Week 10: Gait and Stairs Flashcards
Outline how to assess walking
- Walk at least 10 m –> opportunity to assess speed & identify their impairments
- Assess 1 leg at a time –> go systematically through joints eg ankle, knee, hip (often good to start at the ankle because a lot of problems we see at the knee/hip/trunk stem from the ankle because that is the BOS.
- Assess one phase at a time (tip: start with stance) –> 60% of gait –> a lot of problems will occur here because its longer and requires balance!
- Assess one joint at a time (tip: start at the foot)
- Follow a logical order
- Consider supplementary walking assessment software/equipment (helpful to film them moving – in different planes!)
- Consider using checklists (i.e. Gait assessment rating scale)
Outline normative values for walking
- Stride duration
- Stance/swing time
- Double/single support time
- Stride duration: ≈1.1s/stride
- Stance/swing time: 60/40% gait cycle
- Double/single support time: 20/80% stride time
Outline normative values for walking
- Cadence
- Velocity
- Toe out
- Cadence: ≈110 step/min
- Velocity: 70-90m/min (4.2-5.4 km/h) Step length: ≈1/3 height (ie 180 = ~60cm) BOS: ≈2-12 cm between heels
- Toe out: ≈7 deg (when we push off we don’t push off completely with the toes point forward, we push off on a little bit of an angle and that helps with the mechanics of the stepping)
What are some other forces relevant to stance phase?
- The other external force we need to control is ground reaction force - everytime your foot hits the surface there is a force that goes through your joint in the opposite direction that the force that you applied against the ground
- Another force we need to fight when we are walking is inertia. Need to go against inertia when we start, stop & change directions during gait
- What is a BWS?
- Pros
- Cons
- Evidence?
Body-Weight Support (BWS):
A system commonly used to assist individuals with impaired balance or lower limb strength to practice walking. It supports a portion of their body weight during gait training, often used with treadmills.
Pros:
- Allows control over the amount of weight-bearing through the limbs.
- Supports safer practice for individuals with significant impairments in balance or strength.
- Facilitates early gait training when overground walking is not feasible.
- Promotes repetitive practice of gait, aiding motor learning.
Cons:
- Expensive to purchase and maintain.
- Requires specialized equipment and training for therapists to use effectively.
- May limit natural movement patterns if over-reliance occurs.
- Space-intensive, requiring a dedicated area in a clinic.
- Potential for discomfort or skin irritation from the harness.
Evidence:
- No long-term superiority over other physiotherapy approaches.
- Small increase in walking velocity (0.03 m/s) favoring BWS over treadmill training, but the effect is minimal.
Key Note:
At least 40% of body weight should be supported through the limbs. Avoid exceeding 60% of weight support to ensure effective gait practice.
Pros of robotic gait training
Facilitates Independent Walking: Increases the odds of independent walking compared to standard physiotherapy (OR: 2.01, 95% CI 1.51–2.00). More effective in non-walkers and acute stroke patients.
Improves Walking Velocity: Small but significant increase in walking speed (0.06 m/s, 95% CI 0.02–0.10).
Reproducible and Precise Training: Delivers consistent gait patterns.
Reduced Therapist Strain: Minimizes physical effort required by therapists in manual gait training.
Patient Motivation: Real-time feedback can enhance patient engagement.
Cons of robotic gait training
Limited Improvement in Endurance:
No significant impact on walking distance in 6-minute walk tests (10.9m, 95% CI -5.7 to 27.4).
Variable Outcomes:
Results depend on the type of device, training frequency, and inclusion of adjuncts like FES.
Some studies included patients who were already independent walkers, diluting the effect.
Resource Intensive:
Requires specialized equipment, staff training, and funding.
Not Suitable for All Phases:
Less benefit for chronic stroke patients or those already walking independently.
Best candidates and limitations of robotic gait training
Best Candidates: Non-walkers in the acute phase of stroke recovery benefit the most.
Limitations: While robotic training can improve walking speed, its impact on endurance and long-term functional outcomes is less clear.
VR: pros
Pros:
- Enhanced Engagement: VR can increase motivation and engagement by offering an interactive, game-like experience, which may lead to improved participation in therapy.
- Controlled Environment: VR allows therapists to control the intensity, duration, and type of tasks, making it adaptable to individual needs and rehabilitation goals.
- Real-Time Feedback: VR provides immediate feedback on movements, helping patients correct their actions and improve performance.
- Repetition and Intensity: It enables high repetition of movements, which is crucial for neuroplasticity and recovery post-stroke.
VR: Cons
- Insufficient Evidence: Current research is inconclusive on the effects of VR on gait speed, balance, participation, and quality of life (QOL) for stroke patients.
- Access and Cost: VR equipment can be costly, and access may be limited, especially in resource-constrained settings.
P- otential for Fatigue or Dizziness: Some patients may experience discomfort, dizziness, or fatigue with prolonged VR use. - Technical Expertise Required: Therapists need training to use VR systems effectively, and technical support may be required.
VR: evidence
A review of 72 trials (n = 2470) examined the use of VR and interactive gaming for stroke rehabilitation.
Current Findings: There is insufficient evidence to draw definitive conclusions on the impact of VR on gait speed, balance, participation, or QOL for stroke patients.
Research Needs: More high-quality studies are needed to understand the long-term effects and to establish evidence-based guidelines for VR use in stroke rehabilitatio
What is an AFO
Ankle-foot orthoses (AFOs) are devices designed to support the foot and ankle, commonly used to address foot drop, improve gait, and aid individuals with limited range of motion, strength, or balance due to conditions such as stroke. Different types of AFOs provide varying levels of support and functionality based on the material and design.
Three types of AFOS; Rubber, metal and thermoplastic
AFO Pros
Improves gait stability, weight distribution, and foot positioning.
Increases independence, allowing safer and more efficient walking.
Supports patients with limited ankle and foot mobility or strength.
AFO cons
Potential Dependency: Prolonged use may reduce active muscle engagement, potentially leading to decreased muscle strength and flexibility.
Lack of Active Training: AFOs do not train muscles; once removed, the patient often reverts to previous gait patterns.
Limits Dorsiflexion (DF): Some designs may block dorsiflexion, limiting active movement and muscle activation.
AFO evidence
Independence: AFOs significantly improve independence for users immediately after application.
Walking Speed: Small but positive effect on walking speed (increased by 0.06 m/s).
Balance and Weight Distribution: AFOs enhance weight distribution, aiding balance.
Gait Biomechanics: AFOs prevent foot drop, increase weight-bearing on the affected leg, and reduce the energy cost of walking.
Limitations: Minimal impact on timed mobility tasks (e.g., TUG, stairs) and postural sway.
Overall: AFOs provide functional support and stability but do not contribute to long-term gait retraining.
