly supinated Toes are neutral



Toe-Off

Phase 5 The second double stance

interval in the gait cycle.

Begins with the initialcontact of the blue footand ends with red toe-off.

Transfer of body weight

from ipsilateral toopposite limb takes place.



Static Positions at Toe-Off

Shoulder is flexed

Pelvis is rotated right Hip is fully extended and internally rotated


Ankle is plantarflexed

Foot is fully supinated

Toes are fully extended



Stance Phase Characteristics

During a single stride, there are 2 periods ofdouble limb support (both feet on ground):

– Loading response (right) & Toe Off (left)

– Loading response (left) & Toe Off (right)

Gait Progression



Gait Progression



Swing Phase

When foot is NOT contacting the ground,it is swinging!

Limb advancement phase

3 parts of swing phase:

Initial swing

Midswing Terminal swing



Motions during Swing Phase

Shoulder extends

Spine rotates right

Pelvis rotates left (passive)

Hip flexes, ERs

Knee flexes, then extends

Ankle dorsiflexes Foot supination (inversion)

Toes extend



Initial Swing

Phase 6 Begins when the red foot is

lifted from the floor and

ends when the red swingingfoot is opposite the bluestance foot.

It is during this phase that a

footdrop gait is mostapparent.

The blue leg is in mid-stance.

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Static Positions at Initial Swing

Shoulder is flexed

Spine is rotated left

Pelvis is rotated right

hip is slightly extended and internally rotated

Knee is slightly flexed

Ankle is fully plantarflexed Foot is supinated

Toes are slightly flexed



Midswing

Phase 7 Starts at the end of the

initial swing and continues

until the red swinging limbis in front of the body

Advancement of the redleg

The blue leg is in late mid-stance.



Static Positions at Midswing

Shoulder is neutral

Spine is neutral

Pelvis is neutral Hip is neutral

Knee is flexed 60-90°

Ankle is plantarflexed to neutral Foot is neutral

Toes are slightly extended



Terminal Swing

Phase 8

Begins at the end ofmidswing and ends whenthe foot touches thefloor.

Limb advancement iscompleted at the end ofthis phase.



Static Positions at Terminal Swing

Shoulder is extended

Spine is rotated right


Hip is flexed and externally rotated


Ankle is fully dorsiflexed Foot is neutral

Toes are slightly extended



Gait Pathologies

Deviations from “normal” gait pattern Result from– Pain– Injury (ROM restrictions)

– Surgery (ROM restrictions)– Weakness– Balance deficits

Consider all “normal” components of stance

and swing phase of a gait cycle or stride Compare right and left sides when observing a

person’s gait pattern



Antalgic Gait

Painful leg gait

Decreased stance time on painful leg

Increased swing time on painful leg Decreased swing time on non-painful leg

Increased stance time on non-painful leg



Trendelenburg Gait

Gluteus medius weakness gait

Lateral trunk lean towards side of

weakness Maintain body’s COG over weak side duringstance phase



Flexed Knee Gait

Flexed knees Flexed trunk posture No arm swing

No initial contact No Toe-off No hip extension

Short step Shortened stride COG stays within BOS Common in elderly with fear of falling



Flexed Gait Posture



Common Gait Posture in Elderly People



BALANCE

Balance : komponen dasar aktivitas

Ditentukan oleh tonus postural :

– mobilitas– stabilitas

Kualitas balance tergantung intregitas :

– SSP dan SST– muskuloskeletal



Instrumen Pengukur Balance

1 . Sitting Balance Test

– Menilai kemampuan balance posisi duduk

– Prosedur :– Pasien duduk di tepi bed

– kaki disangga

– kedua tangan dalam pangkuan– Dorongan : ke belakang, depan dan

samping.



Penilaian :

4 = dapat bertahan tanpa bantuan3 = dapat bertahan dengan bantuan

2 = dapat bertahan statis (tanpa

dorongan), perlu bantuan1 = tidak dapat mempertahankan

Nilai normatif = 4

Kelebihan dan kelemahan : sederhana,besarnya dorongan tak dapatdistandardisasi.



2. Step Test

Waktu stepping satu tungkai 15 detik Prosedur : Pasien berdiri tanpa alas kaki

5 cm dari blok yang tingginya 7,5 cm.

Pasien melakukan stepping 1 tungkai 15detik kemudian tungkai satunya.

Reliabilitas : Retest ICC > 0,90 (usialanjut) dan > 0,88 (pasien stroke)



•

Nilai normatif :Usia 73 th ; step = 17 ; waktu 15 detik

Kelebihan dan kelemahan :

– cepat, sederhana– sensitif

– sulit dilakukan bila gangguan balanceberat



3. Functional Reach Test (FR)

Mengukur jarak jangkauan Prosedur : Pasien berdiri di samping tembok

Menjangkau jarak maksimal

Titik ukur : caput metacarpal jari tengah Nilai normatif :

20 - 24 th : L = 42 cm ; P = 37 cm

41 - 64 th : L = 38 cm ; P = 35 cm 70 - 87 th : L = 33 cm ; P = 27 cm



Functional Reach Test

Distance reached (inches)

Score (check one) Risk for falling

10 inches6-10 inches

1-6 inches

Unwilling to reach

Unlikely to fall2 times more likely to fall

4 times more likely to fall

28 times more likely tofallModified from Duncan PW and other functional reach ; a new clinical measure of balance, J Gerontol

45(6):M192-197,1990



4 BERG BALANCE



4. BERG BALANCE

Terdiri atas 14 kriteria, dimana masing-masing point mempunyai skor 0 – 4 (Jumlah total : 56)

– Aspek yang dinilai : Sitting to standing ___________

Standing unsupported ___________

Sitting unsupported ___________

standing to sitting ___________

Transfers ___________

Standing with eyes closed ___________ Standing with feet together ___________

Reaching forward with outstretched arm ___________

Retrieving object from floor ___________

Turning to look behind ___________

Turning 360 degrees ___________

Placing alternate foot on stool ___________

Standing with one foot in front ___________

Standing on one foot ___________

Total Score max 56



• Nilai normatif = 56Interrater ICC = 0, 98

Validitas :

– Concurrent dengan instrumen lain.



5. Timed up and Go Test

Mengukur kecepatan berjalan dari duduk pp

Prosedur :

– Pasien duduk bersandar di kursi (45 cm)– Berjalan 3 m, balik, duduk lagi

– Kecepatan : maksimal, tetapi enak.

– Hitung waktunya.

• Reliabilitas :



Interrater ICC = 0, 99

Retest ICC = 0, 99

Validitas :

– Concurrent dengan instrumen lain

( Berg, BI ) Kelemahan :

– kurang sensitif

Nilai normatif :

– Usia 75 th = 85 detik



TIMED UP AND GO TEST(berapa waktu yang dicapai dari duduk berdiri jalan 3

meter kemudian berputar kembali duduk kekursi semula)

TIMED UP AND GO TEST



TIMED UP AND GO TEST(berapa waktu yang dicapai dari duduk berdiri jalan 3 meter kemudian

berputar kembali duduk kekursi semula)

PEME-RIKSAAN

Tgl: Tgl: Tgl: Tgl: Tgl: Tgl: Tgl:

Waktu

Ket

M difi d G t U d G T t



Modified Get-Up and Go Test

Task Score

1 = normal

2 = slightly abnormal

3 = mildly abnormal

4 = moderately abnormal

5 = severely abnormal

1. Rising from Chair

2. Walking 10 feet

3. Turning around4. Sitting down in chair

Summed score

TOTAL SCORE (summed score divided by four)



6. Pastor’s Test (Marsden’s Test)

Mengukur kemampuan mempertahankanbalance terhadap gangguan eksternal

Prosedur : Pasien berdiri, mata terbuka– Berikan dorongan mendadak ke belakang

Penilaian :0 = tetap tegak, tanpa melangkah

1 = tegak kembali ; satu langkah ke belakang(tanpa bantuan)

Penilaian :



Penilaian :

0 = tetap tegak, tanpa melangkah

1 = tegak kembali ; satu langkah ke belakang (tanpabantuan)

2 = tegak kembali ; 2 langkah / lebih ke belakang(tanpa bantuan)

3 = tegak kembali ; beberapa langkah ke belakangdengan bantuan

4 = jatuh ke belakang tanpa mencoba melangkah

Reliabilitas : Retest tinggiValiditas : Kemampuan diskriminasi

Kelemahan : Dorongan tidak dapat distandardisasi

Nilai normatif : 0 - 1.



7. Falls diary

Mencatat :

– kejadian jatuh

– lingkungan kejadian jatuh– konsekuensi jatuh

Prosedur :

– Pasien mengisi kalender :v= tidak jatuh

x= jatuh

l h l



Bila jatuh, mengisi lembar uraian:

Tempat jatuh Sedang apa ?

Bangun sendiri ?

Perlu bantuan medis ?

Arah jatuh

Pingsan ?

Terpeleset ?

Perubahan aktivitas ?

8. Tinnetti balance and gait test

pemeriksaan gait, locomotion, and balance

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