The restoration of independent and functional community ambulation is probably the most common goal included in a physical therapy plan of care, especially for those who work with older adults. Yet many of us struggle when it comes to objectively measuring gait.
When assessing gait, most of us turn to our eyes. Volumes have been written about observational gait analysis and many hours of physical therapy education are spent helping students observe normal and pathological gait.
Despite this, research has shown the reliability of observational gait analysis to be low.1-2 More recently the use of video, which can be slowed down and repeated, has been used as an adjunct to observational gait analysis. Even so, Eastlack et al. found that physical therapists using video observational gait analysis were only slightly more reliable, and that improved inter-rater reliability of therapists using the technique was needed.3
|Items Scored as Part of the Functional Gait Assessment|
|Gait on level surface|
|Gait with gait in speed|
|Gait with horizontal head turns|
|Gait with vertical head turns|
|Gait and pivot turn|
|Step over obstacles|
|Gait with narrow base of support|
|Gait with eyes closed|
Walking up/down stairs
Lab-quality gait assessment systems that utilize cameras and force sensors aren’t readily available in most clinics. Lower-cost alternatives that use gyroscope-based sensors strapped to the patient’s extremities and that sync data directly to your phone or tablet are becoming more common, but the validity of such systems has not been well-established. Technology may indeed hold great promise in this area but the evidence is just not there yet.
So, what’s an evidence-loving geriatric physical therapist to do?
For starters, let’s not throw the baby out with the bath water. Clearly, keen observation of our patients’ gait is important; it can certainly help us identify gross deficits in gait pattern and can inform our impairment-based treatment plan. We all know a stiff ankle that contributes to toe-drag when we see it and should, of course, observe and document what we see.
But when it comes to objective measurement of gait, perhaps it is better to take a step back and look more broadly at how a patient performs the act of walking overall. To that end, we recommend measuring gait speed and using an evidence-based outcome measurement such as the Functional Gait Assessment (FGA). Rather than focusing on impairment-level observations, why not measure what it the patient cares about doing? Walking!
For the general older adult population, we think that measuring walking speed is a great place to start. If you haven’t read Fritz and Lusardi’s seminal white paper on gait speed,4 find it and read it now. The test is reliable, simple to complete, and an excellent way to objectively measure improvement. Again, Fritz and Lusardi said it best:
“Walking speed is ‘almost the perfect measure.’ A reliable, valid, sensitive, and specific measure, self-selected walking speed (WS), also termed gait velocity, correlates with functional ability and balance confidence. It has the potential to predict future health status, and functional decline including hospitalization, discharge location, and mortality.
Walking speed reflects both functional and physiological changes, is a discriminating factor in determining potential for rehabilitation, and aids in prediction of falls and fear of falling. Furthermore, progression of WS has been linked to clinical meaningful changes in quality of life and in home and community walking behavior.”
The Functional Gait Assessment was developed to measure gait, balance, and fall risk in older adults. The FGA builds on the older Dynamic Gait Index by adding several slightly more difficult performance items. It asks the tester to score 10 items on a 4-level ordinal scale. The full FGA can be found free online.
The FGA has been established as a reliable and valid measure of balance while walking in a number of patient populations including older adults,5 patients with Parkinson diseases,6 and vestibular disorders. Normative date by age has also been published.7
In summary, observation-based descriptions of gait can be helpful, but often fall short when asked to reliably measure gait performance. High-tech systems are often too expensive, lack portability, and lack reliability data to support their use.
Our patients and third-party payers are much more interested in overall gait performance and function. To that end, gait speed and the FGA are great measures that can be used in every type of clinical setting every day.
- Miyazaki S, KubotanT. Quantification of gait abnormalities on the basis of continuous foot-force measurement: correlation between quantitative indices and visual rating. Med BioI Eng Comput. 1984;22:70-76.
- Goodkin R, Diller L. Reliability among physical therapists in diagnosis and treatment of gait deviations in hemiplegics. Percept Mot Skills. 1973;37:727-734.
- Eastlack ME, Arvidson ], Snyder-Mackler L, et al. Interrater reliability of Videotaped observational gait-analysis assessments. Phys Ther. 1991; 71:465-472.
- Fritz S, Lusardi M. White paper: walking speed: the sixth vital sign. Journal of Geriatric Physical Therapy Vol. 32;2:09.
- Thieme, H., Ritschel, C., et al. (2009). “Reliability and validity of the functional gait assessment in subacute stroke patients.” Arch Phys Med Rehabil 90(9): 1565-1570
- Leddy, A. L., Crowner, B. E., et al. (2011). “Functional gait assessment and balance evaluation system test: reliability, validity, sensitivity, and specificity for identifying individuals with Parkinson disease who fall.” Phys Ther 91(1): 102-113.
- Walker.2007. Reference Group Data for the Functional Gait Assessment. PTJ 87(11):1468-1477.