Functional Upright Mobility Deficits in Neuromuscular Disorders Flashcards
factors contributing to functional upright mobility:
individual variables
mobility task & regulatory features
environmental variables
individual variables:
age
prior experience
motor abilities
diagnosis
motivation
primary impairments
secondary impairments
mobility tasks:
walking, stair climbing, inclines, curbs, obstacle negotiation, single or dual task
regulatory features:
surface conditions
object characteristics
changes in regulatory conditions between attempts
environmental variables:
moving or stationary environment
changes in regulatory conditions between attempts
Examination of Gait/Upright Mobility
observational gait analysis
digitial video recording
Gait/Upright Mobility
Outcome Measures:
Gait Speed (10MWT), Endurance (6MWT)
FGA, DGI
FIM, Functional Ambulation Category
(FAC), Walking Index for SCI (WISCI II)
HiMAT
Three essential requirements for successful locomotion:
Progression (moving through space)
Postural control (upright)
Adaptation (to the environment)
Stance Phase:
This phase begins when the heel strikes the ground and ends when the toe lifts off
It accounts for about 60% of the gait cycle
subdivisions of stance phase:
Initial Contact: The moment the heel touches the ground.
Loading Response: The period when the foot continues to sink into the ground and absorb shock.
Midstance: When the body weight is directly over the supporting leg.
Terminal Stance: When the heel begins to lift off and the body moves forward.
Pre-Swing: When the toe is about to leave the ground.
Swing Phase:
This phase starts when the toe leaves the ground and ends when the heel touches down again
It makes up about 40% of the gait cycle
subdivisions of swing phase:
Initial Swing: When the leg begins to lift off the ground.
Midswing: When the leg is moving forward and is directly under the body.
Terminal Swing: When the leg is decelerating in preparation for the next heel strike.
4 Biomechanical Subcomponents of Gait:
Propulsion
Stance control
Limb advancement/swing
Postural/Lateral stability
Propulsion –
redirect falling COM to kinetic energy; drivers: plantar flexors
*greatest metabolic cost of walking
42-48% of total metabolic cost
force and mechanisms involved in moving the body forward = occurs during the push-off phase of the gait cycle
During the terminal stance and pre-swing phases, the body utilizes the muscles of the calf (gastrocnemius and soleus) and the elastic recoil of the Achilles tendon to generate forward momentum
Stance Control -
maintenance of upright posture; passive vs. active support
ability to maintain balance and stability while one foot is in contact with the ground
ensures that the body weight is effectively supported and managed during the stance phase of the gait cycle
control of ground reaction forces, joint stability, and shock absorption
body relies on the musculoskeletal system, including muscles, tendons, and ligaments, to absorb impact and maintain equilibrium during the initial contact, loading response, and midstance phases of gait
Active Stance Control
dynamic and voluntary use of muscles to stabilize the body and manage balance during the stance phase of gait
muscles actively contract to provide stability and manage ground reaction forces = quadriceps, hamstrings, gluteal muscles, and calf muscles
central nervous system (CNS) plays a crucial role in coordinating muscle activity to adjust posture, maintain balance, and adapt to changes in the terrain or gait speed
Active stance control relies on _____ to make real-time adjustments in muscle activity and body posture.
sensory feedback (proprioception, visual input)
For example, if you encounter an uneven surface, the muscles actively adjust to maintain stability.
Passive Stance Control
“hang out on ligaments”
stabilization provided by the body’s structural and mechanical properties without active muscle engagement
involves the inherent mechanical properties of the joints, tendons, and ligaments
Passive control is influenced by the elastic properties of tendons and ligaments, as well as the mechanical alignment of the joints
natural alignment and distribution of body mass contribute to passive stability
body’s response to gravity and ground reaction forces without requiring active muscle contractions
In practice, both active and passive mechanisms work together to maintain stability during the stance phase:
passive control provides a baseline of stability and support, active control allows for dynamic adjustments and fine-tuning of balance and posture
while standing on a flat surface, passive structures maintain stability, but active muscle engagement is needed for fine adjustments and responses to external perturbations
Limb advancement/swing –
progression of non-weight bearing limb to accept weight; drivers: hip flexors
movement of the leg forward during the swing phase of the gait cycle, preparing it for the next step
muscles of the hip (hip flexors) and knee (hamstrings) work to lift and advance the leg
motion is facilitated by the coordination of muscle contractions and the passive pendulum-like swing of the leg
ensures that the foot clears the ground and positions itself for the next heel strike
Postural/Lateral stability –
altered foot position to reduce lateral COM movement
maintaining balance and stability while shifting weight from one foot to the other and ensuring that the body remains upright and aligned
control of lateral movements and balance adjustments to prevent excessive swaying or tilting
Common Gait Deviations - Stroke (Ankle/Foot)
stance
- foot slap
- forefoot/ flat foot contact
- equinus gait (heel does not touch ground)
- no/decreased heel off (decreased propulsion)
swing
- Foot drop/drag
- Persistent equinus
foot slap =
Occur in: Initial Contact to Loading Response (more LR)
occurs as the foot makes initial contact with the ground and during the early phase of weight acceptance
heel strikes the ground with an uncontrolled force due to weakness in the dorsiflexors
sudden and uncontrolled contact of the heel with the ground, creating a slapping noise
usually occurs because of weakness in the dorsiflexor muscles (e.g., tibialis anterior)
Increases the risk of tripping and reduces stability during walking
Forefoot/Flat Foot Contact =
Occur in: Initial Contact to Loading Response (more IC)
deviation happens when the foot lands flat or on the forefoot rather than the heel, affecting the initial phase of weight acceptance and shock absorption
Instead of the heel making initial contact with the ground, the foot lands on the forefoot or entire foot
can occur due to weakness or spasticity affecting the ankle dorsiflexors and/or plantarflexors
Reduces shock absorption and may lead to inefficient gait mechanics and discomfort
Weak DF or spasticity of PF, excessive knee flexion
Equinus Gait (Heel Does Not Touch Ground) =
Occur in: Midstance to Terminal Stance
heel does not make contact with the ground, and in terminal stance, the heel remains elevated
deviation affects the ability to perform a normal heel strike and can impair propulsion
heel remains elevated, and the foot lands on the toes or forefoot
caused by spasticity or shortening of the calf muscles (gastrocnemius and soleus) or weakness in the dorsiflexors
During heel strike? - Stays in PF, contracture of PF
No/Decreased Heel Off (Decreased Propulsion) =
Occur in: Terminal Stance to Pre-Swing
during the terminal stance phase when the heel is supposed to lift off the ground to push off = reduced or absent heel off impacts forward propulsion
heel does not lift off the ground, or the push-off phase is significantly reduced = often results from weakness or spasticity in the calf muscles
Reduces forward propulsion and gait efficiency, which can lead to a slower walking speed and reduced mobility
Foot Drop/Drag =
Occur in: Initial Swing to Terminal Swing
foot cannot be lifted properly, causing it to drag on the ground = due to weakness in the dorsiflexors and impacts foot clearance
Difficulty in lifting the foot during the swing phase, leading to the foot dragging on the ground
Increases the risk of tripping and falling, and requires compensatory strategies like high-stepping or hip hiking to clear the foot
Weak DF, spastic/contracture of PF, excessive hip/knee extension
Persistent Equinus =
Occur in: Initial Swing to Terminal Swing
foot remains in a plantarflexed position throughout the swing phase, which may require high-stepping or hip hiking to clear the foot from the ground
foot remains in a plantarflexed position (toes pointing downward) throughout the swing phase, similar to the stance phase
can be caused by spasticity or contractures in the calf muscles
Leads to a high-stepping gait or increased hip flexion to clear the foot, impacting gait efficiency and potentially causing compensatory movements that can lead to joint stress
Common Gait Deviations - Stroke (Knee)
stance
- Excessive knee flexion
- Hyperextension
swing
- Decreased flexion (initial/mid swing)
- Inadequate knee extension at terminal swing/initial contact
Excessive knee flexion =
Occurs in: Midstance to Terminal Stance
knee is excessively bent during the stance phase, more than what is typically observed
weak knee extensors (quads), spastic flexors (hamstrings)
can lead to instability and difficulty in bearing weight properly
Hyperextension =
Occurs in: Midstance to Terminal Stance
knee extends beyond its normal anatomical position, resulting in a hyperextended knee
Weakness in the quadriceps or hamstring muscles, combined with reduced proprioception and impaired control, can lead to hyperextension
can cause instability, increased risk of falls, and excessive stress on the knee joint and surrounding structures
Decreased Flexion (Initial/Mid Swing) =
Occurs in: Initial Swing to Mid Swing
making it difficult for the foot to clear the ground
Weakness in the knee flexors (hamstrings) or spasticity in the extensors (quadriceps) can lead to decreased knee flexion.
can result in foot drag or a compensatory high-stepping gait, increasing the risk of tripping and reducing walking efficiency
Inadequate Knee Extension at Terminal Swing/Initial Contact =
Occurs in: Terminal Swing to Initial Contact
knee does not fully extend during the terminal swing phase, resulting in a lack of proper knee straightening at initial contact
Weakness in the quadriceps or inadequate control of the knee extensors can prevent full knee extension
can lead to an abnormal gait pattern with reduced stability at heel strike, affecting the smooth transition from swing to stance and potentially causing gait instability
Common Gait Deviations - Stroke (Hip)
stance
- poor hip position
- trendelenburg gait
swing
- decreased hip flexion
- hip hike
- abnormal substitutions (circumduction, scissoring)
Poor Hip Position =
Occurs in: All Stance Phases (Initial Contact, Loading Response, Midstance, Terminal Stance)
may be positioned incorrectly, such as being in excessive flexion, extension, or adduction during the stance phase = can affect the alignment and stability of the hip joint
can be due to muscle weakness, spasticity, or abnormal muscle tone affecting the hip muscles (e.g., iliopsoas, gluteals)
can lead to inefficient weight-bearing, reduced stability, and potential discomfort or pain
Trendelenburg Gait =
Occurs in: Midstance to Terminal Stance
dropping of the pelvis on the side opposite to the stance leg, resulting in an abnormal gait pattern = due to weakness in the gluteus medius and minimus muscles on the stance side
Weakness or dysfunction in the hip abductor muscles
pelvis drops on the side of the non-stance leg, which can lead to a noticeable hip drop or tilt, impacting overall gait stability and balance
Decreased Hip Flexion =
Occurs in: Initial Swing to Mid Swing
making it difficult for the leg to advance properly.
Weakness in the hip flexors (e.g., iliopsoas) or spasticity in the hip extensors (e.g., gluteus maximus)
results in reduced leg swing, potentially causing foot drag or a compensatory high-stepping gait to clear the ground
Hip Hike =
Occurs in: Initial Swing to Mid Swing
abnormal lifting of the pelvis on the swing side to help clear the foot from the ground = compensatory mechanism to address foot drop or insufficient hip flexion
Reduced hip flexion or foot drop can lead to hip hiking to ensure adequate foot clearance during the swing phase
helps with foot clearance but can lead to an inefficient gait pattern and potential overuse of the lower back and hip muscles
Abnormal Substitutions (Circumduction)
Occurs in: Initial Swing to Terminal Swing
compensatory movement where the leg swings in a circular motion away from the body to clear the ground
often used when there is reduced hip flexion or foot drop
Adds complexity to the gait pattern and can lead to increased energy expenditure and gait inefficiency
Abnormal Substitutions (Scissoring)
Occurs in: Mid Swing to Terminal Swing = when the legs cross in front of each other
gait pattern where the legs cross in front of each other during the swing phase
can occur due to spasticity or increased tone in the adductor muscles or poor coordination
Causes a narrow base of support, increasing the risk of tripping and instability
Common Gait Deviations - Stroke (Trunk/Pelvis)
stance:
- Increased trunk flexion
- Lateral trunk lean
- Pelvic drop
swing:
- Decreased (forward) pelvic rotation
- Backward trunk lean
Increased Trunk Flexion =
Occurs in: Midstance to Terminal Stance
Excessive forward bending of the trunk
Weakness in the hip extensors, trunk extensors, or poor control of the trunk due to muscle imbalances or spasticity
compensatory mechanism for reduced propulsion or poor balance
deviation can reduce stability, affect forward progression, and increase energy expenditure during walking
Lateral Trunk Lean =
Occurs in: Midstance to Terminal Stance
trunk leans excessively to one side, typically towards the weak or affected side
Weakness in the hip abductor muscles (e.g., gluteus medius) on the stance side, or a compensatory strategy to maintain balance due to muscle weakness or spasticity
deviation can impair balance and stability, and may lead to increased risk of falls
Pelvic Drop =
Occurs in: Midstance to Terminal Stance
noticeable dropping of the pelvis on the side opposite to the stance leg
Weakness in the hip abductors on the stance leg side (e.g., gluteus medius), often associated with Trendelenburg gait
can affect gait stability, increase the risk of falls, and result in an inefficient gait patter
Decreased (Forward) Pelvic Rotation =
Occurs in: Initial Swing to Mid Swing
Reduced rotation of the pelvis forward relative to the trunk and legs during the swing phase
Reduced hip flexion or poor coordination of the trunk and pelvis, often due to muscle weakness or spasticity
can limit stride length, decrease gait efficiency, and affect overall walking speed
Backward Trunk Lean =
Occurs in: Swing Phase, particularly Terminal Swing
Excessive backward leaning of the trunk
Weakness in the hip flexors or excessive hip extension, sometimes as a compensatory mechanism for poor forward propulsion or trunk control
deviation can affect balance, reduce efficiency in leg swing, and contribute to an abnormal gait pattern
Common Gait Deviations - Stroke
Decreased weight-bearing over hemiparetic leg
Unequal step/stride length; narrow BOS
Decreased cadence/abnormal timing
Decreased weight-bearing over hemiparetic leg
Reduced amount of weight supported by the affected (hemiparetic) leg compared to the non-affected leg
Weakness, spasticity, pain, or impaired proprioception in the hemiparetic leg
patient may avoid putting full weight on the affected side due to fear of instability or discomfort
Occurs in: All Phases of the gait cycle, but most noticeable during the Stance Phase when the leg is supporting the body’s weight = more pronounced weight shift to the unaffected leg.
Unequal Step/Stride Length
Discrepancy in the length of steps or strides between the affected and unaffected legs
hemiparetic leg may have a shorter step/stride length
causes: Decreased range of motion, reduced strength, or impaired motor control on the affected side
Occurs in: Swing Phase and Stance Phase
Shortened step length can be observed as the affected leg swings forward and during stance when the leg is bearing weight.
Narrow Base of Support (BOS)
distance between the feet is reduced, leading to a narrower stance width
causes: Poor balance or coordination
Occurs in: All Phases, but most noticeable during Stance Phase as the feet are in contact with the ground.
Decreased Cadence
Reduced number of steps taken per minute, leading to a slower walking speed
causes: Weakness, reduced muscle control, or pain in the hemiparetic leg
Patients may have difficulty maintaining a normal cadence due to the effort required to move the affected leg
Occurs in: All Phases, but the overall effect is seen in the decreased speed of the gait cycle
Abnormal Timing
Disruption in the normal timing of the gait cycle phases, leading to irregularities in the rhythm of walking
causes: Motor control issues, muscle weakness, or spasticity affecting the timing and coordination of the gait cycle
Occurs in: All Phases, with irregularities often observed throughout the Stance and Swing Phases as the gait pattern becomes less smooth
Deficits in Biomechanical Subcomponents & INTERVENTION FOCUS
Propulsion – reduced speed/symmetry
Stance control – buckling, hip/knee collapse
Limb advancement/swing – limited paretic step length/speed
Postural/Lateral stability – balance difficulty, reduced speeds
Propulsion – reduced speed/symmetry
leads to slower walking speed and less symmetrical gait patterns
can affect the efficiency and fluidity of walking, making it harder for the patient to maintain a consistent pace
Evaluate the effectiveness of the push-off phase and the overall power generated during gait = Assess symmetry of propulsion between legs and observe the ability to maintain or increase walking speed
Propulsion Intervention Focus:
Focus on strengthening the muscles involved in propulsion, such as the calf muscles (gastrocnemius and soleus) and the hip extensors (gluteus maximus)
Implement techniques to improve the push-off phase during the stance phase, such as toe raises and progressive weight-bearing activities
Use orthotics or shoe inserts to improve push-off and reduce asymmetry
Include exercises that simulate walking on various surfaces and inclines to improve propulsion and speed
Stance control – buckling, hip/knee collapse
can lead to instability and difficulty maintaining an upright posture
often results from weakness or poor control of the muscles that stabilize the joint
Observe stability and control during the stance phase
> Look for signs of knee or hip buckling, uneven weight distribution, and overall balance while standing and transitioning weight
Stance control Intervention Focus:
Target the muscles responsible for joint stability, including the quadriceps, hamstrings, hip abductors (gluteus medius), and hip extensors
Engage in exercises that improve balance and proprioception, such as standing on unstable surfaces or performing weight-shifting activities
Practice controlled weight-bearing activities and retrain proper stance mechanics to prevent knee or hip collapse
Consider using braces or orthotics to provide additional support and reduce the risk of buckling
Limb advancement/swing – limited paretic step length/speed
Limited step length and speed on the affected (paretic) side can lead to an asymmetrical gait and difficulty in achieving a smooth and efficient walking pattern
Measure the length and speed of the swing phase of the affected limb
> evaluate the ability to advance the limb and clear the ground during swing
Limb advancement/swing Intervention Focus:
strengthening the hip flexors (iliopsoas) and improving the range of motion of the hip and knee to facilitate better limb advancement
functional gait training techniques such as treadmill walking with body-weight support, high-step walking drills, and stride length exercises
stretching exercises to improve flexibility and reduce muscle tightness that may limit limb advancement
Functional Electrical Stimulation (FES): Implement FES to stimulate the muscles involved in limb advancement and enhance swing phase performance
Postural/Lateral stability – balance difficulty, reduced speeds
Difficulty maintaining balance and reduced walking speeds are common issues
This can lead to an increased risk of falls and reduced mobility
Assess overall balance and stability during walking
> look for deviations in posture and lateral stability, and evaluate the ability to maintain an upright position and control body sway
Postural/Lateral stability Intervention Focus:
Engage in exercises that improve static and dynamic balance, such as standing on one leg, walking on uneven surfaces, and performing balance board exercises
Strengthen core muscles and lower extremity muscles to enhance overall stability and control
Incorporate activities that improve coordination and proprioception, such as agility drills and task-specific training
Implement gait training that focuses on improving walking speed and stability, including treadmill training and over-ground walking exercises with varying speed
Common Gait Deviations - Parkinson’s Disease (PD)
Initial motor symptom in ~ 13% to 33% of patients
Resting Tremor
Bradykinesia (Slowness of Movement)
Rigidity = increase m. tone
Postural Instability
Unilateral symptoms (eventually become bilateral)
Gait changes:
Reduced arm swing with asymmetry
Festinating gait (anteropulsive/retropulsive)
Shuffling gait
Freezing of gait (FOG)
Difficulty turning or changing directions
Reduced Arm Swing
Limited or absent swinging of the arms while walking
Rigidity and bradykinesia affect the ability to swing arms naturally
> deviation can lead to reduced balance and coordination
can affect overall gait stability and efficiency
Festinating Gait
Progressive increase in walking speed with increasingly shorter steps, often accompanied by a forward-leaning posture
Difficulty in controlling the speed of movement, often due to impaired postural control and bradykinesia
Can lead to a loss of balance and difficulty stopping or changing direction
Shuffling Gait
Small, rapid steps with minimal heel-to-toe movement
Difficulty in initiating and maintaining movement due to bradykinesia and rigidity. Feet may appear to drag or remain close to the ground
Increases the risk of tripping and falls, and reduces walking speed
Freezing of Gait (FoG)
Brief, sudden inability to move the feet forward, often described as feeling “stuck” or “glued” to the floor
Related to motor planning difficulties and disturbances in the basal ganglia circuits that are involved in initiating and maintaining movement
Increases fall risk and significantly impairs mobility
Difficulty Turning
Problems with initiating and executing turns while walking
Rigidity and bradykinesia make it hard to coordinate body movements and shift weight effectively during turns
Can lead to hesitation, unsteady movements, and increased fall risk during turns
Common Gait Deviations – Multiple Sclerosis (MS)
Gait changes secondary to muscle weakness, spasticity, fatigue, altered sensation, impaired balance, visual problems, and/or FEAR OF FALLING
Toe drag, genu recurvatum, circumduction
Staggering, uneven steps; poor foot placement; uncoordinated limb movements (“drunk gait”)
Scissoring gait pattern
Walking is more energy consuming and slow
Toe Drag
front part of the foot drags on the ground during the swing phase of gait
Weakness in the dorsiflexor muscles (e.g., tibialis anterior) or spasticity can lead to insufficient lifting of the foot
Increases the risk of tripping and falling, reduces walking efficiency, and can cause foot and toe injuries
Genu Recurvatum
Hyperextension of the knee joint during the stance phase, causing the knee to bend backward
Muscle weakness, particularly in the quadriceps or hamstrings, or spasticity can lead to instability and hyperextension
Causes instability and can lead to knee pain and increased fall risk
Circumduction
swinging motion of the leg outward during the swing phase, often involving a wide arc of movement
Weakness or spasticity in the hip flexors or knee extensors, or a compensatory strategy to lift the foot clear of the ground
Results in a less efficient gait pattern and can contribute to increased fatigue and difficulty with coordination
Staggering
Unsteady and irregular gait with noticeable swaying or weaving, often described as a “drunk gait”
Impaired balance and coordination, potentially due to cerebellar involvement or sensory disturbance
Increases fall risk and reduces overall gait stability and efficiency
Uneven Steps
Asymmetry in the length and placement of steps, with noticeable variations in step length and width
Muscle weakness, spasticity, and poor coordination can lead to irregular step patterns and variability in foot placement
Contributes to an unstable gait and difficulty in maintaining a consistent walking pattern
Poor Foot Placement
Difficulty in placing the foot accurately during walking, leading to missteps or uneven footfalls
Sensory deficits or coordination problems can affect the ability to place the foot correctly
Increases the risk of tripping, stumbling, and falling
Uncoordinated Limb Movements (“Drunk Gait”)
Erratic and uncoordinated movements of the limbs, often resembling an intoxicated gait
Impaired motor control and coordination, commonly due to cerebellar dysfunction or lesions affecting motor pathways
Results in a highly unstable and inefficient gait, with increased fall risk and difficulty in performing everyday tasks
Scissoring Gait Pattern
legs cross over each other during walking, often resulting in a narrow base of support and difficulty in leg clearance
Spasticity in the adductor muscles of the thighs, leading to excessive internal rotation and crossing of the legs
Causes a characteristic gait pattern that can be inefficient and contribute to tripping and difficulty navigating through spaces
Common Gait Deviations - SCI
Can be quite variable in incomplete SCI
speed modulation of specific gait parameters (e.g., step length, cadence), up to a point, may be preserved
Different from observations in conditions affecting supraspinal motor centers
Absent or Reduced Arm Swing
Hip Hiking
Circumduction
Hypertonia
Impaired Gait Speed
Unsteady gait
Reduced or Absent Trunk Control
Absent or Reduced Arm Swing
Limited or no movement of the arms during walking
May result from impaired trunk control and balance or compensatory strategies for lower limb weakness
Affects overall gait stability and can lead to inefficient movement patterns
Hip Hiking
Elevated hip on the affected side during swing phase to facilitate foot clearance
Weakness or paralysis of the hip flexors and knee extensors may necessitate compensatory hip hiking
Can lead to an inefficient gait pattern and increased energy expenditure
Circumduction
Outward swinging of the leg during the swing phase
Similar to hip hiking, this compensatory mechanism helps clear the foot from the ground due to weakness in the hip flexors and knee extensors
Reduces gait efficiency and can result in fatigue
Gait Abnormalities Related to Weakness
Weakness in specific muscle groups leads to deviations such as knee buckling or difficulty in maintaining a stable gait
Loss of function in muscles innervated below the level of injury
Can lead to instability, increased fall risk, and compensatory gait patterns
Hypertonia or Spasticity
Increased muscle tone leading to stiffness and potentially abnormal postures
Spasticity resulting from injury-induced changes in spinal cord pathways
Can cause stiff, jerky movements and affect gait fluidity and efficiency
Impaired Gait Speed Modulation
Difficulty adjusting gait speed in response to different walking conditions or tasks
Residual function in incomplete SCI may preserve some speed modulation, but not as effectively as in able-bodied individuals
Limits adaptability in various walking environments and tasks
Unsteady or Asymmetric Gait
Uneven gait patterns with differences in step length, cadence, or weight-bearing
Variable function of the lower limbs and trunk control depending on the level and completeness of the injury
Can lead to inefficiencies in walking and increased risk of falls
Reduced or Absent Trunk Control
Difficulty maintaining an upright posture and controlling trunk movements during gait
Loss of motor control and strength in trunk muscles
Affects overall balance and coordination, leading to unsteady gait and increased fall risk
How might gait be affected in persons with the following movement system diagnosis?
Movement pattern coordination deficit
Inability to coordinate a task due to altered timing/sequencing of movement components
Unsteady or Jerky Movements = irregular or discontinuous, with noticeable jerks or hesitations
Inconsistent Step Length = Variation in the length of steps taken
Difficulty in smoothly transitioning between phases of the gait cycle due to poor coordination
unsteady gait = increases the risk of tripping and falling
Poor Foot Placement = difficulty in placing the foot accurately on the ground, leading to missteps and uneven contact with the floor
Arm swing may be exaggerated or diminished due to difficulty in coordinating upper and lower body movements
Excessive elevation of the hip on the swing side to clear the foot or insufficient hip hiking due to coordination problems
How might gait be affected in persons with the following movement system diagnosis?
Force production deficit
Reduced Gait Speed = Insufficient force generation during both the stance and swing phases of gait, leading to decreased propulsion and slower movement
shorter strides = Inability to generate enough force to propel the body forward effectively
Difficulty with Push-Off = Weak plantar flexors or insufficient muscle activation during the push-off phase
Excessive Hip Flexion = compensate for weak ankle dorsiflexors or plantar flexors
Knee Hyperextension or Buckling = Weak quadriceps or insufficient control of knee flexor/extensor muscles, leading to instability and difficulty maintaining knee alignment
compensatory movements such as excessive hip hiking, circumduction, or lateral trunk lean to aid in foot clearance and forward propulsion
How might gait be affected in persons with the following movement system diagnosis?
Fractionated movement deficit
Associated with hyperexcitability
Involuntary Muscle Contractions (Spasticity) = Excessive muscle contractions and stiffness, leading to reduced flexibility and difficulty in smooth movement
Problems with the precise control of movements, affecting coordination = uneven or irregular gait patterns, and difficulty in making precise adjustments during walking, such as avoiding obstacles
Elevated muscle tone, especially in the lower limbs, leading to a stiff gait
Inadequate Foot Clearance = Spasticity in the calf muscles or weakness in the dorsiflexors affects foot lift
Unpredictable and jerky movement patterns during gait
Slower walking speed due to difficulty in generating smooth, coordinated movements
How might gait be affected in persons with the following movement system diagnosis?
Postural vertical deficit
Increased Risk of Falling = Difficulty in perceiving and maintaining vertical alignment affects balance and stability
Deviations from a normal gait pattern, such as uneven step length or asymmetric stride
Forward Lean or Backward Lean = Impaired perception of vertical alignment can cause individuals to adopt compensatory postures to maintain balance
Shuffling or Cautious Gait = Fear of falling and difficulty in maintaining balance may lead to a more conservative and less dynamic gait pattern
Reduced Arm Swing = compensatory strategy to stabilize the body
Unsteady or Wobbly Gait
Difficulty with Navigation = Impaired perception of vertical orientation affects spatial awareness
Mobility in Persons with Neurological Conditions
Goals of therapy:
Facilitate lost movement = Restore or improve the ability to perform movements that have been compromised or lost due to neurological impairments.
Improve efficiency = Enhance the effectiveness and efficiency of movement to reduce fatigue, improve speed, and optimize overall mobility.
Facilitate lost movement:
Task-specific training
functional electrical stimulation (FES) to activate muscles and enhance motor learning
Resistance training targeting specific muscle groups that are weak or impaired
Passive or active-assisted ROM
Balance and coordination exercises to refine motor skills and movement patterns
Improve efficiency:
gait retraining exercises to focus on smoother, more coordinated movement patterns
strategies to manage and conserve energy during activities
Simulation of daily activities (e.g., walking to the store, climbing stairs) to practice and refine functional skills
Enhance mobility and independence through the use of devices
Incorporation of aerobic exercises to improve cardiovascular fitness
Mobility in Persons with Neurological Conditions:
Task-oriented approach – PRACTICE WALKING!!
Adaptation to the environment
Overground Walking: Practice walking in a controlled environment to simulate real-world conditions.
Treadmill Training: Use a treadmill with or without body weight support to focus on walking mechanics and endurance.
Walking in Different Environments: Practice walking on various surfaces (e.g., uneven terrain, inclines) to enhance adaptability.
Incorporate drills that focus on specific aspects of walking, such as foot clearance, step length, and cadence
Create a course with various challenges (e.g., cones, steps) to improve navigation and maneuverability
Components of program:
1) muscular strength/endurance
2) motor control/coordination
3) CV endurance
training for neuroplasticity:
1) task complexity
- Multistep Exercises
- Functional Tasks
- Progressive Overload
- Task Variation
2) task specificity
- Task-Specific Training
- Fine Motor Tasks
- Coordination Drills
- Simulation of Real-Life Tasks
3) task difficulty
- Gradual Intensity Increase
- Interval Training
- Functional and Challenging Activities
- Exercise Variety
- Environmental Variation
No matter what the activity: What are the variables that I have to account for or manage during treatment?
Individual Patient Factors
Exercise and Activity Variables
Safety and Risk Management
Progress Monitoring and Adaptation
Environmental and Contextual Factors
Individual Patient Factors
Diagnosis and Severity
Functional Abilities
Comorbidities
Motivation and Psychological Factors
Exercise and Activity Variables
Intensity
Duration
Frequency
Type of Activity
Safety and Risk Management
Fall Risk
Injury Prevention
Medical Stability
Progress Monitoring and Adaptation
Assessment and Feedback
Goal Setting
Program Adaptatio
Environmental and Contextual Factors
Home Environment
Accessibility
Support Systems
No matter what the activity: What are the variables that I have to account for or manage during treatment?
Examples:
Visual field cut
Encourage the patient to consciously scan their environment more thoroughly
visual markers or cues to draw attention to important areas of the visual field
No matter what the activity: What are the variables that I have to account for or manage during treatment?
Examples:
Perceptual inattention
Challenges in recognizing or attending to stimuli, which can affect spatial awareness and movement planning
Focused Attention Exercises: Use exercises designed to improve attention to specific tasks or environments
Create structured and clutter-free environments to minimize distractions and focus attention
No matter what the activity: What are the variables that I have to account for or manage during treatment?
Examples:
Distractability/Cognition/Psychological
Cognitive issues like distractibility or psychological factors like anxiety can impact concentration, learning, and performance
Provide simple, clear, and concise instructions. Break tasks into smaller, manageable steps
Use of Reminders: Employ visual or auditory cues to help the patient stay on track.
Minimize environmental distractions and provide a calm, supportive setting to reduce anxiety and improve focus
No matter what the activity: What are the variables that I have to account for or manage during treatment?
Examples:
Communication disorders (what do my instructions have to look or sound like?)
Difficulty understanding or producing speech can affect the ability to follow instructions or express needs
Use short sentences and simple language. Avoid jargon or complex terminology
Incorporate visual aids or demonstrations to supplement verbal instructions
Repeat instructions as needed and ask for confirmation to ensure understanding
No matter what the activity: What are the variables that I have to account for or manage during treatment?
Examples:
Pain
Pain can limit movement, reduce participation, and impact overall treatment effectiveness
Regularly assess the patient’s pain levels and adjust activities accordingly
Adjust the intensity, duration, or type of activities to accommodate pain levels. Avoid activities that exacerbate pain
Utilize pain management techniques such as heat/cold therapy, relaxation techniques, or medication
Categories of Intervention
compensation
restoration
prevention
compensation
adapt to their impairments by using external aids, modified strategies, or assistive devices
AFO’s (Ankle-Foot Orthoses) = Provide support and stability to the ankle and foot, correct foot drop, and improve gait mechanics
Assistive devices = Enhance mobility and function by providing external support
Altered gait strategies = Modify walking patterns to accommodate functional limitations or improve gait efficiency
restoration
restore lost function and improve physical capabilities through targeted exercises and training
Strengthening = Resistance training, weight-bearing exercises, and functional strength exercises
Gait/balance (motor control) retraining = Improve motor control, gait mechanics, and balance to enhance walking ability and prevent falls
CV training = Aerobic exercises such as walking, cycling, or swimming
prevention
prevent complications, injuries, and deterioration of function
Fall risk reduction strategies = Remove trip hazards, install grab bars, and improve lighting = Exercises designed to improve balance and strengthen key muscle groups = Teach patients and caregivers about fall prevention techniques and safety measures
Activity restriction = Advise on adjusting or avoiding specific activities that pose risks
Gait Interventions…What is the Evidence?
Chronic stroke:
good: mod to high-intensity gait training; VR gait training]
okay: (strength training; combined strategies; VR balance activities)
High-intensity gait training has been shown to improve gait speed, endurance, and overall walking ability in individuals with chronic stroke
VR gait training has shown positive outcomes in improving gait performance, balance, and mobility
Strength training can help improve muscle strength and functional mobility, which may contribute to better gait performance
Combining various strategies, such as gait training with strength training or balance activities, may offer additional benefits compared to single-modality
Gait Interventions…What is the Evidence?
Parkinson’s Disease
good/okay: aerobic exercise, balance/resistance training; gait training; external cueing; community-based exercise
Aerobic exercise has been shown to improve cardiovascular fitness, endurance, and functional mobility, which can indirectly enhance gait performance
Gait training, particularly when done with moderate to high intensity, has robust evidence supporting its efficacy in improving gait speed, endurance, and functional mobility
Gait Interventions…What is the Evidence?
Multiple Sclerosis
good: (exercise training)
okay: (VR – positive impact on gait/balance & cognitive function; TM training; balance-based torso weighting)
Exercise training, particularly when involving strength, endurance, and functional tasks, has been shown to significantly improve gait parameters such as speed, endurance, and overall mobility
VR interventions have shown positive impacts on gait, balance, and cognitive function. They provide engaging and interactive environments that can enhance motor learning and rehabilitation outcomes
Treadmill training is effective for improving gait speed, endurance, and walking patterns
Gait Interventions…What is the Evidence?
Incomplete SCI
good: mod to high-intensity gait training = improves gait performance, walking ability, and overall functional mobility
> Typically involves repetitive walking practice with high intensity, including treadmill training with or without body-weight support, and over-ground walking
okay: strength training; acute intermittent hypoxia = positive effects on muscle strength, endurance, and functional mobility
> strengthening key muscle groups involved in gait, such as the lower limbs and core
clinical practice guideline to improve locomotor function following chronic stroke
Engage in high-intensity gait training and task-specific exercise to improve walking speed, endurance, and overall gait function
Incorporate strength training to enhance muscle strength and endurance, which supports gait function
Implement balance training exercises to address postural control and stability
Utilize assistive devices (e.g., AFOs, canes) as needed to support mobility and safety
clinical practice guideline to improve locomotor function following ISCI
Perform moderate to high-intensity gait training to enhance walking ability and functional mobility
Engage in strength training to improve muscle strength, which supports locomotor function
Use treadmill training with or without body-weight support to facilitate walking practice
Incorporate balance and coordination exercises to enhance overall stability and movement control
clinical practice guideline to improve locomotor function following brain injury
Engage in task-oriented training focused on specific motor tasks and functional activities
Implement gait training interventions, including over-ground and treadmill training, to improve walking patterns
Include balance and coordination exercises to address deficits and improve functional outcomes
Use multimodal interventions combining physical therapy, cognitive training, and occupational therapy for comprehensive rehabilitation
High-Intensity Gait Training (HIGT, HIT, HIIT)
Importance, definition, application & monitoring of intensity
particularly effective for individuals with chronic stroke and incomplete SCI
involves treadmill walking with varying speeds and inclines, or over-ground walking with added resistance or intensity
High-Intensity Gait Training (HIGT):
Focuses on improving gait specifically through high-intensity walking exercises. Effective in enhancing gait speed and endurance.
High-Intensity Training (HIT):
A broader approach that includes various high-intensity exercises to improve overall fitness and functional mobility.
High-Intensity Interval Training (HIIT):
Involves alternating between high-intensity and low-intensity intervals to maximize cardiovascular and muscular benefits in a time-efficient manner.
How can we increase intensity of walking?
Increase Walking Speed
Incorporate Inclines and Hills
Add Intervals
Increase Duration and Frequency
Use Weighted Vest or Ankle Weights
Incorporate Functional Tasks
Add Resistance Training
Use External Cues and Feedback
Define successful walking in terms of biomechanical components of gait (propulsion, limb swing, stance control, postural stability)
During the terminal stance phase, the push-off from the forefoot is strong and occurs at the appropriate time, providing sufficient forward propulsion
Proper heel-off occurs in the stance phase, facilitating smooth transition to the swing phase
The swinging leg clears the ground sufficiently to avoid dragging or tripping = proper knee and ankle flexion
Smooth weight transfer from heel strike to toe-off, with minimal lateral or forward/backward sway
upright posture and balance throughout the gait cycle
Define failure = 3-5 consecutive errors
Postural Stability Errors: Excessive lateral sway, forward or backward lean, or frequent balance loss.
Propulsion Errors: Inadequate push-off, excessive foot drag, or delayed heel-off.
Limb Swing Errors: Poor leg clearance, abnormal swing timing, or excessive hip flexion.
Stance Control Errors: Buckling of the knee, hip collapse, or instability during weight-bearing.
Postural Stability Errors: Excessive lateral sway, forward or backward lean, or frequent balance loss.
Assessing patient readiness
Considerations for implementation
Possible to have varied degree of deficits in different subcomponents
Assess the efficiency of push-off, heel-off, and overall forward propulsion
Look for abnormal swing patterns, such as excessive hip flexion or foot drag
Check for knee buckling, hip collapse, or unsteady weight transfer
Observe for excessive lateral sway, forward lean, or loss of balance
Consider their willingness to adhere to the program and their psychological readiness for challenging exercises
progressing biomechanical subcomponents of walking:
propulsion
stance control
limb advancement
stability and balance
LEAPS trial in stroke
3 groups (36 sessions of 90 minutes each for 12-16 weeks)
Early LT (2 months post-stroke)
Late LT (6 months post-stroke)
HEP (2 months post-stroke; limited walking)
No focus on trying to achieve/maintain higher heart rates during LT (*intensity)
No difference between groups!
timing of intervention (early vs. late) or the type of intervention (long-term therapy vs. home exercise) did not lead to significantly different outcomes
study did not focus on maintaining higher heart rates or intensity during the long-term interventions may imply that intensity could be a crucial factor in improving outcomes
