ORIGINAL ARTICLE Incidence of Gait Abnormalities After Traumatic Brain Injury Gavin Williams, PhD, Meg E. Morris, PhD, Anthony Schache, PhD, Paul R. McCrory, MD ABSTRACT. Williams G, Morris ME, Schache A, McCrory PR. Incidence of gait abnormalities after traumatic brain injury. Arch Phys Med Rehabil 2009;90:587-93. Objective: To identify the most common gait abnormalities presenting after traumatic brain injury (TBI) and quantify their incidence rate. Design: Case series. Setting: Biomechanics laboratory. Participants: A convenience sample of 41 people with TBI receiving therapy for gait abnormalities, and a sample of 25 healthy controls. Intervention: Three-dimensional gait analysis. Main Outcome Measures: Spatiotemporal, kinematic, and kinetic data at a self-selected walking speed. Results: People with TBI walked with a significantly slower speed than matched healthy controls. There was a significant difference between groups for cadence, step length, stance time on the affected leg, double support phase, and width of base of support. The most frequently observed biomechanical abnor- mality was excessive knee flexion at initial foot contact. Other significant gait abnormalities were increased trunk anterior/ posterior amplitude of movement, increased anterior pelvic tilt, increased peak pelvic obliquity, reduced peak knee flexion at toe-off, and increased lateral center of mass displacement. Ankle equinovarus at foot-contact occurred infrequently. Conclusions: People with TBI were found to have multijoint gait abnormalities. Many of these abnormalities have not been previously reported in this population. Key Words: Biomechanics; Brain injuries; Gait; Rehabili- tation. © 2009 by the American Congress of Rehabilitation Medicine T RAUMATIC BRAIN INJURY is a leading cause of death and disability for adolescents and young adults. 1 The prev- alence of TBI in the community is high because of the survival rate, and the demographic group at most risk is adolescents and young adults. 1,2 The sequelae of severe TBI include motor, cognitive, behavioral, and emotional dysfunction. 1 Indepen- dent gait is often a major goal of rehabilitation after moderate to severe TBI. Adverse effects associated with gait abnormal- ities include falls, 3 reduced aerobic fitness, 4 and limited com- munity access. 5 Because falls are a major cause of TBI, 1,6 and people with TBI are at a heightened risk of reinjury, there is a pressing need to ensure optimal therapy outcomes. In contrast with the vast literature on neuropsychologic impairments after TBI, surprisingly little is known about the effect on gait. 7 The key biomechanical abnormalities of gait after TBI are yet to be determined. 3DGA is a method for accurately measuring joint movement and is the current crite- rion standard for evaluating gait disorders. Despite 3DGA being used in numerous gait studies in TBI, investigations have restricted data reporting to spatiotemporal variables 7-12 or fo- cused on a single aspect of gait such as the hip, 13 knee, 14 ankle, 15 or COM. 16-18 Only 1 study has used 3DGA to compute data for all lower-limb joints. McFadyen et al 19 reported kine- matic analyses for the hip, knee, and ankle in obstructed and unobstructed walking for 8 high-functioning adults with TBI. To be included in this study, subjects were required to be able to walk without gait aids at a speed greater than 1m/s and walk independently in the community. These inclusion criteria make the findings difficult to generalize to other TBI populations, such as those who are mobile but are not high-functioning and exhibit severe and complex gait disorders. 3DGA has had a positive impact on clinical evaluation and surgical intervention in cerebral palsy 20,21 and stroke. 22 In contrast, the use of 3DGA in the treatment of people with TBI has to date been limited. Detection of the gait variables most frequently affected by TBI may streamline assessment proce- dures, inform clinical decision-making, and direct intervention programs. The aim of this study was therefore to identify the type and incidence of gait abnormalities after TBI. In particu- lar, we attempted to determine the gait abnormalities that are characteristic of TBI and report biomechanical data for the trunk, pelvis, and lower limbs. METHODS This project was approved by Epworth Hospital’s Human Research Ethics Committee (study no. 340006) and the Uni- versity of Melbourne (Ethics ID: 060496.1). Participants Subjects with TBI were recruited for this project from Ep- worth Hospital, Melbourne, Australia. Patients currently at- tending physiotherapy for gait limitations after TBI were asked to participate in this project. The inclusion criteria were pa- tients who (1) had sustained a TBI and (2) were able to walk independently over a distance of 20m without the use of a gait From the Epworth Hospital, Melbourne, and Centre for Health Exercise and Sports Medicine, School of Physiotherapy (Williams); School of Physiotherapy (Morris); School of Mechanical Engineering (Schache); Centre for Health Exercise and Sports Medicine, School of Physiotherapy (McCrory), The University of Melbourne, Mel- bourne, Australia. Presented in platform format to the International Brain Injury Association, Lisbon, Portugal, April 9-12, 2008. Supported by the Victorian Neurotrauma Initiative and Royal Automobile Club Victoria. No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit on the authors or on any organi- zation with which the authors are associated. Correspondence to Gavin Williams, PhD, Physiotherapy Dept, Epworth Hospital, 89 Bridge Rd, Richmond, 3121, Victoria, Australia, e-mail: gavin.williams@epworth. org.au. Reprints are not available from the authors. 0003-9993/09/9004-00635$36.00/0 doi:10.1016/j.apmr.2008.10.013 List of Abbreviations BOS base of support CI confidence interval COM center of mass HC healthy control HiMAT high-level mobility assessment tool 3DGA three-dimensional gait analysis TBI traumatic brain injury 587 Arch Phys Med Rehabil Vol 90, April 2009