Comparing the applicability of temporal gait symmetry, variability and laterality in bilateral gait conditions: A feasibility study of healthy individuals and people with diabetic neuropathy


      • Gait Symmetry measurement for use in bilateral gait disorders.
      • Gait Symmetry Index is insufficient in quantifying degree of gait disorder.
      • New index for measurement of gait laterality.
      • Use of new index to decide cut-off between symmetrical and asymmetrical gait.
      • Correlation of indices to healthy and diabetic participants.



      Gait symmetry is used to measure pathological gait but is usually applied to unilateral pathology. This study aims to investigate bilateral impairment using existing and new gait symmetry methods.


      15 healthy volunteers and 14 people with diabetes and distal symmetrical polyneuropathy participated in this study. Three temporal parameters (combined step, stance phase and double stance), expressed as a percentage, were extracted for comparing gait symmetry between healthy volunteers and patients using in-shoe measurements (Pedar-X). Three indices were calculated, including the widely used Symmetry Index; the well-established Variability Index; and the newly developed Laterality Index, that calculates how well distributed a condition is across both legs.


      In all three parameters, Symmetry and Variability Index proved to be significantly greater in the diabetic cohort (p-values range < 0.001–0.0226). The Laterality Index was significantly greater in the diabetic cohort for the stance and double stance phases (p-values 0.03 and < 0.001), but not for the combined step (p-value 0.3953). In both cohorts, Laterality Index <1 (fractional laterality) was associated with small Symmetry Index data, whereas in large Symmetry Index data, the Laterality Index was 1 (unilateral condition).


      Gait symmetry and variability are useful tools for quantifying locomotion and the effects of aging and diseases. We have shown the ability of these two indices in differentiating two extreme groups of individuals. For cases with small Symmetry Index, the current method of using an arbitrary value is not ideal. The newly developed Laterality Index can be used to decide on the cut-off between symmetrical and asymmetrical gait.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic and Personal
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Clinical Biomechanics
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Arts M.L.J.
        • Bus S.A.
        Twelve steps per foot are recommended for valid and reliable in-shoe plantar pressure data in neuropathic diabetic patients wearing custom made footwear.
        Clin. Biomech. 2011; 26: 880-884
        • Baltadjieva R.
        • Giladi N.
        • Gruendlinger L.
        • Peretz C.
        • Hausdorff J.M.
        Marked alterations in the gait timing and rhythmicity of patients with de novo Parkinson’s disease.
        Eur. J. Neurosci. 2006; 24: 1815-1820
        • Barbieri F.A.
        • Polastri P.F.
        • Baptista A.M.
        • Lirani-Silva E.
        • Simieli L.
        • Orcioli-Silva D.
        • Gobbi L.T.
        Effects of disease severity and medication state on postural control asymmetry during challenging postural tasks in individuals with Parkinson's disease.
        Hum. Mov. Sci. 2016; 46: 96-103
        • Blin O.
        • Ferrandez A.M.
        • Serratrice G.
        Quantitative analysis of gait in Parkinson patients: increased variability of stride length.
        J. Neurol. Sci. 1990; 98: 91-97
        • Dyck P.J.
        • Albers J.W.
        • Andersen H.
        • on behalf of the Toronto expert panel on diabetic neuropathy
        • et al.
        Diabetic polyneuropathies: update on research definition, diagnostic criteria and estimation of severity.
        Diabetes Metab. Res. Rev. 2011; 27: 620-628
        • England J.D.
        • Gronseth G.S.
        • Franklin G.
        • et al.
        Distal symmetrical polyneuropathy: a definition for clinical research. A report of the American Academy of Neurology, the American Association of Electrodiagnostic Medicine, and the American Academy of Physical Medicine and Rehabilitation.
        Arch. Phys. Med. Rehabil. 2005; 86: 167-174
        • Gabell A.
        • Nayak U.S.L.
        The effect of age on variability in gait.
        J. Gerontol. 1984; 39: 662-666
        • Gouelle A.
        • Mégrot F.
        • Presedo A.
        • Husson I.
        • Yelnik A.
        • Penneçot G.F.
        The gait variability index: a new way to quantify fluctuation magnitude of spatiotemporal parameters during gait.
        Gait Posture. 2013; 38 (33): 461-465
        • Hausdorff J.M.
        Gait variability: methods, modeling and meaning.
        J. Neuroeng. Rehabil. 2005; 2: 1-9
        • Hausdorff J.M.
        • Edelberg H.K.
        • Mitchell S.L.
        • Goldberger A.L.
        • Wei J.Y.
        Increased gait unsteadiness in community-dwelling elderly fallers.
        Arch. Phys. Med. Rehabil. 1997; 78: 278-283
        • Hausdorff J.M.
        • Cudkowicz M.E.
        • Firtion R.
        • Wei J.Y.
        • Goldberger A.L.
        Gait variability and basal ganglia disorders: stride-to-stride variations of gait cycle timing in Parkinson’s disease and Huntington’s disease.
        Mov. Disord. 1998; 13: 428-437
        • Hausdorff J.M.
        • Lertratanakul A.
        • Cudkowicz M.E.
        • Peterson A.L.
        • Kaliton D.
        • Goldberger A.L.
        Dynamic markers of altered gait rhythm in amyotrophic lateral sclerosis.
        J. Appl. Physiol. 2000; 88: 2045-2053
        • Hausdorff J.M.
        • Nelson M.E.
        • Kaliton D.
        • Layne J.E.
        • Bernstein M.J.
        • Nuernberger A.
        • Singh M.A.F.
        Etiology and modification of gait instability in older adults: a randomized controlled trial of exercise.
        J. Appl. Physiol. 2001; 90: 2117-2129
        • Hausdorff J.M.
        • Schaafsma J.D.
        • Balash Y.
        • Bartels A.L.
        • Gurevich T.
        • Giladi N.
        Impaired regulation of stride variability in Parkinson’s disease subjects with freezing of gait.
        Exp. Brain Res. 2003; 149: 187-194
        • Hsu A.L.
        • Tang P.F.
        • Jan M.H.
        Analysis of impairments influencing gait velocity and asymmetry of hemiplegic patients after mild to moderate stroke.
        Arch. Phys. Med. Rehabil. 2003; 84: 1185-1193
        • Mauritz K.H.
        Gait training in hemiplegia.
        Eur. J. Neurol. 2002; 9: 23-29
        • McGrath R.E.
        • Meyer G.J.
        When effect sizes disagree: the case of r and d.
        Psychol. Methods. 2006; 11: 386
        • Nolan L.
        • Wit A.
        • Dudziñski K.
        • Lees A.
        • Lake M.
        • Wychowañski M.
        Adjustments in gait symmetry with walking speed in trans-femoral and trans-tibial amputees.
        Gait Posture. 2003; 17: 142-151
        • Patterson K.K.
        • Parafianowicz I.
        • Danells C.J.
        • Closson V.
        • Verrier M.C.
        • Staines W.R.
        • McIlroy W.E.
        Gait asymmetry in community-ambulating stroke survivors.
        Arch. Phys. Med. Rehabil. 2008; 89: 304-310
        • Plotnik M.
        • Wagner J.M.
        • Adusumilli G.
        • Gottlieb A.
        • Naismith R.T.
        Gait asymmetry, and bilateral coordination of gait during a six-minute walk test in persons with multiple sclerosis.
        Sci. Rep. 2020; 10: 1-11
        • Rinkel W.D.
        • van der Oest M.J.
        • Coert J.H.
        Item reduction of the 39-item Rotterdam Diabetic Foot Study Test Battery using decision tree modelling.
        Diabetes Metab. Res. Rev. 2020; 36e3291
        • Robinson R.O.
        • Herzog W.
        • Nigg B.M.
        Use of force platform variables to quantify the effects of chiropractic manipulation on gait symmetry.
        J. Manipulative Physiol. Ther. 1987; 10: 172-176
        • Sadeghi H.
        • Allard P.
        • Prince F.
        • Labelle H.
        Symmetry and limb dominance in able-bodied gait: a review.
        Gait Posture. 2000; 12: 34-45
        • Schaafsma J.D.
        • Giladi N.
        • Balash Y.
        • Bartels A.L.
        • Gurevich T.
        • Hausdorff J.M.
        Gait dynamics in Parkinson’s disease: relationship to Parkinsonian features, falls and response to levodopa.
        J. Neurol. Sci. 2003; 212: 47-53
        • Sheridan P.L.
        • Solomont J.
        • Kowall N.
        • Hausdorff J.M.
        Influence of executive function on locomotor function: divided attention increases gait variability in Alzheimer’s disease.
        J. Am. Geriatr. Soc. 2003; 51: 1633-1637
        • Stolze H.
        • Kuhtz-Buschbeck J.P.
        • Drücke H.
        • Jöhnk K.
        • Illert M.
        • Deuschl G.
        Comparative analysis of the gait disorder of normal pressure hydrocephalus and Parkinson’s disease.
        J. Neurol. Neurosurg. Psychiatry. 2001; 70: 289-297
        • Tesfaye S.
        • Boulton A.J.
        • Dickenson A.H.
        Mechanisms and management of diabetic painful distal symmetrical polyneuropathy.
        Diabetes Care. 2013; 36: 2456-2465
        • Tura A.
        • Raggi M.
        • Rocchi L.
        • Cutti A.G.
        • Chiari L.
        Gait symmetry and regularity in transfemoral amputees assessed by trunk accelerations.
        J. Neuroeng. Rehabil. 2010; 7: 4
        • van Netten J.J.
        • Bus S.A.
        • Apelqvist J.
        • Lipsky B.A.
        • Hinchliffe R.J.
        • Game F.
        • Senneville É.
        Definitions and criteria for diabetic foot disease.
        Diabetes Metab. Res. Rev. 2020; 36e3268
        • Wall J.C.
        • Turnbull G.I.
        Gait asymmetries in residual hemiplegia.
        Arch. Phys. Med. Rehabil. 1986; 67: 550-553
        • Zhang Y.
        • Lazzarini P.A.
        • McPhail S.M.
        • van Netten J.J.
        • Armstrong D.G.
        • Pacella R.E.
        Global disability burdens of diabetes-related lower-extremity complications in 1990 and 2016.
        Diabetes Care. 2020; 43: 964-974