CVA - 5a Stroke Rehab Gait Flashcards
primary vs secondary LE impairments
primary:
- motor control/activation
- altered ms tone
- loss of sensation
- coordination problems
secondary:
- weakness, atrophy
- ms length, ROM
- edema
- pain
what is the emphasis of LE neurorehab and why
gait training
amb is key functional activity for participation and quality of life
what are 3 interventions of LE neurorehab
functional retraining
gait training*
strength training
what functional retraining interventions are included in LE neurorehab
bed mobility
bridging
balanced sitting/standing
sit to stand transfers
what context is strength training often utilized for LE neurorehab
more functional and get them on programs to be doing outside PT
what does evidence say ab the use of PNF and NDT in LE neurorehab
lack of evidence to support use in gait/amb training
may be beneficial for pre-gait activities and bed mobility
what is the majority of stroke survivors ambulation status 6mo post
independent but most have gait abnormalities
majority of stroke survivors are dc to where after rehab and what is their functional abilities at this point
home
but not functional community amb
stance phase: normal hip movement and why
flex -> ext
flex - proper heel strike
ext - facilitate push off position to trigger hip flex to step
stance phase: normal pelvis and trunk motion and why
(tiny) lateral horizontal shift of pelvis and trunk
critical for loading and unweighting contralateral limb
stance phase: normal knee movement
10-15deg flex at IC
ext
flex in terminal stance
6 common gait deviations in stance phase
- poorly aligned trunk/pelvis
- dec peak hip ext
- knee hyper ext
- lack of knee ext
- dec PF at toe off
- WTB on MT heads
HCF for knee hyper ext in stance and what problems can knee hyper ext lead to
dec quad strength (eccentric)
can lead to issues w joint capsule and overstretching structures on post aspect of knee
- leading to inc instability of knee
HCFs for lack of knee ext in stance
knee flex tone
knee/quad weakness
HCF for dec PF at toe off in stance
strength deficits
what leads to pts WTB on MT heads in stance and what problems can this lead to
for pt unable to maintain DF while amb
can lead to skin breakdown and injure integrity of ankle/foot
hip and knee movement from initial to mid to terminal swing
initial - knee flex w hip ext
mid - hip flex w knee ext
terminal - knee full ext and ankle DF before heel strike
pelvis motion in swing phase
lateral pelvic tilt downward direction 5deg
forward rotation of ipsilateral pelvis
6 common gait deviations in swing phase
- dec peak hip flex
- no UE swing on hemi side
- inc hip and knee flex (ataxic)
- dec peak knee flex in early swing
- dec knee ext in late swng
- lack of DF/toe clearance
what impact does dec hip flex have on the swing phase
dec step length
what impact does no UE swing have in the swing phase
impacts balance, posture, speed
what impact does inc hip/knee flex have in swing phase and what type of CVA is this commonly seen in
affects stepping, balance
cerebellar strokes
what impact does dec peak knee flex have in early swing
affect momentum to swing leg through
- impacts step length
what impact does dec knee ext have in late swing
IC w flex knee -> make leg unstable
dec step length
what impact does a lack of DF have in the swing phase and what are likely HCFs
impacts toe clearance
d/t weakness, spasticity in PFs
general spatial and temporal characteristics of gait post stroke (4)
- dec walking speed
- dec stride length and cadence
- shorter stance time and longer swing time of affected leg
- shorter step length of unaffected limb (caused by dec affected limb stance time)
how should gait training start in post stroke and how do you progress from there
start w postural alignment and static/stand phase control
progress to dynamic control and swing phase
when do you see the most recovery post stroke
first 6mo, but can continue past
what are the key ms to focus on for gait training
paretic limb:
- PF
- hip flex
- knee ext and flex
non-paretic limb:
- PF
- knee flex
what does evidence say ab the use of ms strengthening in gait training
graded ms strengthening improves strength but doesn’t lead to improved walking ability w/o functional training
how and when is intensive mobility training utilized post stroke
focuses on strength, balance, and aerobic exercises on a variety of walking tasks
improves gait in sub-acute and chronic stroke
what are pre-gait (part-task) activities for stance phase control (5)
paretic limb loading
sit to stand - quad control
unilateral stance
side stepping
standing wt shifting activities
what are pre-gait (part-task) activities for swing phase control (4)
step to and step thru
toe clearance
heel strike
wt transference to hemi side w contra swing
what motor learning principles can be applied to overground whole-task gait training
quickly move out of || bars
dec manual assistance, facilitation, verbal cues, feedback asap to prevent PT dependence
specificity of training:
- HEP
- environmental factors
what are 3 things to think ab when working on whole-task gait training
apply motor learning principles
eval need for orthotics/ADs
focus on trunk/UE as well as LE
why do you want to move out of || bars as soon as possible when doing whole task gait training
want to unweight UE and onto LE
often pt is pulling on bars and that isn’t functional or a normal gait pattern
what is the goal of dec the feedback you give the pt during whole task gait training
want them to focus on their internal feedback
what are environmental factors to consider with whole-task gait training
open vs closed environment
- amt of stim
terrain/slope/even-ness
what is the main goal of LE orthosis
walking aids to promote early mobility in non-ambulators after strokes
what gait deviations can an AFO prevent and how
foot drop and knee hyper ext
gastroc crosses 2 joints, the position of the ankle prevents knee hyper ext
how does the use of a LE fit into the approaches to rehab
want to do restorative approach first, don’t want to do compensatory strategy too soon
but if only can progress forward with AD then use orthotic
what can AFOs improve in gait (5)
ankle/knee kinematics
kinetic/energy cost of amb
walking activity
walking impairment
balance
what is the goal of using FES in amb
activate/strengthen DF to prevent foot drop
what does the evidence say about the use of FES for amb
similar outcomes to orthotics but higher quality studies are needed
when is an appropriate time to implement body wt support treadmill training
early gait retraining - high reps
- initiate gait
what are the pros of using body wt support treadmill training compared to overground
less risk of falls
safe manual facilitation of normal kinematics w fewer PTs
what is the locomotor training protocol as applied to body wt support treadmill training
20-30min
3x/wk
12 wks
what are the guidelines for the use of body wt support treadmill training
maximize wt bearing thru LE
- start w 30% of wt supported
- wean down from there
want to normalize kinematics while minimizing compensation
what does evidence say about body wt support treadmill training vs what anecdotal says
insufficient evidence that improves (I) walking ability
- no evidence of persisting beneficial effects
anecdotal evidence in clinics of quicker progress via inc walking speed and endurance
- so still used
what needs to be better understood about body wt support treadmill training
effects of different frequencies, durations, intensities
what did evidence say about robotic assisted gait training
improved outcomes as compared to conventional gait training
what are the 3 functional walking categories
physiological
household walker
community walker
what interventions are appropriate for a physiological walker and what are these walkers limited by
exercise only: || bars, BSWTT, robotic
unable to walk otherwise
what interventions are appropriate for a household walker and what are these walkers limited by
short distances, ADs
difficulty w stairs and uneven surfaces
what interventions are appropriate for a community walker and what are these walkers limited by
faster gait speed, (I) on uneven surfaces and in crowds
- enter and leave home (I)
- manage stairs and curbs (I)
limited by:
slower gait speed and/or unable to (I) negotiate crowded areas
