The 5 Point Turn (in a human). Do you know this gait problem ?
Here is a video link for the full video case study with diagnosis and more details on this client’s gait but our point here today is to look at the uniquely pathologic turning motor pattern deployed by this patient.
Gait analysis is so much more than watching someone move on a treadmill. Forward momentum at a normal speed can blur out many of a person’s gait pathologies. We discussed this in detail in this blog post on slowing things down with the “3 second gait challenge”. Furthermore, most gait analysis assessments do not start seated, then watching the client progress to standing, and then initiating movement. Watching these intervals can show things that simple “gait analysis” will not. Finding stability over one’s feet and then initiating forward motion can be a problem for many. Those first moments after attaining the standing position afford momentum to carry the person sideways just as easily as carrying them forward. In other words, once momentum forward begins, a normal paced gait can make it difficult to see frontal plane deficits. Our point here, transitional movements can show clues to gait problems and turning to change direction is no different.
Typically when we turn we use a classic “plant and pivot” strategy. We step forward on a foot (right foot for example here), transfer a majority load on that forward right foot, we then pivot the left foot in the next anticipated direction of movement, and then push off the right foot directionally while spinning our body mass onto that left foot before initiating the right limb swing through to continue in the new direction. This is not what this patient does. Go ahead, stand up and feel these transitions, if you are healthy and normal they are subconscious weight bearing transitions but for some one who is old and losing strength and proprioception/balance or some one with neurologic decline for one reason or another, these directional changes can be extremely difficult as you see in this video here. A full 180 degree progression is often the most difficult when things get really bad. And more so, if one leg is more compromised than the other, turning one way a quarter turn (a 90 degree directional change) might be met with an alternative 270 degree multiple-point turn in the opposite direction over the more trusted limb to get to the same directional change. When there is posterior column disease or damage this seemingly simple “plant/weight shift/ pivot and push off” cannot be trusted. So a 5 point (or more) turn is deployed to be sure that small choppy steps maximize minimal loss of feel and maximal ground contact feel. This can be seen clearly in this video above.
Full video case link here:https://www.youtube.com/watch?v=AYmzQL_NSeI
Just some more things to think about in your gait education. Watch your clients move from sit to stand, from stand to initiating gait, and then watch closely their turning strategies. At the very least, have them make several passes making their about-face turns both to the right and the left. You will often see a difference. Watch for unsteadiness, arm swing changes, cross over steps, reaching for stability (walls, furniture etc), moving of the arms into abduction for a ballast effect and the like. Then correlate your examination findings to your gait analysis. Then, intervene with treatment and rehab, and review their gait again. Remember, explaining their deficiencies is a huge part of the learning process. Make them aware of their 5 point turns, troubles pivoting to the right or the left, and make them understand why they are doing the goofy one-sided rehab exercises. Understanding what is wrong is a huge part of fixing your client’s problems.
* Remember: if your client is having troubles on a stable surface (ie. the ground) then they should engage some rehab challenges on the ground. Giving them a tilt board or bosu or foam pad (ie. making the ground more unstable) will make things near impossible. This is not a logical progression, we like to say, “if you can’t juggle one chainsaw we won’t give you 3”. Improve their function on a stable surface first, then once improvements are seen, then progress them to unstable surfaces.
Shawn and Ivo
The gait guys.