Gait Development in the Growing Child
Original Editor - Kapil Narale
Introduction[edit | edit source]
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).
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.
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.
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.
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.
In a study performed by McCollum et al. (1994) 3 basic walking forms were identified:
- 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.
- 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.
- 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.
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.
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. 
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 .
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. 
When categorised the development of gait can be placed into 6 stages:
- Infant stepping
- Inactive period
- Supported locomotion
- Unsupported locomotion
- Mature similar gait
- 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:
- Walking experience
- Body dimensions/ biomechanical development
- Musculoskeletal development (strength and range)
- Sensory development (response to tactile input and proprioceptive input of compressed joints in the gait cycle)
- 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:
- 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.
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.
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.
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. 
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. 
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. 
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. 
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. 
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.
- 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.
- Skill acquisition requires practice and repetition.
- Motor learning involves multiple systems: When considering motor sensory training, it is important to bring in aspects of tactile, proprioception and even vision stimulation.
- Partial body-weight treadmill training may be used as a therapeutic intervention. Evidence suggests it acts on the sensory, motor, neural and musculoskeletal systems.
Resources[edit | edit source]
- Gait Analysis in Cerebral Palsy
- Gait and Lower Limb Observation of the Lower Limb of Paediatrics - (GALLOP) Video summaries of gait development:
A presentation on the walking gait development through the four stages of life: Early Childhood, Childhood, Adulthood, and Older Adulthood.
References[edit | edit source]
- 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.
- Teulier Caroline, Lee Do Kyeong, Ulrich Beverly D. Early Gait Development in Human Infants: Plasticity and Clinical Applications. Developmental Psychobiology. 2015:57:447-458.
- 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.
- 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)
- DinoPT. Paediatric gait. Available from: https://blog.dinopt.com/pediatric-gait/ (accessed 11/04/2023)
- McCollum G, Holroyd C, Castelfranco AM. Forms of early walking. Journal of Theoretical Biology. 1995 Oct 7;176(3):373-90.
- 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.
- 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.
- 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.
- Mission Gait. Normal Pediatric Gait Development - 12 Months. Available from: https://www.youtube.com/watch?v=sy9fO-uy28Q [last accessed 27/03/2023]
- Mission Gait. Normal Pediatric Gait Development - 18 Months. Available from: https://www.youtube.com/watch?v=Z6dnbjN594o [last accessed 27/03/2023]
- Mission Gait. Pediatric Gait - 24 Months. Available from: https://www.youtube.com/watch?v=A2g8WoaH9s0 [last accessed 27/03/2023]
- Brantly R. Walking Gait Development pt1. Available from: https://www.youtube.com/watch?v=DJ5zYgTiDp0&ab_channel=RobertBrantly (accessed 31/12/2022)