Pemeriksaan Gait, Locomotion, And Balance
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Transcript of Pemeriksaan Gait, Locomotion, And Balance
8/12/2019 Pemeriksaan Gait, Locomotion, And Balance
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PEMERIKSAAN GAIT,
LOCOMOTION, AND BALANCE
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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
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TUJUAN PEMERIKSAAN
Mengetahui adanya gangguan,
keterbatasan, dan ketidakmampuan
berjalan, berpindah, dan keseimbangan
Menentukan apakah perlu menggunakan
alat bantu, ortotik, prostetik.
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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
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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
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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).
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Walking is a series of gait cycles
– A single gait cycle is known as a STRIDE
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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
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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
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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)
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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.
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A Single Gait Cycle or Stride
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Gait Flow Chart
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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
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Komponent Gait Normal :
1). Weight Acceptance.
2). Single limb Support.
3). Limb Advancement.
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Stance.
Initial Contact.
Loading Response (LR).
Mid Stance (MSt).
Terminal Stance (TSt).
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Swing
Pre-swing (PSw).
Initial Swing (Isw)
Midswing (MSw)
Terminal Swing (TSw)
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Stride length :
Adalah jarak antara dua jejak kaki, pada
kaki yang sama.
Pada orang dewasa pria jaraknyaantara 140 – 156,5 cm.
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Stride duration :
Adalah waktu yang dibutuhkan untuk
jarak tersebut ( stride length ).
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Step length :
Adalah jarak antara dua jejak
kaki , baik dari kanan kekiri atau
sebaliknya. Jarak rata2nya adalah 68 –
78cm.
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Step duration :
Adalah waktu yang dibutuhkan
dari heel strike kaki yang satu ke
heel strike kaki yang lain.
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Cadence :
Adalah jumlah steps permenit.
Dimana nilai rata2nya adalah 112
– 116 permenit.
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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)
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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
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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.
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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
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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.
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Static Positions at Loading
Response Shoulder is slightly extended
Pelvis is rotated left
hip is flexed and slightly externally rotated
knee is slightly flexed
ankle is plantarflexing to neutral foot is neutral
Toes are neutral
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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.
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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
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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
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Static Positions at Terminal Stance
Shoulder is slightly flexed
Pelvis is rotated left
Hip is extended and internally rotated
Knee is fully extended
Ankle is dorsiflexed
Foot is slightly supinated Toes are neutral
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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.
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Static Positions at Toe-Off
Shoulder is flexed
Pelvis is rotated right Hip is fully extended and internally rotated
Knee is fully extended
Ankle is plantarflexed
Foot is fully supinated
Toes are fully extended
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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
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Gait Progression
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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
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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
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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
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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.
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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
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Terminal Swing
Phase 8
Begins at the end ofmidswing and ends whenthe foot touches thefloor.
Limb advancement iscompleted at the end ofthis phase.
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Static Positions at Terminal Swing
Shoulder is extended
Spine is rotated right
Pelvis is rotated left
Hip is flexed and externally rotated
Knee is fully extended
Ankle is fully dorsiflexed Foot is neutral
Toes are slightly extended
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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
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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
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Trendelenburg Gait
Gluteus medius weakness gait
Lateral trunk lean towards side of
weakness Maintain body’s COG over weak side duringstance phase
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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
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Flexed Gait Posture
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Common Gait Posture in Elderly People
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BALANCE
Balance : komponen dasar aktivitas
Ditentukan oleh tonus postural :
– mobilitas– stabilitas
Kualitas balance tergantung intregitas :
– SSP dan SST– muskuloskeletal
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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.
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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.
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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)
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•
Nilai normatif :Usia 73 th ; step = 17 ; waktu 15 detik
Kelebihan dan kelemahan :
– cepat, sederhana– sensitif
– sulit dilakukan bila gangguan balanceberat
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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
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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
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4 BERG BALANCE
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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
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• Nilai normatif = 56Interrater ICC = 0, 98
Validitas :
– Concurrent dengan instrumen lain.
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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 :
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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
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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
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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
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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)
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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 :
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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.
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7. Falls diary
Mencatat :
– kejadian jatuh
– lingkungan kejadian jatuh– konsekuensi jatuh
Prosedur :
– Pasien mengisi kalender :v= tidak jatuh
x= jatuh
l h l
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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
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