Masterclass: Stroke - Gait and Stairs

Question 1

Outline how to assess walking

Answer 1

*Walk at least 10 m
*Assess 1 leg at a time
*Assess one phase at a time (tip: start with stance)
*Assess one joint at a time (tip: start at the foot)
*Follow a logical order
*Consider supplementary walking assessment software/equipment
*Consider using checklists (i.e. Gait assessment rating scale)

Question 2

Outline normative values for walking

Answer 2

In healthy people
Stride duration: ≈1.1s/stride
Stance/swing time: 60/40% gait cycle
Double/single support time: 20/80% stride time
Cadence: ≈110 step/min
Velocity: 70-90m/min (4.2-5.4 km/h)
Step length: ≈1/3 height (60-65 cm)
BOS: ≈2-12 cm between heels
Toe out: ≈7 deg

Question 3

Outline the different phases (initial contact, loading response….) of the gait cycle, muscle actions and joint movements involved in each.

Answer 3

1. Initial Contact:
   Muscles: Ankle dorsiflexors, knee extensors, and eccentric hip extensors.
   Movement: Heel strikes the ground; prepares for weight acceptance.
2. Loading Response:
   Muscles: Eccentric quadriceps, dorsiflexors, and gluteus maximus.
   Movement: Knee flexion and controlled plantarflexion absorb shock.
3. Midstance:
   Muscles: Minimal knee and hip muscle activity; eccentric plantarflexors.
   Movement: Body weight moves forward; controlled dorsiflexion maintains stability.
4. Terminal Stance:
   Muscles: Eccentric control by soleus, concentric action of gastrocnemius.
   Movement: Heel rises, followed by plantarflexion for push-off.
5. Pre-Swing:
   Muscles: Hip flexors, slight plantarflexion.
   Movement: Rapid unloading and initial swing preparation.
6. Initial Swing:
   Muscles: Hip flexors, dorsiflexors.
   Movement: Hip flexion, knee flexion, and dorsiflexion for foot clearance.
7. Mid-Swing:
   Muscles: Hip flexors, dorsiflexors, and contralateral hip abductors for pelvic stability.
   Movement: Continued limb advancement and foot clearance.
8. Terminal Swing:
   Muscles: Hip extensors, knee flexors, and dorsiflexors.
   Movement: Deceleration and preparation for heel contact​

Question 4

Outline how specific impairments could affect each phase of the walking cycle

Answer 4

Weak Hip Extensors: Reduced control in initial contact, leading to slower gait speed and shorter strides.

Weak Dorsiflexors: Leads to foot slap during loading response and toe drag in swing, causing knee hyperextension and hip flexion compensations.

Weak Quadriceps: Difficulty controlling knee flexion in loading, causing knee hyperextension and potential hip flexion.

Weak Plantarflexors: Poor push-off in terminal stance, reducing stride length and stability.

Hip Flexor Contracture: Limits hip extension, forcing increased anterior pelvic tilt, lumbar lordosis, and a crouch gait pattern in pre-swing.

Hip Abductor Weakness: Leads to Trendelenburg gait in mid-swing, causing lateral trunk lean to compensate

Question 5

Outline the pros, cons and evidence for using BWS, Robotics, virtual reality, AFOs and circuit classes to increase walking ability post-stroke.

Answer 5

Circuit class therapy and treadmill training with or without BWS is strongly supported. Improvement in walking is most seen with the use of an AFO. Robotics, VR are inconclusive, but may be used in conjunction with the above.

Question 6

Understand the training principles, rationale and provide suggestions for promoting flexibility of performance for part and whole task-practice exercises o based on patient problems.

Answer 6

Training principles for gait involve breaking down movements (part-task) or practicing the complete action (whole-task), based on patient needs:

Part-Task Practice:
Rationale:
Useful for targeting specific weaknesses or impaired phases of the gait cycle, such as focusing on dorsiflexion during swing if foot clearance is an issue.
Suggestion: Use part-task practice to build strength or control in isolated muscle groups before combining them into whole-task practice.

Whole-Task Practice:
Rationale:
Promotes coordination and the smooth execution of complete gait patterns, essential for overall gait recovery.
Suggestion: Whole-task walking is ideal for patients who can perform individual gait phases but need to integrate them smoothly.

For flexibility of performance, adjust task difficulty or context (e.g., add uneven surfaces, obstacles) to help patients adapt to varied real-world conditions and environments, reinforcing motor learning and adaptation