L10-11: Gait post stroke - common presentations Flashcards
What are 6 reasons for gait retraining?
- Gait commonly affected
- Main goal for many patients
- Impedes social interaction independence
- Interferes with self care
- Linked with community ambulation and social integration
- Is a test of sensory-motor integration
What are 6 functions of the lower limb?
- Balance and mobility
- Weight shift, move weight from one leg to other, walk, run, hop, skip etc
- Open chain tasks
- Related to tasks, lots of variety e.g. tasks in sitting e.g. putting on shoes
- Support – of the upper body by extensor muscles
- Propulsion - drive the body forward, rhythm
- Balance – maintaining upright posture
- Absorption – of shock and to control forward acceleration
Walking is a ____ and ____ activity
complex, coordinated
______ uses 1000 muscles in a synchronous pattern to move 200 bones around 100 moveable joints.
Walking
______ m/s is regarded as community ambulation speed (able to cross the road) in walking
1.1-1.5
What is the problem with inefficient gait patterns?
costly to energy output
What are 5 common walking myths for stroke?
- Independent walkers ≠ community ambulant walker
- 10m walk test may over predict walking speed (10sec)
- Dynamic gait index = better assessment
- Stroke patients often only have one speed
- Get them to walk fast and slow
- Decreased ability to increase speed and adjust gait for balance purposes
- Inability to negotiate stairs indicator of non participation in community
What is the assessment and treatment clinical reasoning?
What are 13 components in stance and swing stages of gait?
- Stride duration
- Stance time
- Swing time
- Single support time
- Double support time
- Stride length
- Step length
- BOS
- Cadence
- Velocity
- Arm swing
- Trunk movement
- Adaptive patterns
What does the problem solving approach to gait retraining look like for assessment?
What are the gait parameters (time distance)?
What are the different parameters of gait?
What are the 3 components of gait in stance?
- Heel strike to foot flat = Loading response – early stance
- Foot flat to heel off = Midstance
- Heel off to toe off = Pre-swing (late stance)
What are the GRF in gait/
What are ranges for hip, knee and ankle in initial contact (HS) of gait?
Hip : 25 F
Knee : 0-5 F
Ankle 0 (90)
What are 3 features of initial contact in gait?
- Hip stabilised by extensor activity of HS and Gluts
- Knee stabilised by co-contraction of quads and HS
- Ankle pre-tibial DF to position for contact
What are the rnages for hip, knee and ankle in loading response (HS to FF)?
Hip : (15)25 F
Knee : 0-15 F
Ankle 0–10 PF
What are 5 features of loading response (HS to FF) in gait?
- Hip abd stabilise pelvic drop in frontal plane
- Start to shift onto stance phase leg
- Hip extensors counteract trunk and hip flexion
- Quads control kn F providing shock absorption from GRF
- Ankle DF decelerate foot drop
- Tib Ant & post eccentrically decelerate pronation
What are the ranges of hip, knee and ankle in midstance (FF to MS) in gait?
Hip 25 – 0 F
Knee : 15 – 0 F
Ankle 10 PF to 5 DF
What are 4 features of midstance (FF to midstance) in gait?
- Hip abd minimises pelvic drop frontal plance- To avoid Trendelenburg
- Quads resist knee flexion until COG passes over BOS, then they are silent (Raise COM to clear the foot)
- Soleus and gastroc eccentrically controls tibial forward progression (2˚ DF required for mid stance)
- Hip extensor propel trunk forward
What are the ranges for hip, knee and ankle in terminal stance (FF to HO) in gait?
Hip 0 – 10-15 E
Knee 0-5 F
Ankle 5DF
What are the 5 features of midstance (MS to HO) in gait?
- Brief burst from hip F resisting hip E
- To ensure that you don’t fall forward from hip extensor
- Hip extensors to translate trunk
- Tensor fascia latae active (resist pelvic drop)
- So the swing leg does not have to move as much
- Minimal quad or HS (passive tension slight ecc hold)
- Ankle PF break tibial translation and contribute to passive tension to raise heel (Knee must bend and ankle DF)
What are the 3 ranges of the hip, knee and ankle in pre-swing (HO to TO) in gait?
Hip 20 E – 0
Knee : 5-40 F
Ankle 5 Df – 20 Pf
What are 4 features of pre-swing (HO to TO) in gait?
- Hip flexion via momentum and gravity with add longus and rec fem
- Add stabilise WS across midline to other foot
- Rec Fem restrain passive Kn F – break
- Ankle Pf passive tension facilitates knee flexion and active power generation (Most important for propulsion)
What are the ranges of the hip, knee and ankle in initial swing TO in gait?
Hip 15 F
Knee 60 F
Ankle 10 Pf
What are the 3 features of initial swing TO in gait?
- Hip flexors flex hip
- Add longus (Hamstring) brings leg toward midline
- Ankle Tib ant – DF
What are the ranges of hip, knee and ankle in Mid swing in gait?
Hip 25 F
Knee 25 F
Ankle 0
What are the 3 features in mid swing in gait?
- Hip Flexors with momentum
- HS deceleration of knee extension – knee extension from tibial forward momentum
- Ankle Tib Ant concentrically contract
Starts to extend to prepare and get heel out and down
What are the ranges of hip, knee and ankle in terminal swing (MS-Deceleration) in gait?
- Hip Flexors with momentum
- HS deceleration of knee extension – knee extension from tibial forward momentum
- Ankle Tib Ant concentrically contract
What are the 5 essential components of stance in gait?
- Hip extension throughout
- Hip extension + DF brings the trunk forward over the stance foot (E/Mstance)
- Ankle DF (e and mid) then fast PF (end and terminal)
- Rapid PF at end stance propels body forward (80% propulsion)
- Knee flexion (2-10/20º) at HS (early), extension through mid stance and flexion (end stance) before toe off at last stage of stance
- Lateral horizontal shift of pelvis and trunk – 5 cm
- Lateral trunk displacement is accompanied by stance
- hip adduction and eversion of stance foot
Weight shift (2cm to each side) –> shoulder width (not too wide –> hard to SW)
What are the 6 essential components of swing in gait?
- Knee flexion with hip extended
- commences in late stance and continues into swing
- Hip flexion in first 1/2 swing then sustained.
- Knee Ext –> just prior to HS - the knee flexes in preparation for next stance (terminal swing)
- Ankle DF commences just after toe-off and maintained through swing
- Forward rotation of pelvis 8 degrees (reduces the angles of hip F/E longer step length no loss of COG
- Slight lateral pelvic tilt downwards – mid swing – 5 degrees reduced height of COG curve
identify missing components
a
What are 3 things that abnormalities may be due to (when identifying impairments in assessment)?
- Primary impairment
- Secondary impairment
- Compensation
- Eg. circumduction of leg when walking)
What are 4 types of impairments in assessment?
- Motor: paresis, spasticity, co-ordination/dexterity, non-neural weakness
- Sensory: tactile loss, proprioception loss, vision or vestibular
- Cognitive and perceptual: pain, habits, fear of falling, dementia, unilateral spatial neglect, vertically problems
- Musculoskeletal: joint ROM, muscle length changes, muscle stiffness (resistance to passive movement as a consequence of spasticity), alignment problems.
Primary (eg. _____) and secondary (eg. _____) impairments may present with similar consequences to absent or altered essential components of _____ .
tone; length changes; kinematic
______ hip flexors may act in a similar manner to overactive hip flexors blocking hip extensor range at the hip in _______ stance – may look like weak concentric hip extensors.
Tight; mid to terminal
Not all _____impairments can contribute to a movement lack or are likely in gait
secondary
Why is tight gluteal muscles not likely in gait?
Constantly sit–> put on stretch
Why is tight hamstrings that inhibit knee extension for terminal stance not likely?
Not impact of high hamstring impacting on stance (need more range tested to be tight)
What is the assessment and treatment strategies for the pathology for Stroke, TBI, GB, (MS)?
expect recovery
What is the assessment and treatment strategies for the pathology for PD, MS, PN, LEOP?
progressive deterioration, however potential for neuroplastisity, maximise what they have, maintain function, prevent secondary loss. Manage fatigue and pain, educate management of complicating symptoms, cognitive issues.
What is the assessment and treatment strategies for the pathology for Elderly?
Consider age related gait changes, age related
pathological changes, goals
What is the assessment and treatment strategies for the secondary pathology?
adaptations leading to gait changes
What ae 8 common adaptive features in stance of gait?
- Walking slowly
- Increase time spent in double support
- Short step lengths
- Trunk inclined forward during stance
- Knee hyper extended in stance
- Hip retracted on weaker side
- Excessive lateral pelvic shift
- Excessive downward tilt / drop pelvis during swing
What are 5 common adaptive features in swing of gait?
- Wide base of support
- Knee flexed and ankle dorsiflexed at end of stance
- Elevation of the pelvis and abduction of leg
- Toes not clearing the ground during swing
- Trunk inclined back at end of or start of swing
Hip hitch –> compensatory technique
Why is a 4 point can suboptimal?
Suboptimal (4 point cane) -> comes too dependent (poor weight shift)
What are 3 features of decreased Peak hip extension in late stance phase in hemiplegic gait (hip)?
- Decreased Hip extensor activity early / late stance
- Shortening hip flexors (end stance)
- ↑Hip flexor activity in stance
What are 35features of decreased Peak hip extension in late stance phase in hemiplegic gait (further down)?
- ↑ Activity PF (prevents shankrolling over foot)
- Shortening PF (A/A)
- Decreased Hip flexors activity late stance
- Decaresed Activity Knee extensors (rising up body)
- Decreased Activity PF (end stance)
What are 2 features of decreased Peak lateral pelvic displacement in stance phase in hemiplegic gait?
- Decreased activity hip adductors early stance
- Decreased activity hip abductors early to mid stance
What are 3 features of increased peak lateral pelvic displacement in stance phase in hemiplegic gait?
- Shortening hip adductors
- ↑ Activity hip adductors in stance
- Decreased activity hip abductors early to mid stance
What are 4 features of decreased knee flexion or knee hyperextension in stance phase in hemiplegic gait?
- Decreased activity knee flexors in mid stance
- Decreased activity knee extensors mid stance
- ↑ Activity PF in early or mid stance
- Shortening TricepSurae
What are 4 features of decreased knee flexion or knee hyperextension in stance phase in hemiplegic gait?
- Decreased activity knee extensors inner range during stance
- Adaptive shortening of knee flexor muscle*** (is this likely) or loss of compliance of tissues on the flexor aspect of the knee
- Will not be hamstrings (will still be doing hip extension)
- ↑ Activity knee flexors in stance
What are 3 features of decreased ankle plantarflexion at toe off in stance phase in hemiplegic gait?
- Decreased activity ankle PFs in late stance
- Poor overall segmental alignment – did not get through cycle to use.
- Overactive PF in mid to late stance
What are 3 features of decreased peak hip flexion in swing phase in hemiplegic gait?
- Decreased active tension development in hip flexors in pre-swing or early swing (did not get into hip extension)
- Decreased activity in hip extensors in late stance
- Decreased activity of plantar flexors in late stance
What are 5 features of decreased peak knee flexion in early swing in hemiplegic gait?
- Decreased activity knee flexors in pre-swing
- ↑ Activity knee extensors in pre-swing or early swing
- ↑ Activity ankle PFs in late stance
- Shortened PFs – prevented early set up from stance
- Decreased peak hip extension in late stance
What are 5 features of decreased knee extension prior to heel strike in swing pahse in hemiplegic gait?
- Decreased activity knee extensors early swing
- ↑ Activity knee flexors in swing
- Shortened knee flexors (not likely why?)
- Decreased knee flexion in early swing
- Tight posterior capsule of knee
- Increased knee extension – flick prior to heel strike
- Decreased hamstring activity late swing
What are 5 features of decreased ankle DF during swing phase in hemiplegic gait?
- Decreased activity DFs in swing
- ↑ Activity PFs in swing
- Shortened PFs
What are 5 objective measurements in the assessment of gait?
- Functional Scale
- Scored observational gait analysis
- Timed functional mobility tasks
- Walking speed and walking distance
- Temporal-spatial variable measurement
What is the stance objective measurement?
Missing component– lack of knee extension mid stance
What are 3 underlying impairments of stance phase as an objective measurement?
- Knee structure flexion contracture - ROM
- Lack strength quads inner range – test and consider range and speed when testing
- Overactive knee flexors – tardieu scale consider range and speed when testing
What are 5 contexts of the individual for problem-solving approach to gait retraining?
- Goals
- Personality and behaviour
- Social situation
- Rehabilitation environment
- Physical characteristics
