Gait Development in the Growing Child: Difference between revisions

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Gait is defined as "[[Gait Definitions|upright locomotion in a particular manner of moving on foot which may be a walk, jog or run]]".
Gait is defined as "[[Gait Definitions|upright locomotion in a particular manner of moving on foot which may be a walk, jog or run]]".


A narrative review done by Wei Liu et al. (2022) further described gait as "... a movement pattern of limbs, especially lower limbs on a substrate, which can fulfill the primary need of locomotion and provide propulsion and support for the body." This definition itself was taken from 'Gait Analysis' written by M.W. Wittle (1991).<ref>Liu W, Mei Q, Yu P, Gao Z, Hu Q, Fekete G, István B, Gu Y. [https://www.mdpi.com/2227-9067/9/3/406#B1-children-09-00406 Biomechanical Characteristics of the Typically Developing Toddler Gait: A Narrative Review.] Children. 2022 Mar 13;9(3):406.</ref>
A narrative review done by Wei Liu et al. (2022) further described gait as " a movement pattern of limbs, especially lower limbs on a substrate, which can fulfill the primary need of locomotion and provide propulsion and support for the body." This definition itself was taken from 'Gait Analysis' written by M.W. Wittle (1991).<ref>Liu W, Mei Q, Yu P, Gao Z, Hu Q, Fekete G, István B, Gu Y. [https://www.mdpi.com/2227-9067/9/3/406#B1-children-09-00406 Biomechanical Characteristics of the Typically Developing Toddler Gait: A Narrative Review.] Children. 2022 Mar 13;9(3):406.</ref>


The first observed gait-type behavior can be seen is at birth, with the flexion-extension of the legs when the infant is held over a support surface. With this observed, recent studies demonstrate that only 70-84% of healthy infants will demonstrate step-like patterns and only 25% will use a left-right patterning of stepping. More observable than a stereotypical stepping pattern is a variety of limb movements which are noted to be reproductions of limb movements in the womb.<ref name=":2" />
=== When Does Gait Development Start? ===
The first observed gait-type behaviour can be seen is at birth, with the flexion-extension of the legs when an infant is held over a support surface and moved slowly across the support surface. With this observed, recent studies demonstrate that only 70-84% of healthy infants will demonstrate step-like patterns and only 25% will use a left-right patterning of stepping. More observable than a stereotypical stepping pattern is a variety of limb movements which are noted to be reproductions of limb movements in the womb.<ref name=":2">Teulier Caroline, Lee Do Kyeong, Ulrich Beverly D. [https://hal.science/hal-03551416/document Early Gait Development in Human Infants: Plasticity and Clinical Applications.] Developmental Psychobiology. 2015:57:447-458.  </ref>


The initiation of independent gait is generally considered to be around 12 months of age. However, Wei Liu's review cited that up to 10% of children at 12 months had difficulty with this milestone at 12 months. Furthermore, in a study done by the WHO in 2006 independent ambulation (without support) occurred across a spectrum of 8 to 18 months.<ref>Martorell R. de Onis M. Martines J. Black M. Onyango A. Dewey K. [https://cdn.who.int/media/docs/default-source/child-growth/child-growth-standards/indicators/motor-development-milestones/who-motor-development-study-windows-of-achievement-for-six-gross-motor-development-milestones.pdf?sfvrsn=3425c1dc_0 WHO Motor Development Study: Windows of achievement for six gross motor development milestones] WHO MULTICENTRE GROWTH REFERENCE STUDY GROUP1,2 1. Acta Pediatrica. 2006. Suppl 450:86-95.</ref>
The initiation of independent gait is generally considered to be around 12 months of age. However, Wei Liu's review cited that up to 10% of children at 12 months had difficulty with this milestone at 12 months. Furthermore, in a study done by the WHO (World Health Organization) in 2006 independent ambulation (without support) occurred across a spectrum of 8 to 18 months.<ref>Martorell R. de Onis M. Martines J. Black M. Onyango A. Dewey K. [https://cdn.who.int/media/docs/default-source/child-growth/child-growth-standards/indicators/motor-development-milestones/who-motor-development-study-windows-of-achievement-for-six-gross-motor-development-milestones.pdf?sfvrsn=3425c1dc_0 WHO Motor Development Study: Windows of achievement for six gross motor development milestones] WHO MULTICENTRE GROWTH REFERENCE STUDY GROUP1,2 1. Acta Pediatrica. 2006. Suppl 450:86-95.</ref>
== Ages and Stages of Gait ==
At birth reflex stepping is observed, as described above. This persists until 2-3 months of age, disappears and then re-emerges close to the onset of autonomous walking.<ref name=":2" />
[[File:1 year old gait.jpg|thumb|Early autonomous gait]]
With the start of autonomous walking, there is flat-footed stepping, with the emergence of heel strike around 18 months. There is no arm swing, rather upper limbs are kept in a 'high guard' position. Persistent knee flexion, along with hip abduction and external rotation is also observed. There is also short steps, a rapid cadence and generally a large degree of pelvic rotation.<ref name=":3">University of Oklahoma Health Sciences Center. Changes in gait pattern across the lifespan. Available from: https://ouhsc.edu/bserdac/dthompso/web/gait/matgait/matgait.htm (accessed 11/04/2023)</ref><ref>DinoPT. Paediatric gait. Available from: https://blog.dinopt.com/pediatric-gait/ (accessed 11/04/2023)</ref>


In recent research, it has been recognised that gait development not only occurs across a varied time span but also with varied observable development. Factors that influence gait development include:
In a study performed by McCollum et al. (1994) 3 basic walking forms were identified:<ref>McCollum G, Holroyd C, Castelfranco AM. [https://www.academia.edu/26789041/Forms_of_Early_Walking Forms of early walking]. Journal of Theoretical Biology. 1995 Oct 7;176(3):373-90.</ref>


* Age
# The Twister - Who winds up the trunk like a spring and then swings a leg around using the torque and angular momentum of the trunk. In this form the feet stay about the same width apart. Balance is easily maintained with no forward momentum generated and feet kept wide apart.
* Walking experience
# The Faller - Who exchanges gravitational potential energy for kinetic. This child moves forward onto tiptoe for a moment, with the fall forward allowing the swing leg to be brought forward to break the fall and downward momentum being converted to forward momentum. The Faller is brought back to the original stance leg by a quick step close to the ground. Balance is precarious and the Faller is unable to stop.
* Body dimensions
# The Stepper - Uses conservation/balance strategy. This child uses very small excursions of the feet, i.e., short steps are made from a stable, balanced double stance. Balance is solid due to the double stance phase.
* Maturation of the central nervous system
<br>
* Muscle-fat ratio
Within 3 months of independent walking a child will most likely walk with feet set in parallel lines. Balance also being controlled and with a definite step present.
* Development of the musculoskeletal system
* Head-trunk postural stability


By the age of 2, a child will demonstrate heel strike and reciprocal arm swing. Along with less hip abduction and external rotation. Single leg stance phase is still decreased when compared to a mature gait and the ankles may not move from dorsiflexion to plantar flexion until 50% of the gait cycle. This may be indicative of poor eccentric control.<ref name=":3" />


The development of gait incorporates components such as maximizing step frequency (cadence), gait symmetry, balance control, and stability, of the gait cycle. The function of these components are facilitated with structural development and neural control of movement. <ref name=":1" />  
Generally by age 3, what can be described as a mature gait is present. There are however gait dynamics such as stride-to-stride variability which is seen to change in ages up and beyond 7 years of age, which indicate that even in later childhood years, gait continues to evolve and mature.<ref name=":0">Hausdorff J.M, L. Zemany, C.K Peng, A.L Goldberger. [https://journals.physiology.org/doi/full/10.1152/jappl.1999.86.3.1040?rfr_dat=cr_pub++0pubmed&url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org Maturation of gait dynamics: stride-to-stride variability and its temporal organization in children.] Journal of Applied Physiology. 1999:86(3):1040–1047.</ref>


The development of gait is categorized into six stages: infant stepping, inactive period, supported locomotion, unsupported locomotion, mature similar gait, and mature gait. <ref name=":1">Muller Juliane, Muller Steffen, Baur Heiner, Mayer Frank. [https://www.sciencedirect.com/science/article/abs/pii/S0966636213001252 Intra-individual gait speed variability in healthy children aged 1–15 years.] Gait & Posture. 2013:38:631-636.
Children between 7 and 8 years old are able to achieve independent control of each anatomical segment with walking, and thus maintain a stable posture during gait compared to children between 3 and 6 years old. The reduction in gait speed variability as children age could be due to improvements in balance control and posture. It is seen that gait development progresses until the age of 8. <ref name=":1">Muller Juliane, Muller Steffen, Baur Heiner, Mayer Frank. [https://www.sciencedirect.com/science/article/abs/pii/S0966636213001252 Intra-individual gait speed variability in healthy children aged 1–15 years.] Gait & Posture. 2013:38:631-636.
</ref>
</ref>


In the developing child, large stride-to-stride variations are seen, including frequent falls, due to the immature control of posture and gait. <ref name=":1" /><ref name=":0">Hausdorff J.M, L. Zemany, C.K Peng, A.L Goldberger. [https://journals.physiology.org/doi/full/10.1152/jappl.1999.86.3.1040?rfr_dat=cr_pub++0pubmed&url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org Maturation of gait dynamics: stride-to-stride variability and its temporal organization in children.] Journal of Applied Physiology. 1999:86(3):1040–1047.</ref>
It should be noted that different features of stride dynamics develop at different times, hence no two features develop at the same time and there are differences between children of the same age <ref name=":0" />.  


Children at the age of 3 years are seen to have a mature gait. Any unsteadiness that can be visually observed develops into a stable gait pattern. However, this does not mean that the gait has been fully matured. Gradual and progressive development in neuromuscular control and locomotor function continue beyond this age. There may be decreased variability in gait after this age. <ref name=":0" />
It has been generally accepted that gait maturation occurs between 5 and 7 years of age. However, it has been noted by Juliane et al., (2013) that children between 7 and 8 years of age achieve greater control of independent anatomical segments during gait when compared with those between the ages of 3 and 6 years old. Furthermore, Juliane's article further cites that until the end of puberty, changes in body structure and sensory motor development have been observed to occur which have an influence on gait development. <ref name=":1" />


During the maturation stage, gait speeds increase to mature values. Despite factors influencing gait and gait speed, such as growth and neuromaturation, that are not fully developed, mature gait is said to be reached at the ages of 5-7 years. Until the end of puberty, changes in body structure and sensory motor development occur. <ref name=":1" />
When categorised the development of gait can be placed into 6 stages:<ref name=":1" />


It is seen that healthy infants generally display organization of thoughts and discovery of new movement patterns, including walking. It is believed that some of these patterns are programmed into the genetic code. <ref name=":2">Teulier Caroline, Lee Do Kyeong, Ulrich Beverly D. [https://hal.science/hal-03551416/document Early Gait Development in Human Infants: Plasticity and Clinical Applications.] Developmental Psychobiology. 2015:57:447-458.  </ref>
# Infant stepping
# Inactive period
# Supported locomotion
# Unsupported locomotion
# Mature similar gait
# Mature gait.  
== Influences in Gait Development ==
In recent research, it has been recognised that gait development not only occurs across a varied time span but also with varied observable development of different systems. Factors that influence gait development include:


== Development and Neuroplasticity ==
* Age
The primary action of neonates that represent gait occurs when they react to tactile sensations by producing alternating flexion and extension of their legs and are slowly moved forward on the support surface. This is seen for up to 2-3 months, and then disappears. It reappears around the age of autonomous walking. It is seen that if newborn stepping was trained everyday from birth, then this pattern did not necessarily disappear, but led to an earlier pattern of walking. Infants were able to produce this pattern after 3 months of age, even in different environments and contexts. This reflex could be a factor leading to the ability to walk on two feet, which can be primed with practice. However, stepping could be a phenomenon that can contribute to walking, and the action of walking itself is a skill to be learned. <ref name=":2" />
* Walking experience
 
* Body dimensions/ biomechanical development
Despite newborns producing a stepping like pattern with the flexion and extension of their lower limbs, only 70-84% of newborns are able to activate their tactile sensation through producing step-like walking patterns. Infact, newborns can produce various lower limb movement patterns, moving one leg or two legs, or alternating leg movements. These movements originate in utero. <ref name=":2" />
* Musculoskeletal development (strength and range)<ref name=":2" />
 
* Sensory development (response to tactile input and proprioceptive input of compressed joints in the gait cycle)<ref name=":2" />
With early stepping there is great variability due to the different possible leg position when the babies are supported in an upright position. Babies have a natural tendency to explore their environment as well. This increases due to the underlying motor and sensory systems, which are better myelinated as the babies move and grow. <ref name=":2" />   
* Neurological: Maturation of the central nervous system
 
* Muscle-fat ratio
A low frequency of stepping movements may be associated with low levels of arousal. However, variability of stepping frequency is high, even when the arousal is 'optimal'. With these observations, it is seen that stepping activity in newborns is not preset or ingrained, but is quite plastic, and develops through time and repetition of practice. <ref name=":2" />
* Development of the musculoskeletal system
 
* Head-trunk postural stability
Between the age of 3 and 4 months, infants experience a gradual increase in stepping frequency and percent of continuously alternating steps, due to the infants' increasing strength and weight, thus increasing favorable contact with the support surface. This helps explain the infants' development of leg extensor and hip abductor strength. At this stage, they are able to accept more weight on their legs. At six to seven months of age, the infants are able to produce alternating steps when supported on a moving treadmill. <ref name=":2" />
* Environmental factors
 
Infants that are 1-year old, have strong plasticity in behavioural outcome and neuro-muscular activation, for the development of stepping ability. Stepping develops from the association between an infant's maturation and the environment, which refers to the concepts of nature and nurture. <ref name=":2" />
 
This movement most likely occurs through a combination of active neural input, and passive dynamics, biomechanics of lower limb rotation with the effect of gravity. <ref name=":2" />
 
Overall, it is seen that meaningful and progressively difficult practice of stepping have a long-term effect on functional neuromotor pathways. <ref name=":2" /> 
 
=== Muscle Activity ===
The development of the neuromuscular pathways is explained through EMG activity of infants that showed basic rhythmic muscular activity at birth, which would develop into an adult-like stepping pattern by two years of age. <ref name=":2" />


There is also random timing of muscle activation. Subsequent steps taken are not seen to be the same as the previous one in a series of steps, with different muscles firing, frequency, duration, and timing. <ref name=":2" />


With the dynamic system, and variability of movement, the neuromuscular plasticity is an essential component of learning. We are able to find pattens that 'fit' the task, and then we can strengthen it, or prime it, with practice. <ref name=":2" />
The above factors influence components of gait development including:<ref name=":1" />
== Gait at Different Age Levels ==
Children between 7 and 8 years old are able to achieve independent control of each anatomical segment with walking, thus maintain a stable posture during gait compared to children between 3 and 6 years old. The reduction in gait speed variability as children age could be due to improvements in balance control and posture. It is seen that gait development increases until the age of 8. <ref name=":1" />


It should be noted that different features of stride dynamics develop at different times, hence no two features develop to the same time. <ref name=":0" /> There are differences between children of the same age. <ref name=":1" /> 
* Step Frequency (cadence)
* Gait Symmetry
* Balance Control
* General Stability


Occasionally, the adult gait pattern is seen to show variability between strides. It is seen that the healthy adult locomotor system has a 'memory' where the change from alternating strides shows a gradual 'hidden' temporal structure that is associated with a long range fractal organization. In individuals with neurological disease or the elderly, especially those who experience frequent falls, there is an increase in stride-to-stride variability, and there is altered temporal organization of stride time dynamics. <ref name=":0" />
== Stepping in Gait Development ==
Stepping, while initially a reflexive movement, is a component which when integrated with other motor and sensory components, contributes to walking as a learnt skill. It is interesting to note that a neonate's stepping reflex shows variability in patterns as well as frequency when compared from one individual to another. In addition, '''step frequency''' and '''variability''' are also influenced by '''environment''' and '''level of arousal'''. These observations highlight the fact that stepping in the newborn is not preset or ingrained, rather it develops with time and repetition of practice. This demonstrates the adaptability of the neural system and a level of neural plasticity.<ref name=":2" />


It is likely that mature locomotion dynamics may be evident when all the contributing components are completely functioning. <ref name=":0" />  
In an longitudinal study performed by Thelen (1986a) babies were put onto a baby treadmill at varying ages. Throughout their development they demonstrated adaptive gait reactions to the speed of the treadmill as well as direction - babies being able to learn to walk backwards.<ref name=":2" />


Gait speed is also commonly used to assess gait development. It is one of the basic characteristics used to assess and analyze gait parameters. There is high variability when comparing different steps taken in children. Age and body height are two factors which contribute to varying walking speed. <ref name=":1" />
From a '''neuromuscular''' aspect of development, the variability in muscle activations observed during early stepping is the same seen in other developmental tasks. Once again showing a multi-system (neural, muscular and sensory) which is plastic and adaptable.<ref name=":2" />


== Gait Speed ==
== Gait Speed ==
An individual's gait speed has an influence on their kinematics and kinetics during gait. Thus, from a study by Stansfied et al, 2001, it was shown that walking speed, not age, has the primary influence on gait kinematics and kinetics in growing children. Speed has a similar effect on muscle activity. At very slow speeds, although muscle activity wouldn't bee expected, there is gradual activation noticed in muscle activity due to the increased stability demands. <ref>Schwartz Michael H, Rozumalski Adam, Trost Joyce P. [https://pubmed.ncbi.nlm.nih.gov/18466909/ The effect of walking speed on the gait of typically developing children.] Journal of Biomechanics. 2008:41:1639-1650. </ref> 
Gait speed is commonly used to assess gait development. It is one of the basic characteristics used to assess and analyse gait parameters.  <ref name=":1" />
 
It is seen that gait speed gradually increases with age and height, up to the age of 15 years, thus it follows that age and body height are some of the determinant factors for walking speed variability. Younger children do have a lower gait speed, while older children have a higher gait speed. <ref name=":1" />  
 
It is seen that walking speed can increase up to the age of 8 years, whereas an enhanced walking speed develops up to the age of 15. However, regardless of age, body height changes display a more uniform increase in walking speed, showing that waling speed is dependent on segment (leg) length and body height. <ref name=":1" />
 
Children at 1 year of age had the slowest walking speed. It is seen that walking speed increases every year as children age, until the age of 15 years. Standard deviations for 1 and 2 year old age groups were the highest, and were the lowest for the 15 years age group. <ref name=":1" />    


The youngest and smallest children displayed the highest variability. The respective phase of motor control learning has a high error rate, a weak reproducibility, and reduced stability. In toddlers, there would be higher variability due to the lack of postural control, efficient integration of afferent information, and supraspinal control. <ref name=":1" />
A study performed by Stansfied et al, 2001, demonstrated that '''walking speed''', not age, has a primary influence on gait '''kinematics''' and '''kinetics''' in growing children. In this study, age and height were deemed factors in the speed of gait. As expected younger children had a lower gait speed, while older children had a higher gait speed. However, regardless of age, body height changes displayed a more uniform increase in walking speed, showing that walking speed was dependent on segment (leg) length and body height as well. <ref name=":1" />


== Stride to Stride Variation ==
Both speed and the demands for stability in motion has an effect on muscle activity. At very slow speeds, although muscle activity wouldn't be expected, there is gradual activation noticed in muscle activity due to the increased stability demands. <ref>Schwartz Michael H, Rozumalski Adam, Trost Joyce P. [https://pubmed.ncbi.nlm.nih.gov/18466909/ The effect of walking speed on the gait of typically developing children.] Journal of Biomechanics. 2008:41:1639-1650.  </ref>
=== Stride to Stride Variation ===
Successive stride-to-stride changes represents the time between one stride and the previous stride. The degree of stride-to-stride variability decreases as healthy children mature. <ref name=":0" />   
Successive stride-to-stride changes represents the time between one stride and the previous stride. The degree of stride-to-stride variability decreases as healthy children mature. <ref name=":0" />   


Stride-to-stride variability is largest in the 4-year old group, a little smaller in the 7-year old group, and the smallest in the 11-year old group. It is seen that there is a highly significant effect of age on variability. The SD (standard deviation) and CV (coefficient of variation) was higher in the 3-4 age group, than the 6-7 age group, and this was higher than the 11-14 age group. The stride-to-stride variability in the 11-14 years age group was similar to that found in healthy young adults. Through observation, even though it may appear that the stride dynamics of children are similar to those of adults, quantitatively it is seen that stride-to-stride control of gait dynamics is not fully matured by the age of 7. <ref name=":0" />
Stride-to-stride variability is largest in the 4-year old group, a little smaller in the 7-year old group, and the smallest in the 11-year old group. It is seen that there is a highly significant effect of age on variability. In a study performed by Hausdorff et al., (1999) the SD (standard deviation) and CV (coefficient of variation) for stride-to-stride variation was higher in the 3-4 age group than the 6-7 age group, and this was higher than the 11-14 age group. The stride-to-stride variability in the 11-14 years age group was similar to that found in healthy young adults. Through observation, even though it may appear that the stride dynamics of children are similar to those of adults, quantitatively it is seen that stride-to-stride control of gait dynamics is not fully matured by the age of 7. <ref name=":0" />  
 
Analyzing stride time dynamics in children may provide insight into the development of neuromuscular control. Stride time dynamics would not be fully matured by the age of 3. The variability of stride time dynamics in younger children can be caused by many factors. It can be caused by a decreased walking speed, and thus decreased postural stability at the lower speeds. <ref name=":0" />
 
==== Stride Dynamics and Height ====
It is seen that after a certain age range, stride length increases linearly with age. However, the relationship between stride length and age becomes constant subsequent to accounting for height or leg length. <ref name=":0" />
 
It is seen that there is a significant increase in walking speed in the 6-7 year old age group, compared to the 3-4 year old age group. However, relative velocity (velocity/height) was identical in these age groups. <ref name=":0" />
 
The studies also showed that the average values of stride time and walking velocity were age dependent. These average values were lowest in the 3-4 age group, moderate in the 6-7 age group, and highest in the 11-14 age group. <ref name=":0" />
 
In addition, it is seen that the temporal structure of gait variability is not fully developed in 7-year old children, whereas in the 11-14 year old age group the stride dynamics are similar to those found in healthy adults. <ref name=":0" />   
 
== Interesting Information ==
Gait patterns in children are similar to those in elderly adults. This may be due to the emergence of primitive reflexes in elderly adults, or reduced balance control. There is also a similarity with the stride dynamics, seen between children, elderly adults, and individuals with neurological impairments. <ref name=":0" />  


There are some important differences to note. It is seen that, throughout the lifespan, there is a negative relationship in the fractal scaling index. It is highest in children, lower in adults, and the lowest in elderly adults and those with neurological conditions. <ref name=":0" />
Analysing stride time dynamics in children may provide insight into the development of neuromuscular control.  
== Implications for Physiotherapy ==


Stride variability is seen to change in a U-shaped fashion, with it being high in children, low in adults, and high in elderly adults and those with neurological conditions. <ref name=":0" />      
* '''Early intervention:''' With gait being an aspect of motor control being developed as early as in-utero, early intervention for those infants with known neuromotor disabilities should be taken as early as possible. Active intervention should not be with held until gait is attempted/ initiated by the infant.<ref name=":2" />
* '''Movement is 1. Goal directed and 2. Influenced by the individual and environment:''' Self-organization and discovery of new movement patterns are goal driven and are directed by an individual's ability and their environment. These should always be held in regard when facilitating patterns of movement and skill acquisition.<ref name=":2" />
* '''Skill acquisition requires practice and repetition'''.<ref name=":2" />
* '''Motor learning involves multiple systems:''' When considering motor sensory training, it is important to bring in aspects of tactile, proprioception and even vision stimulation.<ref name=":2" />
* '''Partial body-weight treadmill training may be used as a therapeutic intervention.''' Evidence suggests it acts on the sensory, motor, neural and musculoskeletal systems.<ref name=":2" />


== Resources ==
== Resources ==
Here are two related pages concerning gait and pediatrics:
Related pages:
 
* [[Gait Analysis in Cerebral Palsy]]
* [[Gait Analysis in Cerebral Palsy]]
* [[Gait and Lower Limb Observation of Paediatrics - (GALLOP)|Gait and Lower Limb Observation of the Lower Limb of Paediatrics - (GALLOP)]]
*[[Gait and Lower Limb Observation of Paediatrics - (GALLOP)|Gait and Lower Limb Observation of the Lower Limb of Paediatrics - (GALLOP)]] Video summaries of gait development:
 
  <div class="col-md-4"> {{#ev:youtube|sy9fO-uy28Q|250}} <div class="text-right"><ref>Mission Gait. Normal Pediatric Gait Development - 12 Months. Available from: https://www.youtube.com/watch?v=sy9fO-uy28Q [last accessed 27/03/2023]</ref></div></div>
 
  <div class="col-md-4"> {{#ev:youtube|Z6dnbjN594o|250}} <div class="text-right"><ref>Mission Gait. Normal Pediatric Gait Development - 18 Months. Available from: https://www.youtube.com/watch?v=Z6dnbjN594o [last accessed 27/03/2023]</ref></div></div>
Here are some videos for a visual, and to better explain gait development in the child:
<div class="col-md-4"> {{#ev:youtube|A2g8WoaH9s0|250}} <div class="text-right"><ref>Mission Gait. Pediatric Gait - 24 Months. Available from: https://www.youtube.com/watch?v=A2g8WoaH9s0 [last accessed 27/03/2023]</ref></div></div>
 
This is a cute video displaying the gait of a healthy 12 month old child:
{{#ev:youtube|sy9fO-uy28Q}}
 
<ref>Mission Gait. Normal Pediatric Gait Development. Available from: https://www.youtube.com/watch?v=sy9fO-uy28Q&ab_channel=MissionGait (Accessed 31/12/2022)  </ref>


This is a presentation on the walking gait development through the four stages of life: Early Childhood, Childhood, Adulthood, and Older Adulthood.
A presentation on the walking gait development through the four stages of life: Early Childhood, Childhood, Adulthood, and Older Adulthood.
{{#ev:youtube|DJ5zYgTiDp0}}<ref>Brantly R. Walking Gait Development pt1. Available from: https://www.youtube.com/watch?v=DJ5zYgTiDp0&ab_channel=RobertBrantly (accessed 31/12/2022)  </ref>
{{#ev:youtube|DJ5zYgTiDp0}}<ref>Brantly R. Walking Gait Development pt1. Available from: https://www.youtube.com/watch?v=DJ5zYgTiDp0&ab_channel=RobertBrantly (accessed 31/12/2022)  </ref>


Latest revision as of 15:11, 26 June 2023

Original Editor - Kapil Narale

Top Contributors - Kapil Narale, Lauren Heydenrych, Naomi O'Reilly, Kim Jackson and Rishika Babburu  

Introduction[edit | edit source]

Gait is defined as "upright locomotion in a particular manner of moving on foot which may be a walk, jog or run".

A narrative review done by Wei Liu et al. (2022) further described gait as " a movement pattern of limbs, especially lower limbs on a substrate, which can fulfill the primary need of locomotion and provide propulsion and support for the body." This definition itself was taken from 'Gait Analysis' written by M.W. Wittle (1991).[1]

When Does Gait Development Start?[edit | edit source]

The first observed gait-type behaviour can be seen is at birth, with the flexion-extension of the legs when an infant is held over a support surface and moved slowly across the support surface. With this observed, recent studies demonstrate that only 70-84% of healthy infants will demonstrate step-like patterns and only 25% will use a left-right patterning of stepping. More observable than a stereotypical stepping pattern is a variety of limb movements which are noted to be reproductions of limb movements in the womb.[2]

The initiation of independent gait is generally considered to be around 12 months of age. However, Wei Liu's review cited that up to 10% of children at 12 months had difficulty with this milestone at 12 months. Furthermore, in a study done by the WHO (World Health Organization) in 2006 independent ambulation (without support) occurred across a spectrum of 8 to 18 months.[3]

Ages and Stages of Gait[edit | edit source]

At birth reflex stepping is observed, as described above. This persists until 2-3 months of age, disappears and then re-emerges close to the onset of autonomous walking.[2]

Early autonomous gait

With the start of autonomous walking, there is flat-footed stepping, with the emergence of heel strike around 18 months. There is no arm swing, rather upper limbs are kept in a 'high guard' position. Persistent knee flexion, along with hip abduction and external rotation is also observed. There is also short steps, a rapid cadence and generally a large degree of pelvic rotation.[4][5]

In a study performed by McCollum et al. (1994) 3 basic walking forms were identified:[6]

  1. The Twister - Who winds up the trunk like a spring and then swings a leg around using the torque and angular momentum of the trunk. In this form the feet stay about the same width apart. Balance is easily maintained with no forward momentum generated and feet kept wide apart.
  2. The Faller - Who exchanges gravitational potential energy for kinetic. This child moves forward onto tiptoe for a moment, with the fall forward allowing the swing leg to be brought forward to break the fall and downward momentum being converted to forward momentum. The Faller is brought back to the original stance leg by a quick step close to the ground. Balance is precarious and the Faller is unable to stop.
  3. The Stepper - Uses conservation/balance strategy. This child uses very small excursions of the feet, i.e., short steps are made from a stable, balanced double stance. Balance is solid due to the double stance phase.


Within 3 months of independent walking a child will most likely walk with feet set in parallel lines. Balance also being controlled and with a definite step present.

By the age of 2, a child will demonstrate heel strike and reciprocal arm swing. Along with less hip abduction and external rotation. Single leg stance phase is still decreased when compared to a mature gait and the ankles may not move from dorsiflexion to plantar flexion until 50% of the gait cycle. This may be indicative of poor eccentric control.[4]

Generally by age 3, what can be described as a mature gait is present. There are however gait dynamics such as stride-to-stride variability which is seen to change in ages up and beyond 7 years of age, which indicate that even in later childhood years, gait continues to evolve and mature.[7]

Children between 7 and 8 years old are able to achieve independent control of each anatomical segment with walking, and thus maintain a stable posture during gait compared to children between 3 and 6 years old. The reduction in gait speed variability as children age could be due to improvements in balance control and posture. It is seen that gait development progresses until the age of 8. [8]

It should be noted that different features of stride dynamics develop at different times, hence no two features develop at the same time and there are differences between children of the same age [7].

It has been generally accepted that gait maturation occurs between 5 and 7 years of age. However, it has been noted by Juliane et al., (2013) that children between 7 and 8 years of age achieve greater control of independent anatomical segments during gait when compared with those between the ages of 3 and 6 years old. Furthermore, Juliane's article further cites that until the end of puberty, changes in body structure and sensory motor development have been observed to occur which have an influence on gait development. [8]

When categorised the development of gait can be placed into 6 stages:[8]

  1. Infant stepping
  2. Inactive period
  3. Supported locomotion
  4. Unsupported locomotion
  5. Mature similar gait
  6. Mature gait.

Influences in Gait Development[edit | edit source]

In recent research, it has been recognised that gait development not only occurs across a varied time span but also with varied observable development of different systems. Factors that influence gait development include:

  • Age
  • Walking experience
  • Body dimensions/ biomechanical development
  • Musculoskeletal development (strength and range)[2]
  • Sensory development (response to tactile input and proprioceptive input of compressed joints in the gait cycle)[2]
  • Neurological: Maturation of the central nervous system
  • Muscle-fat ratio
  • Development of the musculoskeletal system
  • Head-trunk postural stability
  • Environmental factors


The above factors influence components of gait development including:[8]

  • Step Frequency (cadence)
  • Gait Symmetry
  • Balance Control
  • General Stability

Stepping in Gait Development[edit | edit source]

Stepping, while initially a reflexive movement, is a component which when integrated with other motor and sensory components, contributes to walking as a learnt skill. It is interesting to note that a neonate's stepping reflex shows variability in patterns as well as frequency when compared from one individual to another. In addition, step frequency and variability are also influenced by environment and level of arousal. These observations highlight the fact that stepping in the newborn is not preset or ingrained, rather it develops with time and repetition of practice. This demonstrates the adaptability of the neural system and a level of neural plasticity.[2]

In an longitudinal study performed by Thelen (1986a) babies were put onto a baby treadmill at varying ages. Throughout their development they demonstrated adaptive gait reactions to the speed of the treadmill as well as direction - babies being able to learn to walk backwards.[2]

From a neuromuscular aspect of development, the variability in muscle activations observed during early stepping is the same seen in other developmental tasks. Once again showing a multi-system (neural, muscular and sensory) which is plastic and adaptable.[2]

Gait Speed[edit | edit source]

Gait speed is commonly used to assess gait development. It is one of the basic characteristics used to assess and analyse gait parameters. [8]

A study performed by Stansfied et al, 2001, demonstrated that walking speed, not age, has a primary influence on gait kinematics and kinetics in growing children. In this study, age and height were deemed factors in the speed of gait. As expected younger children had a lower gait speed, while older children had a higher gait speed. However, regardless of age, body height changes displayed a more uniform increase in walking speed, showing that walking speed was dependent on segment (leg) length and body height as well. [8]

Both speed and the demands for stability in motion has an effect on muscle activity. At very slow speeds, although muscle activity wouldn't be expected, there is gradual activation noticed in muscle activity due to the increased stability demands. [9]

Stride to Stride Variation[edit | edit source]

Successive stride-to-stride changes represents the time between one stride and the previous stride. The degree of stride-to-stride variability decreases as healthy children mature. [7]

Stride-to-stride variability is largest in the 4-year old group, a little smaller in the 7-year old group, and the smallest in the 11-year old group. It is seen that there is a highly significant effect of age on variability. In a study performed by Hausdorff et al., (1999) the SD (standard deviation) and CV (coefficient of variation) for stride-to-stride variation was higher in the 3-4 age group than the 6-7 age group, and this was higher than the 11-14 age group. The stride-to-stride variability in the 11-14 years age group was similar to that found in healthy young adults. Through observation, even though it may appear that the stride dynamics of children are similar to those of adults, quantitatively it is seen that stride-to-stride control of gait dynamics is not fully matured by the age of 7. [7]

Analysing stride time dynamics in children may provide insight into the development of neuromuscular control.

Implications for Physiotherapy[edit | edit source]

  • Early intervention: With gait being an aspect of motor control being developed as early as in-utero, early intervention for those infants with known neuromotor disabilities should be taken as early as possible. Active intervention should not be with held until gait is attempted/ initiated by the infant.[2]
  • Movement is 1. Goal directed and 2. Influenced by the individual and environment: Self-organization and discovery of new movement patterns are goal driven and are directed by an individual's ability and their environment. These should always be held in regard when facilitating patterns of movement and skill acquisition.[2]
  • Skill acquisition requires practice and repetition.[2]
  • Motor learning involves multiple systems: When considering motor sensory training, it is important to bring in aspects of tactile, proprioception and even vision stimulation.[2]
  • Partial body-weight treadmill training may be used as a therapeutic intervention. Evidence suggests it acts on the sensory, motor, neural and musculoskeletal systems.[2]

Resources[edit | edit source]

Related pages:

[10]
[11]
[12]

A presentation on the walking gait development through the four stages of life: Early Childhood, Childhood, Adulthood, and Older Adulthood.

[13]

References[edit | edit source]

  1. ↑ Liu W, Mei Q, Yu P, Gao Z, Hu Q, Fekete G, István B, Gu Y. Biomechanical Characteristics of the Typically Developing Toddler Gait: A Narrative Review. Children. 2022 Mar 13;9(3):406.
  2. ↑ 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 2.11 Teulier Caroline, Lee Do Kyeong, Ulrich Beverly D. Early Gait Development in Human Infants: Plasticity and Clinical Applications. Developmental Psychobiology. 2015:57:447-458.
  3. ↑ Martorell R. de Onis M. Martines J. Black M. Onyango A. Dewey K. WHO Motor Development Study: Windows of achievement for six gross motor development milestones WHO MULTICENTRE GROWTH REFERENCE STUDY GROUP1,2 1. Acta Pediatrica. 2006. Suppl 450:86-95.
  4. ↑ 4.0 4.1 University of Oklahoma Health Sciences Center. Changes in gait pattern across the lifespan. Available from: https://ouhsc.edu/bserdac/dthompso/web/gait/matgait/matgait.htm (accessed 11/04/2023)
  5. ↑ DinoPT. Paediatric gait. Available from: https://blog.dinopt.com/pediatric-gait/ (accessed 11/04/2023)
  6. ↑ McCollum G, Holroyd C, Castelfranco AM. Forms of early walking. Journal of Theoretical Biology. 1995 Oct 7;176(3):373-90.
  7. ↑ 7.0 7.1 7.2 7.3 Hausdorff J.M, L. Zemany, C.K Peng, A.L Goldberger. Maturation of gait dynamics: stride-to-stride variability and its temporal organization in children. Journal of Applied Physiology. 1999:86(3):1040–1047.
  8. ↑ 8.0 8.1 8.2 8.3 8.4 8.5 Muller Juliane, Muller Steffen, Baur Heiner, Mayer Frank. Intra-individual gait speed variability in healthy children aged 1–15 years. Gait & Posture. 2013:38:631-636.
  9. ↑ Schwartz Michael H, Rozumalski Adam, Trost Joyce P. The effect of walking speed on the gait of typically developing children. Journal of Biomechanics. 2008:41:1639-1650.
  10. ↑ Mission Gait. Normal Pediatric Gait Development - 12 Months. Available from: https://www.youtube.com/watch?v=sy9fO-uy28Q [last accessed 27/03/2023]
  11. ↑ Mission Gait. Normal Pediatric Gait Development - 18 Months. Available from: https://www.youtube.com/watch?v=Z6dnbjN594o [last accessed 27/03/2023]
  12. ↑ Mission Gait. Pediatric Gait - 24 Months. Available from: https://www.youtube.com/watch?v=A2g8WoaH9s0 [last accessed 27/03/2023]
  13. ↑ Brantly R. Walking Gait Development pt1. Available from: https://www.youtube.com/watch?v=DJ5zYgTiDp0&ab_channel=RobertBrantly (accessed 31/12/2022)
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