Exam/Treatment of Gait Flashcards
What are key elements of gait?
Stance phase Swing phase Symmetry Step pattern Speed Trunk posture Arm swing
What are aspects of motor control of gait?
Steady state velocity Initiate a step Change speed or stop Turns: spin turn or step turn Recover from trip or slip Walk-run transition
What is needed for normal gait?
Progression
Stability/Postural control
Adaptation: obstacles, surfaces, carrying items (dual task paradigm: cognitive demand while walking)
Where is center of pressure when taking a step?
When stepping with left foot: First put weight over right foot then shift weight to the left foot to take step
What is they hypothesis oriented model of observing abnormal gait?
Use exam findings to generate hypothesis about cause of problem.
Which impairment to address? ROM loss, hypertonicity, weakness, incoordination/synergy, sensory/perceptual/cognitive lsot
What are gait deviations causing impaired heel strike?
Low heel, flat foot, or forefoot contact
Excessive inversion: synergy
Excessive eversion: hypotonicity
What are possible causes for low heel, flat foot, or forefoot contact during heel strike?
Ankle PF: hypertonic pulling
Ankle DF: weak, can’t lift against gravity
Knee cause: lack extension in late swing/early stance
What may happen if there is excessive inversion or eversion during heel strike?
Inversion: toe clawing/supination during stance, will want AFO to go to toes
Eversion: pronation during stance, may have callous formation on navicular
What are possible abnormal gait patterns during midstance?
Knee hyperextension problems
Knee flexion problems
Hip flexion problems
What are possible causes of knee hyperextension during impaired midstance?
Ankle PF cause: hypertonic, loss of ROM into DF because or tight PF
Quadriceps cause: weakness, want to lock into recurvatum
What are possible causes of knee flexion or hip flexion in impaired midstance?
Knee flexion: hamstrings are hypertonic and pulling them into crouch, quads are weak and they want to lock into recurvatum
Hip flexion: may have hip or knee flexion contracture, hypertonicity of flexors
What are some abnormal gait patterns during terminal stance?
Insufficient hip extension
Insufficient toe off
What is cause of insufficient hip extension or insufficient toe off during terminal stance?
Hip flexor cause: contracture, hypertonicity
Hip extensor cause: weakness, poor stability
PF cause: weakness of PF
If no toe off: a lot of stopping, starting, less momentum and speed
What are some abnormal gait patterns during swing?
Inadequate foot clearance Excessive external rotation Scissoring Inadequate knee extension Poor foot placement
What are causes for inadequate foot clearance during swing?
Weak hip flexors
Weak knee flexors
Weak DF
Proprioception: poor awareness, due to stroke, MS, LE surgery, neuropathy
What are causes for excessive external rotation during swing?
Hip flexors: weak, poor pull through
Hip adductors: use to compensate for flexors
What are causes of scissoring during swing? What about poor foot placement?
Hip adductor spasticity (bilateral or unilateral)
Poor coordination or proprioception
What are causes for inadequate knee extension during swing?
Weak quads
Hypertonicity, contracture of hamstrings
What does gait look like in different neuro disorders?
Stroke: step asymmetry
PD: shuffling, poor momentum control, decreased trunk rotation, freezing
Cerebellar: ataxic (inconsistent foot placement)
CP: crouched gait (hypertonicity in LE), may also see crouched gait in MS or incomplete SCI
What are ways to examine gait at the participation level?
Self report measures of mobility: questionnares, life space
Activity monitors: pedometers, step activity monitors, accelerometers
Ths is most difficult for us to assess
What is definition of community ambulation?
Important for discharge planning
1000 feet
Speed: traffic lights, busy sidewalks
Ambient conditions: rain, temperature, light
Physical loads: packages, manual doors
Terrain: stairs, curbs, slopes, obstacles
Attentional demands
What can be used to examine gait at the functional level?
6 min walk
Dynamic gait index (walking with head turns)
TUG
10 meter walk
What are the reference values for comfortable vs. maximum pace by decade and gender?
Young adults: 1.4 m/s vs. 2.5 m/s
Older adults: 1.3 m/s vs. 1.8 m/s
What can the 10 m walk predict?
Predicts community mobility
Can use AD or different surfaces
What is ambulation status for people based on their walking speed?
0.8 m/s = Full community
Average gait speed = 0.42 m/s
T/F: gait velocity gains which result in transition to higher ambulation category are associated with better function and quality of life
True
What are strategies to examine gait?
Visual analysis: Tinettis gait and balance scale: rate quality, subjectivity in ratings, 12 points for gait, 16 points for balance Ranchos form GARS others
How is gait examined in a research lab?
Spatio-temporal parameters
Kinematics: motion analysis
Kinetics (force measures): EMG, force plate
What must we consider for patient application during examination of gait?
Classy functional/participation level (limited household/unlimited community)
Consider progression/stability/adaptation (obstacles, challenges)
Consider impairments
What are possible goals for gait?
STGs: change impairments, improve gait patterns, interim step towards LTGs
LTGs: functional, patient oriented. Think of distance, level of assistance, AD, safety, energy expenditure
Progression/stability/adaptation
Wha is task oriented approach for gait training?
Modify task/environment to allow practice
Modify individual: treat or minimize impairments
Principles of motor learning
What are ways to improve movement strategies: progression?
Manually assist movement if they can’t clear foot.
Use ace wrap as temporary orthotic.
Focus on activating PF, hip flexors to generate momentum: facilitation, augmented feedback, exaggerate motion (marching), increase speed demands
What are ways to improve stability in gait?
Postural alignment: visual target to keep eyes forward, augmented feedback, adjust height of AD
Postural control: mediolateral, single/double support phase, practice weight shifts
T/F: practicing weight shifts alone will help improve gait
False
What are ways to improve stability on stance limb?
Extensor support: augmented feedback, practice stepping with opposite leg, knee brace or orthotic
Foot placement and heel strike/foot flat transition: augmented feedback, hinged orthotic
AD
What are ways to improve movement strategies: adaptation?
Vary speed, surfaces, visual environment
Obstacles: stationary, moving, surprises
Stop abruptly, change direction, turn head
Dual task: carry object, open door, cognitive task
How can part practice be used in gait training?
Motor learning approach: break down task into pieces
Stance: unilateral WBing activities
Swing: step forward, back, side, use target or stool
Treadmill with body weight support
What is BWSTT?
Decrease BWS and increase speed during training
Options for assistance: manual, electrical stim, robotic
Treadmill vs. overground
How does BWSTT work?
Peripheral sensory input processed by CNS (CPG)
Residual connections in damaged spinal cord are plastic and recover
LE strength gains
Cardiovascular endurance gains
Massed practice
Decreased fear
Can BWSTT be used with SCI?
ASIA A: no motor or sensory function below level of lesion: SC can “learn”, EMG timing and pattern of EMG activity improves, improvements are small not functional
Chronic incomplete SCI: increases walking speed and distance, improves limb coordination, improves strength and energy expenditure
