lev-os Managing Gait Analysis
Structures observational and instrumented gait analysis including temporal-spatial parameters, kinematic deviation identification by gait phase, and assistive device assessment. Links gait deviations to underlying impairments and intervention planning using Rancho Los Amigos observational gait analysis methodology.
Why This Skill Exists
Gait is the primary indicator of functional mobility and the most visible measure of rehabilitation outcome. Gait analysis determines assistive device prescription, orthotic needs, surgical candidacy (e.g., selective dorsal rhizotomy, tendon lengthening), fall risk, and community ambulation potential. Payers require objective gait documentation for medical necessity of locomotion training (CPT 97116). Legal proceedings rely on gait analysis to establish permanent impairment and lost earning capacity. Poorly documented gait assessments that use vague descriptors ("antalgic gait") without specifying the phase, deviation, and underlying cause fail to support clinical decisions. This skill produces systematic, phase-by-phase gait documentation.
Checkpoint A — Intake Verification
Before beginning gait analysis, confirm:
Required clinical questions:
- What is the primary diagnosis affecting gait (neurological, orthopedic, cardiopulmonary)?
- What is the patient's current assistive device and is it properly fitted?
- Are there weight-bearing restrictions or precautions?
- What was the patient's pre-morbid gait pattern and community ambulation status?
- Is the patient safe for unsupported walking during observation?
- Is instrumented gait analysis (motion capture, pressure mapping) indicated or is observational sufficient?
Required documents:
- Physician referral with diagnosis and precautions
- Lower extremity strength testing (MMT or dynamometry)
- Lower extremity ROM measurements
- Sensory examination results (proprioception, light touch LE)
- Balance assessment scores (Berg, TUG)
- Current orthotic/prosthetic prescriptions if applicable
Step 1 — Assess Temporal-Spatial Parameters
Measure and document the fundamental gait metrics:
- Cadence: Steps per minute (normal adult: 100-120 steps/min)
- Gait speed: Meters per second (normal: 1.2-1.4 m/s; community ambulation threshold: 0.8 m/s; household ambulation: <0.4 m/s)
- Step length: Distance from heel strike of one foot to heel strike of opposite foot (normal: 65-75 cm; compare symmetry)
- Stride length: Distance from heel strike to next heel strike of same foot (normal: 130-150 cm)
- Step width (base of support): Lateral distance between feet (normal: 5-10 cm)
- Single limb support time: Percentage of gait cycle on one leg (normal: ~40% each side; asymmetry >5% is significant)
- Double limb support time: Percentage of cycle with both feet on ground (normal: ~20%; increases with instability and slower speed)
Measurement methods:
- Stopwatch and measured walkway (10-meter walk test for speed, timed over middle 6m)
- GAITRite or Zeno pressure mat for instrumented temporal-spatial data
- Video recording at 30+ fps from sagittal and frontal planes
Step 2 — Perform Phase-by-Phase Observational Analysis
Use the Rancho Los Amigos observational gait analysis system. Analyze each phase from pelvis through foot:
Stance phase (60% of gait cycle):
| Phase | Normal Event | Common Deviations | Possible Causes |
|---|---|---|---|
| Initial contact | Heel strike with ankle at neutral | Foot flat or forefoot contact | Dorsiflexor weakness, spasticity, neuropathy |
| Loading response | Controlled knee flexion to 15 degrees | Excessive knee flexion or hyperextension | Quad weakness (flexion), quad spasticity or plantar flexor weakness (hyperextension) |
| Midstance | Single limb support, trunk over stance limb | Trendelenburg (pelvis drops contralateral) | Hip abductor weakness (glut med <3+/5) |
| Terminal stance | Heel rise, hip extends past neutral | Inadequate hip extension, early heel-off | Hip flexion contracture, plantar flexor weakness |
| Pre-swing | Knee flexion begins, push-off | Absent push-off, inadequate knee flexion | Plantar flexor weakness, knee joint restriction |
Swing phase (40% of gait cycle):
| Phase | Normal Event | Common Deviations | Possible Causes |
|---|---|---|---|
| Initial swing | Hip flexion, knee flexion to 60 degrees | Circumduction, hip hiking, vaulting | Foot drop (dorsiflexor weakness), stiff knee |
| Mid-swing | Limb advances, tibia vertical | Foot clearance failure, toe drag | Foot drop, inadequate knee flexion |
| Terminal swing | Knee extends, ankle dorsiflexes for heel strike | Knee hyperextension snap, foot slap | Quad spasticity, dorsiflexor weakness |
Step 3 — Assess Assistive Device Use and Fit
Document current device and appropriateness:
Device hierarchy (most to least support):
- Parallel bars (clinic setting only)
- Standard walker / platform walker
- Rolling walker (two-wheel or four-wheel)
- Axillary crutches
- Lofstrand (forearm) crutches
- Quad cane (small base or large base)
- Single-point cane (standard or offset)
- No device
Fit verification:
- Walker/cane height: top of device at greater trochanter or wrist crease with arms at sides; elbow flexion 20-30 degrees
- Crutch fit: axillary pad 2-3 finger widths below axilla
- Weight-bearing compliance: verify device use matches ordered WB status (NWB, TTWB, PWB, WBAT, FWB)
- Gait pattern with device: document 2-point, 3-point, 4-point, or swing-through pattern
Step 4 — Quantify Functional Ambulation Level
Use standardized ambulation scales:
Functional Ambulation Categories (FAC):
- 0 = Non-functional ambulator (cannot ambulate or requires 2+ persons)
- 1 = Dependent on physical support of one person (continuous)
- 2 = Dependent on continuous or intermittent support of one person for balance/coordination
- 3 = Supervision required (verbal cueing, standby assist)
- 4 = Independent on level surfaces only
- 5 = Independent on all surfaces including stairs and uneven terrain
Timed walking tests:
- 10-Meter Walk Test (10MWT): comfortable and fast speed; record time and calculate m/s
- 6-Minute Walk Test (6MWT): total distance, rest breaks, Borg RPE, HR/SpO2 response
- Timed Up and Go (TUG): stand, walk 3m, turn, return, sit; record seconds
Community ambulation criteria:
- Speed ≥0.8 m/s for crosswalk timing
- Distance ≥300m for basic community tasks
- Ability to negotiate curbs, ramps, uneven surfaces, and crowds
Step 5 — Link Deviations to Impairments and Intervention Plan
For each identified gait deviation, document the chain:
Example format: "Deviation: Right Trendelenburg sign during left swing phase. Underlying impairment: Right hip abductor strength 3-/5 (MMT). Functional impact: Limits ambulation distance to 150 ft due to compensatory trunk sway and fatigue. Intervention: Hip abductor strengthening (sidelying, standing, resistance band) progressing from gravity-eliminated to full resistance; lateral step-ups; gait training with verbal cueing for pelvic control."
Prioritize deviations by:
- Safety risk (fall risk deviations first)
- Energy cost impact (compensations that increase metabolic demand)
- Long-term joint consequences (deviations causing abnormal joint loading)
Checkpoint B — Pre-Finalization Review
Before finalizing gait analysis documentation:
- Temporal-spatial parameters measured and compared to normative values
- Phase-by-phase deviation analysis completed for stance and swing
- Each deviation linked to underlying impairment with objective data
- Assistive device documented with fit verification
- Functional Ambulation Category assigned
- Timed walking tests completed with normative comparison
- Weight-bearing status compliance verified and documented
- Community ambulation potential assessed
- Video or photographic documentation obtained if available
- Analysis compared to prior gait assessment if reassessment
Quality Audit
- Gait speed calculated in m/s with distance and time documented
- Step length symmetry ratio calculated (involved/uninvolved)
- Every deviation has an identified cause (impairment or structural)
- Assistive device fit verified with objective measurements
- FAC score assigned and justified
- 10MWT and/or 6MWT values recorded with normative comparison
- Orthotic need assessed for identified deviations
- All [VERIFY] flags resolved or escalated
- Gait analysis supports the treatment plan intervention selection
- Documentation signed with evaluator credentials and date
Guidelines
- Use the Rancho Los Amigos terminology (initial contact, loading response, midstance, terminal stance, pre-swing, initial swing, mid-swing, terminal swing) — not outdated terms like "heel strike" in isolation
- Always document gait from at least sagittal and frontal planes
- A gait speed <0.8 m/s predicts inability to safely cross a street and is a threshold for community ambulation limitation
- Minimal clinically important difference for gait speed is approximately 0.1-0.2 m/s depending on population
- 6MWT minimal clinically important difference: approximately 50m for most rehabilitation populations
- Never prescribe an assistive device based on gait observation alone — integrate with strength, balance, and endurance testing
- Document the surface and footwear during testing — carpet, tile, shoes, bare feet all affect gait
- For pediatric gait, developmental norms differ by age — mature gait pattern not expected until age 7
- Instrumented gait analysis (3D motion capture) is indicated for complex surgical decision-making, especially in cerebral palsy
- Gait training CPT code 97116 requires documentation of skilled interventions performed during the session, not ambulation alone