9/20 - Neurologic Gait Exam and Intervention

Question 1

What are the 4 key gait remediation interventions? Describe key aspects of each.

Answer 1

1) Increase force production
2) Improve postural control
3) Specific gait skill
4) Cognition

Question 2

What factors do you consider when determining gait intervention decisions?

Answer 2

1) Health condition prognosis
2) Prior ambulatory status
3) Co-morbidities
4) Fall risk
5) Cognitive status
6) Walking independence ability

Question 3

What features are important for independent walking?

Answer 3

1) Which muscles are affected
2) Extent of weakness
3) Capacity for substitution of alternate movement patterns
4) Use of compensatory aids

Question 4

When examining gait, what would you look at?

Answer 4

1) History
2) Systems Review
3) Observational gait analysis
4) Generate hypotheses
5) Develop interventions (including hands-on gait training, verbal cues, patient education, instruction, use of equipment, use of assisted devices or other person).

Question 5

Name the 7 components of postural control for gait examination/intervention for individuals with neurologic dysfunction.

Answer 5

1) Musculoskeletal components
2) Neuromuscular synergies
3) Individual sensory systems
4) Sensory strategies
5) Anticipatory mechanisms
6) Adaptive mechanisms
7) Internal representations

Question 6

The locomotor program for progression is part of what system? What should be included in the intervention?

Answer 6

The locomotor program for progression is part of the neuromuscular system. The intervention includes:

1) muscle recruitment and activation
2) activation and timing of agonist/antagonist
3) concentric/eccentric control
4) synergistic movement patterns-normal/abnormal
5) tone (hypertonicity, spasticity, hypotonicity).

These are all important in balance and stability in gait and provide us with interventions.

Question 7

What are key sensory factors related to the neuromuscular system?

Answer 7

1) Foot placement on the ground
2) Proprioception cues with hip extension
3) Visual deficits: stability and adaptation

Question 8

Aside from locomotor program for progression and sensory information, what are the 2 additional points for the neuromuscular system?

Answer 8

The 4 key aspects for the neuromuscular system:

1) Postural Control is necessary for stability
2) Gait patterns must adapt to the task and environment
3) Locomotor program for progression
4) Sensory information

Question 9

What 3 important musculoskeletal system aspects of gait must we look at for individuals with neurologic dysfunction?

Answer 9

1) Lack sufficient ROM &/or contractors
2) Lack ability to bear weight (i.e. fractures, osteoporosis)
3) Changes in postural and LE alignment

Question 10

What would your intervention focus on to increase force production?

Answer 10

• high-intensity resistance training
• resistance exercise
• strength and power training (ankle DF/PF))

Question 11

What would your intervention focus on to improve postural control?

Answer 11

• control HAT segment (HAT=head, arms, thorax)
• extensor support; foot placement at initial contact (normal vs wide BOS)
• and balance during double & single limb support

Question 12

What would your intervention focus on for specific gait skills?

Answer 12

• use part and whole practice
• progress from assistance to facilitation to independence
• progress to variable tasks and environment

Question 13

What would your intervention change depending on cognition?

Answer 13

Cognition might impact intervention by:

- Begin with less demanding environment and minimal novel learning

Question 14

List which category postural control aspects fall in to: A - Growth & Development; B - MCML; C - Movement Science

1) Musculoskeletal components
2) Neuromuscular synergies
3) Individual sensory systems
4) Sensory strategies
5) Anticipatory mechanisms
6) Adaptive mechanisms
7) Internal representations

Answer 14

A - Growth & Development

1) Individual sensory systems
2) Sensory strategies

B - MCML

1) Anticipatory mechanisms
2) Adaptive mechanisms
3) Internal representations

C - Movement Science

1) Musculoskeletal components
2) Neuromuscular synergies

Question 15

When evaluating a patient who has had a recent or increased amount of challenges with gait and cognitive impairments, what potential diagnostic impairment might be suspected? (Could be more than 1 - I’m just thinking of a key one…)

Answer 15

Mini-strokes cause sudden/increased gait and cognitive impairments.

Question 16

An early onset of gait challenges is often an early sign of what progressive disorder? (Again, this could possibly be more than one - I’m just looking at my notes.)

Answer 16

An early onset of gait challenges is often an early sign of dementia.

Question 17

When considering the cognitive system and gait, what aspects should be considered in intervention?

Answer 17

Cognitive system:

1) Consider cognitive level
2) Ability to learn novel tasks
3) Attentional abilities: selective, divided

Question 18

Key aspects to a gait observational analysis:

Answer 18

i. Observe
ii. Identify problems, critical events
iii. Hypothesize cause
iv. Identify tests and measures to narrow down hypotheses (then perform)
v. Develop good intervention development (including tactile, visual, and verbal cues; use of equipment/assisted devices)

Question 19

What is different when performing a gait observational analysis on an individual with a known neurologic dysfunction?

Answer 19

With a known neurologic dysfunction - we must consider how the dysfunction changes gait analysis through tests and measures, hypothesis and intervention.

Question 20

The 3 key areas for observational gait analysis include:

Answer 20

In typical gait, we look at:

1) Observe overall quality of gait
2) Observe specific detail of gait
3) Make hypotheses and test them

Question 21

When observing the overall quality of gait, what should we consider?

Answer 21

When observing the overall quality of gait, we look at:

1. Arm swing
2. Symmetry of UE and LE
3. Head and trunk posture
4. Gait speed

Question 22

When observing the specific details of gait, we look at:

Answer 22

1. Stance and swing phases
2. Critical events
   (Movement science!)

Question 23

When determining and testing a hypothesis, we look at:

Answer 23

1. Motor control
2. Joint mobility
3. Sensation
4. Body mass or leg length problem

Question 24

Name the 7 key aspects to consider when determining what tests and measures should be used for a particular patient?

Answer 24

1) Patient’s goals and overall presentation
2) Health condition and co-morbidities
3) Patient’s goals (repeat?)
4) Consider the ceiling and floor effect of the test
5) Time available for assessment
6) Equipment availability
7) Hypothesize about underlying impairments

Question 25

Name 5 important gait tests and measures:

Answer 25

1) Gait speed
2) DGI
3) FGA
4) Gait Assessment Rating Scale (GARS)
5) POMA
6) TUG

Question 26

Plantar flexor weakness:
Name the part of the gait cycle you’d expect to see problems.
What problems would likely see in this/these parts of the gait cycle?

How do these differ with PF spasticity?

Answer 26

PF weakness:
SLS: Lack of heel rise
SLA: Lack of rapid ankle PF

PF spasticity:
WA: Forefoot contact, lack of controlled ankle PF
SLS: Lack of ankle rocker, early heel rise
SLA: Lack of DF to neutral (compensations related to clear foot through swing)

Question 27

Hip flexor weakness:
Name the part of the gait cycle you’d expect to see problems.
What problems would likely see in this/these parts of the gait cycle?

How do these differ with HF spasticity?

Answer 27

Hip flexor weakness:
SLA: Limited hip flexion, circumduction, vaulting, contralateral trunk lean

Spasticity: Nothing noted

Question 28

Quadricep weakness:
Name the part of the gait cycle you’d expect to see problems.
What problems would likely see in this/these parts of the gait cycle?

How do these differ with Quad spasticity?

Answer 28

Quadricep weakness:
WA: forward trunk lean, lack of controlled knee flexion

Spasticity
WA: Lack of controlled knee flexion
SLS: excessive knee extension
SLA: lack of knee flexion

Question 29

Hip extensors weakness:
Name the part of the gait cycle you’d expect to see problems.
What problems would likely see in this/these parts of the gait cycle?

How do these differ with hip extensor spasticity?

Answer 29

Hip extensor weakness:
WA: backward trunk lean

Spasticity: Nothing noted

Question 30

Hip Abductor weakness:
Name the part of the gait cycle you’d expect to see problems.
What problems would likely see in this/these parts of the gait cycle?

How do these differ with Hip abd spasticity?

Answer 30

Hip abductor weakness:
WA & SLS: poor pelvic stability (pelvic drop), contralateral trunk lean
(Trendelenberg)

Spasticity: Nothing noted

Question 31

Hip Adductor weakness:
Name the part of the gait cycle you’d expect to see problems.
What problems would likely see in this/these parts of the gait cycle?

How do these differ with Hip add spasticity?

Answer 31

Hip adductor weakness: Nothing noted

Spasticity:
WA & SLS: lack of pelvic stability (pelvic drop), SLA: Excessive hip adduction (“scissor gait” if BIL)

Question 32

What key muscle groups are impacted by contractors?
Name the part of the gait cycle you’d expect to see problems.
What problems would likely see in this/these parts of the gait cycle?

Answer 32

PF contracture:
WA: forefoot contact, lack of controlled knee extension
SLS: lack of ankle rocker, early heel rise, knee extension
SLA: lack of ankle DF to neutral

Hamstring contracture:
WA: forefoot or flat foot contact, excessive knee flexion
SLA: lack of full knee extension

Hip flexor contracture:
WA: poor hip stability (excessive flexion)
SLA: Limited hip extension