Walking Post CNS Injury

Question 1

True or False: Very few people, whether they are young or old, are able to walk again after a stroke

Answer 1

False, 85% of Adults learn to walk after a stroke and in pediatrics almost all children with hemiplegia walk by age 3

Question 2

What gait speed is considered “full community ambulation” for a post stroke patient?

Answer 2

.8 m/s (48m/min)

Question 3

If a patient who is post stroke has an ambulatory speed of .5 m/s what would be their functional classification?

Answer 3

Limited community ambulation

Question 4

What gait speed is considered “household ambulation”?

Answer 4

.4 m/s

Question 5

What two ways can we prepare a patient for gait training?

Answer 5

Aerobic exercise (primes the system to improve motor learning including balance)

Motor imagery of physical movement from external perspective (increase cortical excitation)

Question 6

What two things do PTs need to make sure about the task for gait training?

Answer 6

Make sure task is meaningful (pt should understand the purpose and must keep the pt. active, alert and motivated

Select a task and environment which targets the specific gait impairment of the pt.

Question 7

How can we simplify a task if it is too challenging for a pt.?

Answer 7

limit the degrees of freedom or use part practice

Question 8

How do PTs help facilitate movements to enable success?

Answer 8

• Provide assistance for success (via augmented sensory feedback or faciliatory techniques)
• Allow errors to encourage learning (allow for error and discovery)
• Provide extrinsic feedback (give feedback to increase detection of errors)
• enable intrinsic feedback (increase awareness of internal mechanisms)

Question 9

What are the speed recommendation for treadmill training?

Answer 9

• Fast (minimum of 1.8-2.2 mph)
• Variable speed (improves ground gait speed more than constant speed and faster speeds increase ground speed than comfort speed)

Question 10

When patients are allowed to use a harness that supports their body weight it has been shown to provide better outcomes than with across floor gait training. What changes with these patients when their gait speed increases?

Answer 10

Hip extension angle improves
hip flexion power improves
Plantarflexion EMG profile improves

Question 11

True or False: A body weight support track to help patients walk was proven to be more effective than a HEP that included balance exercises and strength training for post-stroke patients

Answer 11

False, both improved patients almost the exact same after 12 months

Question 12

Which walking option on a treadmill can help target gluteus medius activation? Which step option may help target the trailing limb?

Answer 12

lateral walking

backwards walking

Question 13

True or False: High intensity task orientated gait training significantly improved gait speed while circuit training only partially improved gait speed.

Answer 13

False, circuit training significantly improves gait speed while high intensity task orientated gait training may improve gait speed but only if training involved changing the cadence and speed as well as change of direction

Question 14

What 4 techniques have been shown to NOT work in isolation to improve gait speed?

Answer 14

• cardiovascular fitness training
• passive LE robotics
• walking overground on level surfaces
• strengthening

Question 15

What are the 4 critical kinematic gait deviations post-stroke?

Answer 15

• Inadequate shock absorption in loading response
• Inadequate single limb support throughout stance phase
• Inadequate forward propulsion especially in pre-swing
• Inadequate foot clearance in early swing

Question 16

What observations might you see in the gait of a patient who has inadequate shock absorption at weight acceptance?

Answer 16

• instability in early stance
• knee extension or buckling
• forward trunk lean

Question 17

What impairments are related to inadequate shock absorption?

Answer 17

• excessive activation of gastroc-soleus for controlled ankle PF
• impaired activation of quads for controlled knee flexion
• excessive activation of quads for controlled knee flexion
• impaired timing of the gluteus medius, gluteus maximus, and hamstrings for hip stability

Question 18

What interventions help promote proper shock absorption for impairments such as impaired or excessive activation of the quads?

Answer 18

EMG or FES (electrical stimulation) to quads or pre-tibials

Part practice such as stepping to a target
Whole practice such as walking in a floor ladder

Question 19

What interventions help promote proper shock absorption for impairments such as impaired timing of the glutes and hamstrings?

Answer 19

BWSTT
Approximation or compression
Backwards walking on treadmill
Monster Walks

Question 20

What observations might you see in the gait of a patient with inadequate single leg support?

Answer 20

• instability in early and midstance
• short step in uninvolved leg
• late heel lift
• lack of push off in preswing

Question 21

What impairments are related to inadequate single limb support? What are appropriate interventions for each?

Answer 21

• Impaired Activation of Gastroc-Soleus (FES to gastroc and part practice in staggered stance with mirror feedback to maintain stable knee)
• Impaired sensation of the ankle and foot (visual targets to increase step length, sensory E-stim, and mental imagery to restore normal sensory representation)
• Impaired activation of Gluteus Medius (mental imagery for hip abduction, FES to glute med, monster walks, part practice, and unilateral treadmill steppinga)
• Impaired flexibility of iliopsoas (part practice, HEP)

Question 22

How is arm swing related to leg swing? How is this relationship affected by a stroke?

Answer 22

Arm movement is connected to leg movement through spinal neurons while walking but after a stroke sensory input from the involved leg does not trigger the arms

Question 23

What observations might you see in the gait of a patient with inadequate forward propulsion?

Answer 23

reduced trail limb posture in pre-swing and lack of push off

Question 24

What impairments are related to inadequate forward propulsion? What are appropriate interventions for each?

Answer 24

• Impaired power to gastroc-soleus (FES to gastroc, virtual reality biofeedback, BWSTT, and jump training)
• Impaired activation of Iliopsoas, rectus femoris, and adductor longus (part practice w/ rapid hip and knee flexion to a target, treadmill training w/ or w/o BWSTT, and fast marching)
• Impaired proprioception in the hip (whole body vibration, manual cues to facilitate stretch to the iliopsoas on treadmill, and visual targets to increase step length)
• Excessive Activation of the Quads (backward walking to improve trailing limb and EMG to quads)

Question 25

What observations might you see in the gait of a patient with inadequate foot clearance? What are appropriate interventions for each?

Answer 25

Toe Drag or catch
hyperextension in stance
impaired knee flexion in preswing
circumduction in swing leg
decreased angle of hip flexion

Question 26

What are 3 things that cause inadequate foot clearance?

Answer 26

• Lack of PF power in stance and/or pre-swing
• Slowed hip flexion power results in decreased knee flexion in early swing and less toe clearance
• Impaired proximal-distal sequencing of TA and hip flexors (hip flexion power is critical)

Question 27

What impairments relate to inadequate foot clearance? What are appropriate interventions for each?

Answer 27

• Reduced hip flexion power (BWSTT and virtual reality biofeedback)
• Impaired activation of iliopsoas and adductor longus (part practice, unilateral treadmill step, marching in place, facilitation to iliopsoas via t-band or E-stim)
• Excessive activation of the quads (part practice, EMG to quads, Treadmill training (TT) w/ manual facilitation)
• Reduced PF power (auditory cues, fast TT w/ fast PF in PSw phase, FES to ankle PF muscles)
• Excessive activation of gastroc-soleus (EMG to gastrocs)
• Impaired timing of Tibialis Ant. (treadmill training, auditory cues, stepping over obstacles, FES on DF and/or PF, circuit training)
• Impaired Ankle proprioception (E-stim, FES to tib. anterior)