Gait in Obese Patient

Tirza Z. Tamin

Department of Physical Medicine and Rehabilitation, Dr. Cipto Mangunkusumo General Hospital,

Faculty of Medicine, University of Indonesia, Jakarta, Indonesia

tirzaediva.tamin@gmail.com

Keywords: Gait, Obesity

Abstract: Obesity is a known risk factor for several diseases, and also negatively affects physical functioning,

especially walking ability and performance. Some walking abnormalities in gait could be down to foot

problems as increased pressure is placed on the tendons and muscles of the foot, in particular, the plantar

fasciitis. It is widely known that overpronation is a very common occurrence in the obese. Understanding

mechanisms that may affect the ability to walk in older individuals may help to identify the target for

prevention and rehabilitation.

1 INTRODUCTION

Obesity is a known risk factor for several diseases,

and also negatively affects physical functioning,

especially walking ability and performance. Studies

have shown that walking ability is an important

prerequisite for autonomy in activities of daily living

(Seung-uk et al, 2011). Understanding mechanisms

that may affect the ability to walk in older

individuals may help to identify the target for

prevention and rehabilitation. Interestingly, obesity

is one of the main risk factors for knee and hip OA

and recent data have shown that obesity is cross-

sectionally associated with low walking speed and

predicts the development of mobility disability

(International Diabetes Institute, 2000).

2 DISCUSSION

2.1 Obesity

The prevalence of Obesity in Indonesia according to

Riskesdas 2018 increases when compared to 2013,

male 15% to 20% and women 26% to 35% (Kadouh,

2016). Department of Medical Rehabilitation of

RSCM increase in the number of patient visits to

The Obesity Polyclinic from 2015-2016 (from

1174 to 2272) and 2017-2018 (from 2821to 3370).

The high prevalence increases the morbidity and

disability caused by obesity (Winter, 1989).

Obesity can be diagnosed by 2 easily methods,

body mass index and waist size. Body Mass Index

(BMI) is calculated by dividing body weight in

kilograms by height in square meters. BMI

correlates with the amount of body fat to the risk of

disease. World Health Organisation (WHO) says

that central obesity in Asian people can be count

from their waist size > 90 cm for men and > 80 cm

for women.

2.2 Gait

Normal Gait

Gait means the way a person walks. Abnormal

gait or gait abnormality occurs when the body

systems that control the way a person is unable to

walk in the usual way. There are 2 concepts of

normal gait:



Stride length: the distance between points

of contact of the same foot (also one gait cycle).



Step length: the distance between points of

contact of opposite feet (normal is 15-20 in)

Gait cycle has two phases:

• Stance phase: time in which limb is in

contact with the ground (60% of the gait cycle)

• Swing phase: time in which limb is in the

air (40 % of the gait cycle).

Tamin, T.

Gait in Obese Patient.

DOI: 10.5220/0009062300580061

In Proceedings of the 11th National Congress and the 18th Annual Scientiﬁc Meeting of Indonesian Physical Medicine and Rehabilitation Association (KONAS XI and PIT XVIII PERDOSRI

2019), pages 58-61

ISBN: 978-989-758-409-1

Figure 1: Normal Gait (Kadouh et al, 2016)

Figure 2: Types of Gait Cycle

Gait has its determinants that consist of how

anybody walks properly, there are

• Pelvic rotation

• Pelvic tilt

• Knee flexion in stance phase

• Foot mechanics

• Knee mechanics

• Lateral displacement of the pelvis

These factors help minimize the excursion of

COG to maximize forward progression with the least

expenditure of energy.

Abnormal gait

There are many causes of abnormal gait such as

focal weakness (example: dorsiflexion weakness),

joint contractures (example: tight heel cord), pain

(example: hip osteoarthritis), neurological conditions

(examples: stroke, Parkinson disease, CP).

Abnormal gait is categorized as one of five types

based on the symptoms or appearance of an

individual's walk. They are:

1. spastic gait

2. scissors gait

3. steppage gait

4. waddling gait

5. propulsive gait

Spastic gait

Spastic gait occurs when a person drags his or

her feet while walking. This type can also make

someone appear to be very stiff when walking.

Scissors gait

A person whose legs bend inward will often have

a scissors gait. With this type, a person's legs cross

and may hit each other while walking. The crisscross

motion may resemble scissors opening and closing.

Steppage gait

Steppage gait occurs when a person's toes point

towards the ground while walking. Often, the toes

will scrape against the ground as the person steps

forward.

Gait in Obese Patient

Waddling gait

As the name suggests, a person with a waddling

gait moves from side to side when walking.

Waddling involves taking short steps as well as

swinging the body.

Propulsive gait

Propulsive gait is when a person walks with his

or her head and neck pushed forward. It can appear

as though the person is rigidly holding a slouched

position.

In addition to these five types, a person with a

limp is also considered to have an abnormal gait.

Similarly, to other abnormalities, a limp may be

either temporary or permanent. A limp may also

clear up without medical intervention (Ferreira et al,

2013).

Measurement

There are about six quantitative measurements to

know is there any gait problems in an obese patient.

Direct Method

Normal gait movement, rotation, and procedures

can up to 5 times bodyweight at the ankles and 3

times at the knees (shear force). It’s using

intraarticular pressure equipment



is rarely used in

humans. In animal models can causes excessive

dynamic load-cartilage destruction and progressive.

Kinematic Analysis

Obtain hip, knee, and pelvic angles to move the

reflection mark on the joint with 4-6 cameras to

trajectory on the walking track. It is using the

internal axis and rotation angle to describes the 3D

movement of the joint during walking and includes

pelvic tilt and rotation angle, hip flexion, abduction

and adduction angles; knee flexion and abduction

angle; dorsiflexion of the ankle and angle of flexion

of the big toe; and scope of joint motion of the toe.

Weaknesses are complex and time-consuming and

difficult to use in clinical use.

EMG Dynamic

Effective for detecting muscle activity during

walking to analyzing and recording the time and

intensity of muscle activity. Superficial muscles use

surface electrodes, muscles in implanted wire

electrodes. It is important for a gait that is abnormal

with causes on nerves, and muscles. Weaknesses can

make the costs required are quite high and difficult

to accept widely.

Oxygen Consumption

Analyze energy consumption when walking to

using a portable oxygen analyzer. Gas released

during the walk to oxygen consumption analysis

related to mileage: the lower the oxygen cost to the

lower the energy consumption for walking.

Detecting oxygen consumption during walking with

prostheses, orthosis to the assessment of

rehabilitation efficiency.

Temporal-spatial Analysis

Temporal-spatial gait measurement with

footprint method (manual ink) pul computerized

(platform). Limitations do not record body and arm

movements. In the form of an electronic walk pad

inserted with baroreceptors to recording real-time

walking variables to measuring time-space variables

(single foot/feet support time, swing time and pace).

Use the comparison before treatment, determine

pathological pathology and see the effects of therapy

Its use is not much too expensive equipment prices.

Footprint

Implementation using the sole covered in ink and

runs through 4-6 m of cloth or white paper. Some

literature trajectories up to 10 m, with a starting

point of at least three steps before reaching the

platform to ensure a steady-state walking pattern.

The results were considered satisfactory for both

legs full contact with each white paper platform

(Ferreira, 2013).

3 CONCLUSION

Abnormalities in gait could be down to foot

problems as increased pressure is placed on the

tendons and muscles of the foot, in particular, the

plantar fasciitis. It is widely known that

overpronation is a very common occurrence in the

obese. In the study of walking pattern in obesity

with osteoarthritis knee has a result that obesity can

make changes in walking pattern, the step length is

become shorter and also minimize loading of the

knee joint. Increased BMI also has a major

KONAS XI and PIT XVIII PERDOSRI 2019 - The 11th National Congress and The 18th Annual Scientiﬁc Meeting of Indonesian Physical

Medicine and Rehabilitation Association

spatiotemporal modification, so it comes to shorter

step length, lower number of steps and lower

walking speed.

Loading in the musculoskeletal system of obese

patients can make a change in pathological walking

patterns, loss of mobility, and progression becoming

knee disability in osteoarthritis. Bodyweight also can

increase the joint load. Obese patients have an

increased external knee adduction movement

(EKAM) compared to patients with normal body

weight coupled with systemic factors from adipose

tissue and accelerate knee cartilage degeneration in

obese patients.

Quadriceps muscle weakness makes rapid

deceleration before heel strike and reduces high joint

loading adaptation to a walking pattern, so it

decreases ground reaction force and decreases

walking speed (Ferreira, 2013).

Bwop et al say in 55 obese patients with knee

osteoarthritis (OA), who run slower and have a

shorter stride length and higher EKAM than

normoweight with OA knee. So, the weight has a

role in EKAM. Changing the gait pattern can reduce

walking speed and decreases EKAM and smaller

foot length can reduce peak loading in the knee joint.

Harding et al. say that the relationship between

BMI with changes in walking patterns can make

changes in biomechanical patterns, so it decreased

walking speed and step length in obese subjects with

moderate knee OA compared to non-obese with

moderate OA (Butler, 2007).

Older adults with obesity show spatiotemporal

gait patterns which may help to reduce contact

impacts. Also, in obese persons, mechanical energy

usages tend to be lower in the anterior-posterior

plane and higher in the medial-lateral plane. Since

forward progression forces are mainly implicated in

normal walking, this pattern found in obese

participants is suggestive of lower energetic

efficiency (Stein, 2007).

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Gait in Obese Patient