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Table of Contents
ORIGINAL ARTICLE
Year : 2023  |  Volume : 5  |  Issue : 1  |  Page : 94-101

Spatiotemporal parameters of gait in terms of symmetry in asymptomatic individuals


Department of Physiotherapy, Ramaiah Medical College, Bengaluru, Karnataka, India

Date of Submission06-Oct-2022
Date of Decision09-Mar-2023
Date of Acceptance07-Jun-2023
Date of Web Publication11-Aug-2023

Correspondence Address:
Dr. Aditi Chandrakant Bhandarkar
Department of Physiotherapy, Ramaiah Medical College, M. S. R. Nagar, MSRIT Post, Bengaluru - 560 054, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijptr.ijptr_161_22

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  Abstract 


Context: Human gait, or the way people walk, is a complicated motor activity involving coordinated movements of different parts of the body. It is crucial in everyday activities and is influenced by a variety of factors such as age, health status, and musculoskeletal and neurological disorders. Understanding the many characteristics of gait, especially symmetry and asymmetry, is critical for getting insights into normal locomotion patterns and recognising potential deviations associated with certain conditions.
Aims: The current study aims to understand the different aspects of gait such as symmetry and asymmetry of gait to develop a deeper understanding of the underpinnings of human gait.
Settings and Design: Convenience sampling was used. This was a cross-sectional observational study.
Subjects and Methods: A cross-sectional study was done on 72 healthy adults between the age group of 20 and 80 according to the criteria. Convenience sampling was used. Subjects were divided into six groups having 12 subjects in each group. Gait analysis was done using GAITRite. Subjects were asked to walk three times on the walkway at their preferred speed. Since all the variables are continuous, all the data have been processed in terms of the mean.
Statistical Analysis: The Statistical Software, namely Jamovi 0.9.5.12 (jamovi.org), was used for statistical analysis.
Results: It was observed that step time and cycle time can be considered parameters representing symmetry and parameters such as step length, stride length, H-H base of support, swing (% of gait cycle) stance (% of gait cycle), single support (% of gait cycle), and double support (% of gait cycle) represent gait asymmetry.
Conclusions: This study establishes the asymmetric parameters of gait across the age span the minimum detectable difference in all the parameters were calculated.

Keywords: Gait analysis, Gait asymmetry, Gait rite, Gait symmetry, Spatiotemporal parameters


How to cite this article:
Bhandarkar AC, Ravindra S, Visweswara RD. Spatiotemporal parameters of gait in terms of symmetry in asymptomatic individuals. Indian J Phys Ther Res 2023;5:94-101

How to cite this URL:
Bhandarkar AC, Ravindra S, Visweswara RD. Spatiotemporal parameters of gait in terms of symmetry in asymptomatic individuals. Indian J Phys Ther Res [serial online] 2023 [cited 2023 Oct 1];5:94-101. Available from: https://www.ijptr.org/text.asp?2023/5/1/94/383672




  Introduction Top


Walking is defined as a method of locomotion involving the use of two legs alternately to provide both support and propulsion. A particular pattern of how a person walk is called gait. Normal gait is described as a series of rhythmical, alternating movements of the trunk and limbs that result in the forward progression of the center of gravity and the body.[1],[2],[3]

A healthy gait requires the interaction of different body parts and coupling across different joints of the complex kinematic chain. However, is observed that various physiological changes take place with aging, neurodegenerative disease, etc., which reduces the ability of the neuromuscular system to maintain a constant level of mobility that can cause a serious compromise of gait function.

Gait symmetry is considered an indicator of normal gait. Symmetry is defined as the “correspondence of body parts in size, shape, and relative position, on opposite sides of a dividing line.”[4],[5] In this context, gait symmetry means identical movement of the right side of the body to the left side of the body in both space and time,[6],[7] whereas gait asymmetry means that the movement of the right side of the body is different from the left side of the body with respect to both space (spatial) and time (temporal). Asymmetry usually indicates pathology, but some degree of asymmetry is observed in healthy individuals. This asymmetry in healthy individuals was attributed to the natural functional differences between the lower extremities due to dominance. These functional differences were assumed to be due to the contribution of each extremity in carrying out the tasks of propulsion and control during walking in healthy individuals.[4],[5],[8]

Gait asymmetry is a sensitive feature to differentiate between both normal and pathological gait.[9] There is a paucity of literature with normative values for the amount of asymmetry present in normal healthy individuals. Studies show that symmetric gait provides a stable and energy-efficient gait pattern. Gait asymmetry increases the energy cost of walking, it increases the consumption of oxygen, whereas asymmetrical gait is associated with several issues such as inefficient balance control.[5],[7] Asymmetry can lead to an increase in pressure on the contralateral limb and joints which in turn has been implicated as a cause of osteoarthritis (OA) and musculoskeletal injury.[9] Asymmetry can also lead to a reduction in bone mass density and cause osteoporosis on the affected side.[8]

The changes in the parameters from one stride to another are termed gait variability.[10],[11] Studies show that gait variability is associated with an increased risk of falls as it brings the dynamic state of a person closer to their limits of stability.[12],[13]

Thus, measuring gait deviation could be advantageous for various reasons including general health and quality of life, and it can help in the prediction of cognitive decline and fall risk.[14] This makes it important to assess symmetry and asymmetry parameters in normal healthy individuals and understand the amount of asymmetry in various spatiotemporal parameters of gait.

Studies show that age and gender influence the gait parameter e.g. the younger population walks faster with longer steps than the elderly population, or males are faster than females. These changes in gait can be attributed to the normal physiological and neurological decline in function due to aging.[12],[15]

There are various methods of assessing gait asymmetry. The most popular method for assessing asymmetry is by calculating a single value known as a symmetry index for spatiotemporal, kinetic, and kinematic parameters between the right and left sides.[13]

Gait asymmetry was evaluated using both spatial and temporal parameters. In this study, normal healthy individuals with no apparent asymmetry were taken. The study aimed to identify the parameters which were symmetrical irrespective of age, speed of walking height, and parameters that became asymmetrical due to age, speed of walking, etc. Symmetric parameters would help to identify where the person was compensating to achieve normal gait and evaluate how well the person was able to accommodate/compensate for increasing demand and asymmetric parameters would show where the person was not able to compensate.

There were various studies examining symmetry but there was no consensus as to which were the parameters that show consistent asymmetry and symmetry during a normal gait cycle.[16],[17]

Hence, the current study aimed to identify parameters that will indicate symmetry and asymmetry in the general population.


  Subjects and Methods Top


Sample size

Sample size was calculated based on the study by Yogev et al. 2007,[16] revealed the mean swing time among the normal to be 0.40 (standard deviation [SD] =0.04). Based on the above findings of the study assuming the population mean to be 0.417 and keeping the power of the study at 95% and with an alpha error of 5%, it is estimated that 72 normal healthy individuals need to be included in the study for Phase 1. This 72-sample size is divided into six groups (20–29 years, 30–39 years, 40–49 years, 50–59 years, 60–69 years, and 70–79 years) having 12 subjects in each group.

Small sample 100 (1−α)% 100 (1−α)% confidence interval for a population mean:



This formula gives n = 12.

Now, total sample size = n × (number of class intervals)

=12 × 6

=72

A total of 72 subjects (38 females and 34 males) between the age group of 20 and 80 years were included in the study by convenience sampling.

The inclusion criteria were community-dwelling subjects within the age range and having mini–mental state examination (MMSE) scores >24 were included in the study.

The exclusion criteria used were:

  1. Neurological deficits that affect the gait (stroke, multiple sclerosis, etc.,)
  2. Known cases of ischemic heart disease or any cardiovascular disease which might alter the gait
  3. Moderate and severe language/cognitive deficits that might limit the informed consent and affect the gait (MMSE >24)
  4. Orthopedic disorders such as an acute episode of OA knee or hip which might alter gait. Painful conditions of lower limbs such as neuralgia and diabetic neuropathies.


Institutional Ethical clearance was obtained. Participation in the test was voluntary and informed written consent was taken from every participant. Subjects were allocated to the age-appropriate strata. The detailed procedures for obtaining informed consent are documented in Annexure 1 and Annexure 2, which contain the consent forms used for this study. These consent forms provided participants with a clear understanding of the study's objectives, procedures, potential risks, and their rights as participants. Subjects were allocated to the age-appropriate strata.

Procedure

Subjects were divided according to the decades into six groups (20–29 years, 30–39 years, 40–49 years, 50–59 years, 60–69 years, and 70–79 years) having 12 subjects in each group. Screening of the subjects was done using the Johns Hopkins fall risk questionnaire, frailty scale, MMSE, and medical history.

Assessment of vitals such as blood pressure, SPO2, and pulse was taken in three different positions (lying, sitting, and standing). The flow of the study procedure is illustrated in [Figure 1].
Figure 1: Flowchart explaining the methodology of the study

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A GAITRite is a type of portable single-layer pressure-sensitive electronic walkway which is used to assess gait. It is embedded with sensors that can detect pressure and movement when a person walks over the mat, the sensor collects data on various aspects of gait such as spatial and temporal parameters.

Subjects were asked to walk 3 m from the start of the walkway and 2 m after the walkway to account for the acceleration and deceleration phase of the gait. A trial walk for familiarization was given which was not recorded. Subjects were asked to walk three times on the walkway at their preferred speed. Gait data of spatial and temporal parameters were recorded for analysis.

Data processing

Central tendency

Since all the parameters were continuous, all the data were processed in terms of mean and SD.

Asymmetry

For purposes of this study, asymmetry was divided into:

Limb asymmetry

It was defined as the difference between the variables of the right and left limbs.

Gait asymmetry

The average of the differences across the three trials was termed gait asymmetry.

Identifying symmetric and asymmetric parameters consisted of three steps:

  1. The difference between the right and left limbs for all the parameters was calculated for identifying consistency across three trials
  2. If the differences between the parameters in all three trials were 0, then those parameters were considered symmetric
  3. If the difference between the left and right limb parameters were different across all three trials, then they were considered asymmetric.


Consistency of symmetry/asymmetry

This study aimed to calculate the consistency of symmetry/asymmetry of parameters across the three trials in all the age groups. Consistency was measured to identify parameters that do not get affected by age and can compensate for attaining a normal gait pattern.

Identifying consistency of symmetry and asymmetry

  1. They were further divided into consistently symmetrical across three age groups or consistently asymmetrical across the three age groups
  2. The parameter was considered consistently symmetrical if the parameter was symmetric across all three age groups
  3. The parameter was considered consistently asymmetrical if the difference values between the right and left were not replicated even once across all three age groups.


Statistical analysis

Microsoft Excel were used to generate tables and graphs. The Statistical Software, namely Jamovi 0.9.5.12 (jamovi.org), was used for statistical analysis.


  Results Top


[Table 1] shows that the mean of the population was toward the younger side of the age spectrum for their category. A decreasing trend was observed in height, weight, and limb length across the age group. This suggests that in the sample population, the height, weight, and limb length reduced as age increased.
Table 1: Explaining the demographic characteristic of the sample population

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[Figure 2] shows graphical representation of the spatial parameters mean difference. The difference is calculated by subtracting Left side minus right side. For example, left step length minus right step length.
Figure 2: Graphical representation of spatial parameters mean difference (left side-right side)

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Identifying symmetry and symmetry

An increasing trend in step length is observed in [Table 2] for younger age groups till 40–49 years, and at 50–59 years, it plateaued after which it started to decrease. This shows that the step length difference kept increasing till the age group of 49. Between 40 and 59 years, all the subjects had similar differences between their right and left step lengths. This difference started to reduce after the age of 59–79 years. In stride length and base of support, a consistently increasing trend was observed. This shows that the difference between right and left stride length and H-H base of support in the sample population increased from the age of 20 till the age of 79 years.
Table 2: Explaining the mean of the difference between left and right of the three trials of spatial parameters across the age groups

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Temporal parameters

The temporal parameters analyzed here are step time, cycle time, single support (% of gait cycle), double support (% of gait cycle), swing (% of gait cycle), and stance (% of gait cycle) [Table 3].
Table 3: Explaining the mean of difference (left–right) of temporal parameters (step time, stance time, single support (% GC), double support (% of gait cycle), swing (% of gait cycle), and stance (% of gait cycle)) for all the three trials across all age groups

Click here to view


[Figure 3] shows graphical representation of the Temporal parameters mean difference. The difference is calculated by subtracting Left side minus right side. For example, left step length minus right step length.
Figure 3: Graphical representation of the mean of difference (left side-right side) of temporal parameters for all three trials across all age groups

Click here to view


It was observed that the mean difference between the left and right step time and cycle time was 0. This suggests that there was no difference in time taken to cover the distance on both the right and left sides. There was a reduction in single support, swing, and stance (% of gait cycle) from 20 to 49 years. This suggests that as age increases single support, swing, and stance (% of gait cycle) decrease. The age group of 50–59 was higher than 40–49 years and then shows decreasing trend till 70–79 years. This trend was consistent with swing and stance. However, with the double support, there was a plateau after 50 years till 79 years.

Maximum asymmetry was observed in all the temporal parameters in the age group of 50–59 and 60–69 years. This suggests that these are the transitory age groups. The motor control strategies changes are modified in these age groups causing more left-to-right differences.

Identifying consistency in symmetric and asymmetric variables

It was observed [Table 4] that step time and cycle time can be considered parameters representing symmetry and parameters such as step length, stride length, H-H base of support, swing (% of gait cycle) stance (% of gait cycle), single support (% of gait cycle), and double support (% of gait cycle) represents gait asymmetry. This suggests that step time and cycle time do not change with age and are considered symmetrical in parameters such as step length, stride length, H-H base of support, swing (% of gait cycle) stance (% of gait cycle), single support (% of gait cycle), and double support (% of gait cycle), the difference between right and left either increases or decreases showing asymmetry between the two lower limbs.
Table 4: Variables which are consistently symmetric and consistently asymmetric

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It was observed that the distance covered reduces till the age group of 50–59 years and there is a linear increase in distance covered in 60–69 years and 70–79 years. There was a linear increase in ambulation time. A decreasing trend was observed in velocity except for an increase in velocity at 70–79 years of age. The mean normalized velocity was equal in all the age groups. Cadence remained constant between the age groups of 20 and 49 after which it started to reduce with a slight increase observed in 70–79 years [Table 5].
Table 5: Representation of the mean of distance, ambulation time, velocity, and mean velocity for all three trials across age groups

Click here to view



  Discussion Top


The current study aimed to identify different symmetric and asymmetric spatiotemporal parameters of gait in the age group of 20–79 years. This study also aimed to quantify asymmetry across age groups. Parameters were evaluated based on consistency. Consistency was taken as a metric as it shows parameters that resist any change irrespective of all the other confounding variables. This consistency gives reliability to the assumption of whether a parameter is symmetrical or asymmetrical.

In this study, it was observed that cycle time and step time are consistently symmetric parameters, they are not affected by age, speed of walking, etc., This suggests that to maintain the cyclicity of the gait, the body tends to adjust and adapts its step time and cycle time. Step time and cycle time are independent parameters and are indicative of gait being normal. Since there was no difference between the age groups, it could be an index of symmetry. It was observed that the mean difference between the left and right step time and cycle time is 0. An altered cycle time could potentially cause fall risk as the cyclicity of gait which is a fundamental feature of gait is compromised. In this study, it was observed that step time was consistently symmetrical this could be to reduce the energy cost of walking since asymmetric step time increases the energy cost of walking. Stenum et al. did a study assessing the energy cost of asymmetric step time, they observed that step time asymmetry is adaptable and can be changed volitionally according to the demands of the body.[18] Ellis et al. did a study to evaluate the metabolic cost of asymmetric step time and observed that when the step time becomes asymmetric, there is an increase in metabolic cost compared to when the step time remains symmetric.[19] The body tries to keep the step time symmetric to maintain the cyclicity of the gait and reduce the metabolic cost. Step length, stride length, H-H base of support, single support (% of gait cycle), double support (% of gait cycle), swing (% of gait cycle), and stance (% of gait cycle) were parameters that showed consistent asymmetry in all the age groups.

An increasing trend in step length asymmetry was observed in younger age groups till 40–49 years at 50–59 years it plateaued after which it started to show a decreasing trend. This decreasing asymmetry in step length suggests that elderly people walk with caution and pays more attention to gait after the age of 60. Literature suggests as age increases, there is a decrease in step length due to age-related musculoskeletal and neurological factors such as muscle weakness, changes in joint mobility, flexibility, and balance influencing gait.[20],[21],[22]

An increasing trend in the mean asymmetry of stride length and H-H base of support was observed with an increase in the age group.

Literature suggests this increase in stride length and H-H base of support asymmetry could be due to age-related changes occurring due to a general decline in motor control.[20] Furthermore, this could be attributed to the errors in the control of foot placement and centre of mass (COM) displacement.[21] This could be one of the reasons for asymmetric gait and could lead to falls. This study's findings corroborate with the literature that as age increases, there is an increase in the base of support to maintain balance and stability. These findings are consistent with the reports of Mbourou et al.[21] A decreasing asymmetry was observed in the mean difference between single support and swing. These results could be due to the hemispheric asymmetry reduction in older adults (HAROLDS) model or hemispheric asymmetry reduction in older adults. It is possible that the reduced motor asymmetry of older adults is due to the recruitment of bilateral networks and can serve as compensatory functions during motor tasks such as walking.[22]

Stance phase (% of gait cycle) was observed to be reducing suggesting that older individuals have adopted a faster velocity and cadence. However, this faster velocity and mildly increased cadence could be a result of the performance effect as the elderly population seemed to be enthusiastic to perform.

With the double support, there was a plateau after 50–79 years. Since the present study aimed at the healthy elderly population with no comorbidities, it can be extrapolated from the results obtained that the sample population was healthy and devoid of fear of falling. Maximum asymmetry was observed in all the temporal parameters in the age group of 50–59 and 60–69 years. This suggests that these are the transitory age groups. The motor control strategies/changes are modified in these age groups causing more left-to-right differences.

The analysis suggests that step time and cycle time serve as parameters for measuring gait symmetry, while step length, stride length, H-H base of support, swing (% of gait cycle), stance (% of gait cycle), single support (% of gait cycle), and double support (% of gait cycle) are parameters that indicate gait asymmetry. To establish a better understanding of the relationship between these parameters and other aspects of gait, further investigation is required. This may involve exploring how variations in these parameters impact different facets of gait.

Overall, this study shows the effect of age on gait parameters. This study also aimed in finding what is the amount of asymmetry present in normal healthy individuals in different spatiotemporal parameters across age groups. This asymmetry index value will help us identify pathological gait. An asymmetry index value above the stated value will indicate pathological gait and will help in identifying specific parameters affected and that information will help extrapolate the cause of the pathology.

The study only analyses spatiotemporal parameters of gait and does not consider other factors such as joint angle or muscle activity.

The study can be used to establish normative data for different age groups that can be used in clinical practice to identify deviations from typical gait patterns.

The results of the study can be used to identify factors that influence gait, such as aging or neurological disorders, and to develop interventions to improve gait performance.

The study can be used in the clinical setting for the diagnosis and treatment of gait disorders.

The study can also serve as a basis for the development of technology-based interventions for gait rehabilitation.


  Conclusions Top


This study establishes the symmetric and asymmetric parameters of gait across the age span and the asymmetry in spatial and temporal parameters.

This study determines the symmetrical and asymmetrical parameters of gait across the age span and the asymmetry of spatial and temporal parameters. The spatial asymmetric parameters identified were step length, stride length, and base of support, and the temporal asymmetric parameters were swing time, stance time, double support, and single support. The temporal parameters that were identified as symmetrical were step time and cycle time.

This study highlights the presence of both symmetrical and asymmetrical parameters in gait across different age groups. Understanding these differences can be helpful in identifying and treating gait abnormalities or injuries in individuals of different ages.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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