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Obesity Surgery, 15, 1238-1242

Gait Cinematic Analysis in Morbidly Obese Patients


Shirley Aparecida Fabris de Souza1; Joel Faintuch3; Antonio Carlos
Valezi2; Antonio Fernando SantAnna4; Joaquim Jos GamaRodrigues3; Ins Cristina de Batista Fonseca5; Roger Burgo Souza1;
Roger Christian Senhorini6
Departments of 1Physical Therapy, 2Gastroenterology, 4Cardiology, 5Experimental Statistics,
Londrina State University, Londrina, Brazil; 3Department of Gastroenterology, University of So
Paulo School of Medicine, So Paulo, Brazil; 6Physical Therapy student

Background: Functional co-morbidities of excess


body weight such as gait problems are never lifethreatening like those associated with certain metabolic sequelae. Nevertheless, they may interfere with
quality of life and also act as a mirror of muscle, bone
and joint stress. In this prospective study, the goal
was to document dynamic aspects of gait in severely
obese subjects.
Methods: An outpatient population (age 47.2 12.9
years, 94.1% females, BMI 40.1 6.0 kg/m2, n= 34) had
their gait analyzed by an experienced physical therapist. Variables included speed, cadence, stride, support base and foot angle, which were compared to reference values for the Brazilian population.
Results: All variables were significantly lower in the
obese patients, except for support base which was
increased. Speed was 73.316.3 vs 130 cm/s, cadence
was 1.40.2 vs 1.8 steps/s, stride was 106.813.1 vs
132.0 cm, and support was 12.53.5 vs 10.0 cm (P <0.05).
Conclusions: 1) Widespread cinematic impairment
was the rule in the studied population. 2) These findings are consistent with poor skeletal muscle performance, high metabolic expenditure and constant physical exhaustion. 3) Attention should be paid not only to
the metabolic management but also to the physical
rehabilitation required in cases of advanced obesity.
Key words: Obesity, gait, biomechanics, morbidly obesity,
rehabilitation, orthopedics
Reprint requests to: Shirley Aparecida Fabris de Souza,
Londrina State University, Hospital Universitrio, Av. Robert
Koch, 60, 86038-350 Londrina, Paran, Brazil.
E-mail: shirley@inbrapenet.com.br

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Obesity Surgery, 15, 2005

Introduction
Gait consists of a harmonious set of complex and
cyclical movements of the limbs through dynamic
interactions of internal and external forces.1
Interaction between these forces may lead to constant
imbalances during weight transference from one leg
to the other, when moving forward, trying to find the
center of gravity, through various mechanisms of a
complex system which involves neuronal, muscle
and skeletal functions, acting in constant integration,
even while performing different functions.2
Obesity is frequently associated co-morbidities
such as cardiovascular diseases, bone, muscle and
joint alterations, or risk factors like hypertension
and diabetes. Another consequence of obesity is a
deviation from normal gait pattern, with longer
stride cycles, low cadence and reduced speed, when
compared with non-obese individuals.3
This gait pattern is probably related to an increased
need for stabilization and settling of the body structures caused by obesity. The increased need for stabilization is the result of a wider contact angle of the
heel with the floor, secondary to genuvalgum, which
corresponds to lateral angulation of the leg in relation to the thigh (knock-knee) due to a larger thigh
and an overloading of the internal area in the knees.
Furthermore, excess weight reduces the mechanical
effectiveness of gait because of the shorter amplitude
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Cinematic Analysis of Gait in Morbidly Obese Patients

of movements, dyspnea, discomfort, early fatigue


and decreased capacity of shock absorption leading
to joint degradation. For an obese individual, the difficulties associated with increasing age, along with
the lack of regular physical activity, are capable of
making the gait dysfunctions even more severe. The
aim of this study was to document dynamic aspects
of gait in severely obese subjects.

Normal Gait
As noted above, gait consists of a harmonious set of
complex and cyclical movements of the body parts
through a dynamic interaction of the internal and
external forces.4 A complete cycle of the gait comprises two consecutive contacts of the same heel with
the floor, and the time interval between these two
contacts is called the length of gait cycle. Stride is
the distance covered during that period of time. The
time elapsed between the first contact of the heel on
the floor and the loss of contact of the same heel
determines the length of the support phase.5
Each phase of the gait has been divided into subphases of support (contact of the heel, contact of the
sole, medial support and deceleration), which comprises, altogether, 60% of the cycle of the gait. The
phase of swing (acceleration, medial swing and
deceleration) comprises the other 40% of the cycle.
Apart from the phases of swing and support, there
are only two other periods of weight bearing, which
happen during the weight transference from one leg
to the other, as both feet remain in contact with the
floor, and the two periods account together for 22%
of the gait cycle.2,5 Each individual have his/her own
gait pattern used to move effortlessly, with adequate
stability, rhythm and harmonious movements.5
The methodology used for interpreting the gait is
the variable stride, which describes motor patterns,
deviations, body postures and joint angles in specific
parts of the gait cycle.6 The cinematic analysis tries to
obtain data from the variables time and distances,
which might be impaired by factors such as age,
height, and gender, level of understanding, maturity
and the kind of shoes worn at the time. Speed (distance/time), cadence (number of steps/time), length
of step and stride (cm), support base (cm), and foot
angle (degrees)1 are all calculated in this analysis.
The average pattern of the measurements related
to distance/time for normal individuals are: velocity

130 cm/s; cadence 1.8 steps/s; length of step 66 cm;


and length of stride 132 cm.1 In relation to the base
of support, a normal value would range from 5 to
10 cm.2 Concerning the angle of foot positioning, a
high variability was identified in consecutives steps
of the same foot, leading to an average value of 6.8
degrees of abduction, with a variation of 2.4
degrees. When standing on the feet, 25% of the
weight is distributed to each calcaneus (50%) and
another 25% to the head of the five metatarsals for
each foot (50% for both feet).
Gait is not regularly included in the list of co-morbidities of obese individuals, but its assessment is
important because obesity leads to deviations that
interfere with the quality of life in these individuals.

Methods
In this prospective study, 34 patients (2 male and 32
female) were evaluated. The patients were selected
through the calculation of body mass index (BMI), and
the plantar printing test was carried out in the ones
who had BMI 35 kg/m2 (obese class II and III).
Variables included speed, cadence, stride, support base
and foot angle (Table 1).
The test consisted of patients walking along a 7meter long and 0.6-meter wide pathway of paper, on
a flat and uneven floor. Patients were asked to sit in
a chair, immerse their feet in black hydro-soluble
ink, and were instructed to stand up and start walking along the pathway of paper at their normal
speed, until the end of the pathway (Figures 1A and
B). The first and the last meters of the walk along

Table 1. Subject characteristics


N=34

Mean

Median

SD

Age (yr)
Height (m)
Weight (kg)
BMI (kg/m2)
Time (s)
Foot Angle ()

47.2
1.6
99.7
40.1
10.0
13.2

47.0
1.57
94.7
37.2
9.9
11.0

12.9
0.1
17.2
6.0
2.1
7.0

Values are incidence or mean (SD). m = metres. s = seconds.


= degrees.

Obesity Surgery, 15, 2005

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Souza et al

were performed by the same investigator, according


to the protocol for gait analysis proposed by Villar.2
The time elapsed between the first and the last touch
of the heel on the pathway of paper was measured
with the same chronometer for all patients, and was
recorded on their individual evaluation forms.
Values obtained through this analysis were compared to pre-established reference values for the
Brazilian population which are considered as normal.2 All patients signed a written consent.

Statistical Analysis
Data are presented as means, standard deviations
and percentage of normal. Comparison with reference values was performed using Students t-test. A
P-value 0.05 was considered significant.

A
Results
The study was conducted on an outpatient population
aged 47.212.9 years, 94.1% females, with BMI
40.16.0 kg/m2 It was observed that patients presented
with a wider support base (12.53.5 vs 10.0 cm), as
well as a reduction of speed (73.316.3 vs 130 cm/s),
cadence (1.40.2 vs 1.8 steps/s), and stride
(106.813.1 vs 132 cm) (Table 2) (P<0.05).
Other deviations such as dragging of the big toe,
lack of support on the fifth toe, pedis cavus (hollow
foot with high medial arch) and pedis planus (flat
foot or low medial arch) were also observed. In summary, the data from the analysis of the tests on these
obese patients gave significantly lower results than
the pattern described for non-obese individuals.

B
Table 2. Gait features and reference values
Figures 1A and B. Plantar impression test.
n=34

the pathway were discarded in the final evaluation,


and only the 5 meters in between them were
selected for analysis. This methodology is recommended in order to obtain better quality of foot
printing and regularity of speed. Measurements
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Obesity Surgery, 15, 2005

Mean SD

Min

Max Reference
Value

Speed (cm/s)
73.3 16.3 51.2 116.5
Cadence (steps/s) 1.4 0.2 1.0
1.8
Support base (cm) 12.5 3.5 5.0 20.7
Stride length (cm) 106.8 13.1 85.0 132.0
Step length (cm)
54.5 7.8 44.0 71.0

130.0
1.83
10.0
132.0
66.0

Cinematic Analysis of Gait in Morbidly Obese Patients

Discussion
Obesity is basically the result of a long-term positive energy balance. Although a number of studies
have approached several aspects of obesity, there are
few data in the literature concerning gait alterations
secondary to obesity. The values found in our study
reflect physiologic, or even pathologic, compensations related to morbid obesity, that result in an
adaptation of gait biomechanics in response to overload due to excessive body weight.
The results found in the present study showed
enlargement of the support base associated with an
increased foot angle. There is a re-adaptation of balance because of overloading and a larger body.
During the cycle of gait, the phases of swing and of
support are shortened. This shortening of both
phases leads to a decrease in the time of oscillation,
and as a consequence, each leg will be exposed to
body weight for a shorter time. It leads also to an
increase in the period of weight bearing, when both
feet are still in contact with the floor, during the
weight transference from one leg to the other, sharing the load. It was also observed that these deviations found during the gait cycle caused a reduction
in the size and stride of the step, which consequently
reduced the speed and the cadence of the gait.
Spyropolus et al3 in a study of 12 obese men,
reported that obese subjects walked significantly
slower, taking significantly shorter steps and strides
than non-obese subjects, and also presented significantly greater stride widths and longer gait cycle
time. The dragging of the big toe happens because of
the reduction in the length of stride, leading to a
reduction in the angle between foot and floor during
the acceleration period of the swing phase.7 This pattern is consistent with the slow body movements,
poor fitness and easy fatiguability of obese individuals, along with a large and unstable body mass,
requiring a wider base of support. In a follow-up
study, Hills and Parker8 found additional support for
their previous observations; they reported greater
stride, longer gait cycle, slower velocity, and longer
right step length in obese than in non-obese children.
The analysis of gait in the obese population allows
the description of a complex set of factors that might
be related to deficits, imbalances, limitations and disabilities, which are of fundamental importance for the

planning of an adequate therapeutic approach in a


rehabilitation process.9-11 It is important that further
studies, with longer follow-up, be undertaken in order
to obtain further knowledge of the effect of obesity on
daily life in this field, and to achieve a broader understanding of the gait of obese individuals.
Postural changes, musculoskeletal pain, and eventual degenerative arthritis of weight-bearing joints
and low back are well recognized with severe obesity.12-14 In addition, we found that widespread cinematic impairment of gait was the rule in the studied
population. These findings are consistent with poor
musculo-skeletal performance, high metabolic
expenditure and constant physical exhaustion.
Therefore, attention should be given not only to
metabolic management but also to physical rehabilitation of patients with advanced obesity.

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(Received June 7, 2005; accepted August 11, 2005)