Functional Upright Mobility Deficits in Neuromuscular Disorders

Question 1

factors contributing to functional upright mobility:

Answer 1

individual variables

mobility task & regulatory features

environmental variables

Question 2

individual variables:

Answer 2

age
prior experience
motor abilities
diagnosis
motivation
primary impairments
secondary impairments

Question 3

mobility tasks:

Answer 3

walking, stair climbing, inclines, curbs, obstacle negotiation, single or dual task

Question 4

regulatory features:

Answer 4

surface conditions

object characteristics

changes in regulatory conditions between attempts

Question 5

environmental variables:

Answer 5

moving or stationary environment

changes in regulatory conditions between attempts

Question 6

Examination of Gait/Upright Mobility

Answer 6

observational gait analysis

digitial video recording

Question 7

Gait/Upright Mobility
Outcome Measures:

Answer 7

Gait Speed (10MWT), Endurance (6MWT)

FGA, DGI

FIM, Functional Ambulation Category
(FAC), Walking Index for SCI (WISCI II)

HiMAT

Question 8

Three essential requirements for successful locomotion:

Answer 8

Progression (moving through space)

Postural control (upright)

Adaptation (to the environment)

Question 9

Stance Phase:

Answer 9

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

Question 10

subdivisions of stance phase:

Answer 10

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.

Question 11

Swing Phase:

Answer 11

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

Question 12

subdivisions of swing phase:

Answer 12

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.

Question 13

4 Biomechanical Subcomponents of Gait:

Answer 13

Propulsion

Stance control

Limb advancement/swing

Postural/Lateral stability

Question 14

Propulsion –

Answer 14

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

Question 15

Stance Control -

Answer 15

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

Question 16

Active Stance Control

Answer 16

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

Question 17

Active stance control relies on _____ to make real-time adjustments in muscle activity and body posture.

Answer 17

sensory feedback (proprioception, visual input)

For example, if you encounter an uneven surface, the muscles actively adjust to maintain stability.

Question 18

Passive Stance Control

Answer 18

“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

Question 19

In practice, both active and passive mechanisms work together to maintain stability during the stance phase:

Answer 19

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

Question 20

Limb advancement/swing –

Answer 20

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

Question 21

Postural/Lateral stability –

Answer 21

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

Question 22

Common Gait Deviations - Stroke
(Ankle/Foot)

Answer 22

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

Question 23

foot slap =

Answer 23

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

Question 24

Forefoot/Flat Foot Contact =

Answer 24

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

Question 25

Equinus Gait (Heel Does Not Touch Ground) =

Answer 25

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

Question 26

No/Decreased Heel Off (Decreased Propulsion) =

Answer 26

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

Question 27

Foot Drop/Drag =

Answer 27

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

Question 28

Persistent Equinus =

Answer 28

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

Question 29

Common Gait Deviations - Stroke
(Knee)

Answer 29

stance
- Excessive knee flexion
- Hyperextension

swing
- Decreased flexion (initial/mid swing)
- Inadequate knee extension at terminal swing/initial contact

Question 30

Excessive knee flexion =

Answer 30

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

Question 31

Hyperextension =

Answer 31

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

Question 32

Decreased Flexion (Initial/Mid Swing) =

Answer 32

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

Question 33

Inadequate Knee Extension at Terminal Swing/Initial Contact =

Answer 33

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

Question 34

Common Gait Deviations - Stroke
(Hip)

Answer 34

stance
- poor hip position
- trendelenburg gait

swing
- decreased hip flexion
- hip hike
- abnormal substitutions (circumduction, scissoring)

Question 35

Poor Hip Position =

Answer 35

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

Question 36

Trendelenburg Gait =

Answer 36

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

Question 37

Decreased Hip Flexion =

Answer 37

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

Question 38

Hip Hike =

Answer 38

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

Question 39

Abnormal Substitutions (Circumduction)

Answer 39

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

Question 40

Abnormal Substitutions (Scissoring)

Answer 40

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

Question 41

Common Gait Deviations - Stroke (Trunk/Pelvis)

Answer 41

stance:
- Increased trunk flexion
- Lateral trunk lean
- Pelvic drop

swing:
- Decreased (forward) pelvic rotation
- Backward trunk lean

Question 42

Increased Trunk Flexion =

Answer 42

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

Question 43

Lateral Trunk Lean =

Answer 43

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

Question 44

Pelvic Drop =

Answer 44

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

Question 45

Decreased (Forward) Pelvic Rotation =

Answer 45

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

Question 46

Backward Trunk Lean =

Answer 46

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

Question 47

Common Gait Deviations - Stroke

Answer 47

Decreased weight-bearing over hemiparetic leg


Unequal step/stride length; narrow BOS


Decreased cadence/abnormal timing

Question 48

Decreased weight-bearing over hemiparetic leg


Answer 48

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.

Question 49

Unequal Step/Stride Length

Answer 49

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.

Question 50

Narrow Base of Support (BOS)

Answer 50

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.

Question 51

Decreased Cadence

Answer 51

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

Question 52

Abnormal Timing

Answer 52

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

Question 53

Deficits in Biomechanical Subcomponents & INTERVENTION FOCUS

Answer 53

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

Question 54

Propulsion – reduced speed/symmetry

Answer 54

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

Question 55

Propulsion Intervention Focus:

Answer 55

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

Question 56

Stance control – buckling, hip/knee collapse

Answer 56

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

Question 57

Stance control Intervention Focus:

Answer 57

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

Question 58

Limb advancement/swing – limited paretic step length/speed

Answer 58

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

Question 59

Limb advancement/swing Intervention Focus:

Answer 59

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

Question 60

Postural/Lateral stability – balance difficulty, reduced speeds

Answer 60

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

Question 61

Postural/Lateral stability Intervention Focus:

Answer 61

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

Question 62

Common Gait Deviations - Parkinson’s Disease (PD)

Answer 62

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)

Question 63

Gait changes:

Answer 63

Reduced arm swing with asymmetry

Festinating gait (anteropulsive/retropulsive)

Shuffling gait

Freezing of gait (FOG)

Difficulty turning or changing directions

Question 64

Reduced Arm Swing

Answer 64

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

Question 65

Festinating Gait

Answer 65

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

Question 66

Shuffling Gait

Answer 66

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

Question 67

Freezing of Gait (FoG)

Answer 67

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

Question 68

Difficulty Turning

Answer 68

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

Question 69

Common Gait Deviations – Multiple Sclerosis (MS)

Answer 69

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

Question 70

Toe Drag

Answer 70

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

Question 71

Genu Recurvatum

Answer 71

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

Question 72

Circumduction

Answer 72

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

Question 73

Staggering

Answer 73

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

Question 74

Uneven Steps

Answer 74

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

Question 75

Poor Foot Placement

Answer 75

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

Question 76

Uncoordinated Limb Movements (“Drunk Gait”)

Answer 76

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

Question 77

Scissoring Gait Pattern

Answer 77

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

Question 78

Common Gait Deviations - SCI

Answer 78

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

Question 79

Absent or Reduced Arm Swing

Answer 79

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

Question 80

Hip Hiking

Answer 80

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

Question 81

Circumduction

Answer 81

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

Question 82

Gait Abnormalities Related to Weakness

Answer 82

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

Question 83

Hypertonia or Spasticity

Answer 83

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

Question 84

Impaired Gait Speed Modulation

Answer 84

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

Question 85

Unsteady or Asymmetric Gait

Answer 85

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

Question 86

Reduced or Absent Trunk Control

Answer 86

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

Question 87

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

Answer 87

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

Question 88

How might gait be affected in persons with the following movement system diagnosis?

Force production deficit

Answer 88

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

Question 89

How might gait be affected in persons with the following movement system diagnosis?

Fractionated movement deficit
Associated with hyperexcitability

Answer 89

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

Question 90

How might gait be affected in persons with the following movement system diagnosis?

Postural vertical deficit

Answer 90

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

Question 91

Mobility in Persons with Neurological Conditions

Goals of therapy:

Answer 91

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.

Question 92

Facilitate lost movement:

Answer 92

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

Question 93

Improve efficiency:

Answer 93

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

Question 94

Mobility in Persons with Neurological Conditions:
Task-oriented approach – PRACTICE WALKING!!
Adaptation to the environment

Answer 94

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

Question 95

Components of program:
1) muscular strength/endurance

2) motor control/coordination

3) CV endurance

training for neuroplasticity:

Answer 95

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

Question 96

No matter what the activity: What are the variables that I have to account for or manage during treatment?

Answer 96

Individual Patient Factors

Exercise and Activity Variables

Safety and Risk Management

Progress Monitoring and Adaptation

Environmental and Contextual Factors

Question 97

Individual Patient Factors

Answer 97

Diagnosis and Severity

Functional Abilities

Comorbidities

Motivation and Psychological Factors

Question 98

Exercise and Activity Variables

Answer 98

Intensity

Duration

Frequency

Type of Activity

Question 99

Safety and Risk Management

Answer 99

Fall Risk

Injury Prevention

Medical Stability

Question 100

Progress Monitoring and Adaptation

Answer 100

Assessment and Feedback

Goal Setting

Program Adaptatio

Question 101

Environmental and Contextual Factors

Answer 101

Home Environment
Accessibility
Support Systems

Question 102

No matter what the activity: What are the variables that I have to account for or manage during treatment?

Examples:
Visual field cut

Answer 102

Encourage the patient to consciously scan their environment more thoroughly

visual markers or cues to draw attention to important areas of the visual field

Question 103

No matter what the activity: What are the variables that I have to account for or manage during treatment?

Examples:
Perceptual inattention

Answer 103

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

Question 104

No matter what the activity: What are the variables that I have to account for or manage during treatment?

Examples:
Distractability/Cognition/Psychological

Answer 104

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

Question 105

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?)

Answer 105

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

Question 106

No matter what the activity: What are the variables that I have to account for or manage during treatment?

Examples:
Pain

Answer 106

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

Question 107

Categories of Intervention

Answer 107

compensation

restoration

prevention

Question 108

compensation

Answer 108

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

Question 109

restoration

Answer 109

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

Question 110

prevention

Answer 110

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

Question 111

Gait Interventions…What is the Evidence?
Chronic stroke:

Answer 111

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

Question 112

Gait Interventions…What is the Evidence?

Parkinson’s Disease

Answer 112

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

Question 113

Gait Interventions…What is the Evidence?

Multiple Sclerosis

Answer 113

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

Question 114

Gait Interventions…What is the Evidence?

Incomplete SCI

Answer 114

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

Question 115

clinical practice guideline to improve locomotor function following chronic stroke

Answer 115

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

Question 116

clinical practice guideline to improve locomotor function following ISCI

Answer 116

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

Question 117

clinical practice guideline to improve locomotor function following brain injury

Answer 117

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

Question 118

High-Intensity Gait Training (HIGT, HIT, HIIT)

Answer 118

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

Question 119

High-Intensity Gait Training (HIGT):

Answer 119

Focuses on improving gait specifically through high-intensity walking exercises. Effective in enhancing gait speed and endurance.

Question 120

High-Intensity Training (HIT):

Answer 120

A broader approach that includes various high-intensity exercises to improve overall fitness and functional mobility.

Question 121

High-Intensity Interval Training (HIIT):

Answer 121

Involves alternating between high-intensity and low-intensity intervals to maximize cardiovascular and muscular benefits in a time-efficient manner.

Question 122

How can we increase intensity of walking?

Answer 122

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

Question 123

Define successful walking in terms of biomechanical components of gait (propulsion, limb swing, stance control, postural stability)

Answer 123

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

Question 124

Define failure = 3-5 consecutive errors

Postural Stability Errors: Excessive lateral sway, forward or backward lean, or frequent balance loss.

Answer 124

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.

Question 125

Assessing patient readiness

Considerations for implementation

Possible to have varied degree of deficits in different subcomponents

Answer 125

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

Question 126

progressing biomechanical subcomponents of walking:

Answer 126

propulsion

stance control

limb advancement

stability and balance

Question 127

LEAPS trial in stroke

Answer 127

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