Week 3- Common Gait Abnormalities, Orthotics, Modalities and Assisted Technologies Flashcards
PART 1: COMMON GAIT ABNORMALITIES
PART 1: COMMON GAIT ABNORMALITIES
What are the 2 main types of asymmetries seen with hemiplegic gait?
- Spatial asymmetries
- Temporal asymmetries
What is a spatial asymmetry seen with hemiplegic gait?
- ↓ step length
What are some temporal asymmetries seen with hemiplegic gait?
- ↓ single-limb stance time
- ↑ swing time
- intra-limb ratio of swing:stance time
What are some additional asymmetries seen with hemiplegic gait?
- ↓ WB in stance
- ↓ weight shift in stance
- ↓ step height in swing
Temporal Features of Hemiplegic Gait:
- __ stride time
- __ double limb stance time
- __ cadence
-But most importantly, we will see a decrease in ______ _______.
- ↑ stride time
- ↑ double limb stance
- ↓ cadence
-gait speed
- What is the preferred gait speed with a chronic stroke?
- What is the maximum gait speed with a chronic stroke?
- 0.10m/s - 0.76m/s
- 0.76m/s - 1.09 m/s
What are common UE features of hemiplegic gait?
-Decreased or absent arm swing.
What are some common trunk features of hemiplegic gait?
- Ipsilateral lateral trunk lean.
- Forward trunk lean.
What is one of the most common troublemakers with Hemiplegic Gait from IC to MSt?
↓ tibial progression
What will we commonly see to help with the ↓ tibial progression?
Increased knee flexion to push tibia forward.
Pelvis/Hip Common Patterns from IC to MSt? (4)
- ↓ pelvic rotation
- ↓ hip flexion
- ↑ hip IR
- ↑ hip adduction (Trendelenberg)
Knee Common Patterns from IC to MSt? (3)
- ↑ KNEE FLEXION (particularly at IC)
- ↓ knee flexion during the early-stance phase, followed by knee hyperextension in mid to late-stance
- Excessive knee hyperextension throughout most of stance phase
Foot/Ankle Common Patterns from IC to MSt? (7)
- ↓ tibial progression
- ↓ ankle DF
- lack of heel strike
- foot flat IC
- foot slap after IC
- instability at foot/ankle complex → inversion, supination
- pes planus
What is commonly seen with Hemiplegic Gait from MSt to TSt?
We don’t get hip extension, step to pattern common with hemiparetic gait.
Pelvis/Hip Common Patterns from MSt to TSt? (3)
- Decreased pelvic rotation
- Decreased hip extension/terminal stance
- Hip flexion during forward progression
Knee Common Patterns from MSt to TSt? (3)
- Decreased knee extension
- Knee buckling
- Delayed movement into knee flexion in preparation for the swing phase
Foot/Ankle Common Patterns from MSt to TSt? (2)
- May still see ↓ tibial progression (step-to pattern)
- ↓ heel off at terminal stance
What is commonly seen with Hemiplegic Gait in swing phase?
- People aren’t good at foot clearance.
- Reduction in hip flexion.
Pelvis/Hip Common Patterns from ISw to MSw AND MSw to TSw? (3)
- ↓ hip flexion
- Hip hiking
- Circumduction
- ↑ compensatory ER
- Knee Common Patterns from ISw to MSw?
- Knee Common Patterns from MSw to TSw?
- ↓ knee flexion
- ↓ knee extension
Tone Abnormalities:
- How might spasticity present during gait?
- How might hypotonia present during gait?
- movements might appear stiff, en-block movements
- clonus will cause jerky movements at joints
- UE spasticity patterns commonly exacerbated during gait
- Buckling LE
- Floppy UE
Somatosensory Deficits:
-How might somatosensory deficits present during gait?
- Variable foot placement at initial contact
- Risk for ankle rolling
What vision deficits may affect gait?
- Visual Field Losses or Loss of Visual Acuity
- Dysconjugate Gaze
Coordination Deficits: Cerebellar or Sensory originates: -Fractionated, dyskinetic \_\_\_\_\_\_ phase -Fractionated, dyskinetic arm swing -\_\_\_\_\_\_\_\_ movements -Variable \_\_\_\_\_\_ placement -Trunk \_\_\_\_\_\_\_\_ → LOB -Cerebellar only: EOM incoordination → visual disruption → LOB
- swing
- slowed
- foot
- ataxia
Types of Perceptual Deficits that will affect gait? (4)
- Visuospatial Neglect
- Sensory Neglect
- Motor Neglect
- Pusher’s Syndrome
PART 2: ORTHOTICS (1)
PART 2: ORTHOTICS (1)
Basic Terminology:
- What is an orthosis?
- What is a splint?
- What is a orthotist?
- What is a pedorthist?
- Orthosis: device worn to restrict or assist motion, or to transfer stress from one area of the body to another (=brace)
- Splint: temporary orthosis
- Orthotist: designs, fabricates, fits orthoses for limbs and trunks
- Pedorthist: designs, fabricates, fits shoes and foot orthoses
Potential Goals for Orthotics:
- Improving __________
- Minimize influence of abnormal ______
- Increasing _______ at a joint or segment
- Preventing _________ or deformity
- Facilitating weak muscles
- Simulating an _______ or _______ muscle contraction
- Limiting or facilitating motion
- Providing ______________ feedback
- Positioning a body part for optimum function
- alignment
- tone
- stability
- contracture
- eccentric or concentric
- proprioceptive
What are the main goals when using braces? (3)
- assisting mobility
- restricting mobility
- redistributing forces
Foot orthoses are most commonly used for what reason?
Redistributing forces
What are the most common ways foot orthoses help to redistribute weight? (4)
- transfer WBing stresses to pressure-tolerant sites
- protect painful areas from contact with shoe
- correcting alignment
- accommodation for fixed deformity
Foot Orthoses modifications can be _________ or ___________.
- internal
- external
The vast majority of patients post-stroke who need bracing will get a ________________.
Ankle-Foot Orthoses (AFO)
AFO primary action is on the ______ and _______.
foot and ankle
Even though AFOs primarily work at the ankle-foot, they have the ability to affect motion and stability at __________ joints.
-proximal
What are the (3) most common indicators for AFOs?
- Ankle weakness = 4/5
- Impaired or absent proprioception at the ankle and/or knee
- Ankle PF spasticity
- Patients have to be ___________ mobile to even be considered for orthoses.
- Do they have to be walking to be considered appropriate for orthoses?
- functionally
- no
What are the most common gait abnormalities preceding decision for orthotic evaluation? (5)
- foot drop
- poor foot clearance in swing
- ankle instability in stance
- knee buckling in stance
- hyperextension in stance
What are the most common transfer abnormalities preceding decision for orthotic evaluation? (2)
- ankle instability in stance
- knee buckling in stance
Precautions and Exclusion Criteria for Orthoses:
- NO ______ _______
- NO LE _________ or ________ breakdown
- Adequate _______ in braced joints
- Be careful with _________ impairments (specifically ______ touch and ________)
- Considerations for _________, __________, and/or ____________ deficits.
- ankle clonus
- swelling or skin breakdown
- ROM
- sensory (light touch and pressure)
- cognitive, communication, and/or perceptual
At minimum for a LE brace, a patient must be able to reach ________ at the ankle.
neutral
PART 3: ORTHOTICS (2)
PART 3: ORTHOTICS (2)
List these AFOs from most supportive to least supportive.
- Solid
- Posterior Leaf String
- Ground Reaction
- Pre-hinged
- Stirrup/Double Upright
- Hinged/Articulated
- Stirrup/Double Upright
- Solid
- Pre-hinged
- Hinged/Articulated
- Ground Reaction
- Posterior Leaf Spring
What is the Ranchos Orthotic Road Map?
Decision making tree to guide on what type of AFO is most appropriate.
Stirrup/Double Upright AFO Indications:
- ↑↑ concern for _____ integrity
- Chronic ______ issues
Stirrup/Double Upright AFO Considerations:
- Permanently attached to ______
- ________, clunky
- Can be unlocked to allow for ______
- skin
- edema
- shoe
- heavy
- DF
Solid AFO Indications:
- Significant LE ________ or ________ requiring maximum stability
- Primary brace recommended for ____ spasticity
- Alignment issues
Solid AFO Considerations:
- Rigid plastic, minimal pliability
- Provides good support but limited mobility – recommended mostly for ____-___________ patients
- Good for __/__ stability at ankle
- Can include anterior shell for ______ control
- weakness or hypotonia
- PF
- non-ambulatory
- M/L
- knee
Pre-hinged AFO Indications:
-Significant __________ but anticipate continued motor return and potential to progress to articulated AFO
Pre-hinged AFO Considerations:
- A great option to allow the ________ to progress with the patient
- Can add a removable anterior plastic shell to help with ______ buckling
-weakness
- brace
- knee
Hinged/Articulated AFO Indications:
- Active ___ and ____ (ideally ≥3/5)
- Adequate ______ control (quadriceps ≥3+/5)
Hinged/Articulated Considerations:
- Provides adjustable ______ control
- Can be fabricated with ____ assist or _____ stop if needed
- Good __/__ stability
- Allows for __________ gait pattern
- DF and PF
- knee
- ankle
- DF assist or PF stop
- M/L
- reciprocal
Ground Reactive AFO Indications:
- ______ foot
- ___/___ ankle instability
- *Knee buckling in ______ *
Ground Reactive AFO Considerations:
- Creates knee __________ movement to prevent buckling
- Aids in foot __________
- Helpful with _________ gait pattern
- drop
- M/L
- stance
- extension
- clearance
- crouched
Posterior Leaf Spring AFO Indications:
- ____ foot with minimal to no M/L instability
- Absent knee buckling, may see knee hyper________
Posterior Leaf Spring AFO Considerations:
- Allows for some active _____ and _____ (Also provides counter moment to both)
- Otherwise minimal support, will not aid with _____ buckling
- “______ phase AFO”
- drop
- hyperextension
- DF and PF
- knee
- “swing phase AFO”
What is the one exception to the no edema allowed for AFOs?
Stirrup/Double Upright
What is the only AFO that is attached to the shoe?
Stirrup/Double Upright
Which AFO has no ankle mobility?
Solid
Which AFO allows for relatively full DF but prevent most/all PF past neutral and starts to allow reciprocal gait?
Hinged/Articulated
Which AFO requires hamstring ROM testing because of things that can cause crouched gait (flexion/flexion/flexion)?
Hinged/Articuated
Which AFO is used when we see significant weakness but they have positive prognostic factors leading us to anticipate motor return and potential to progress to articulated AFO?
Pre-hinged
Which AFO is a “stance phase AFO” that is used for drop foot with M/L ankle instability?
Ground Reactive
Which AFO is a “swing phase AFO” that is used for drop foot without M/L ankle instability?
Posterior Lead Spring
What orthoses add a thigh component to increase the stability provided at the knee?
KAFO (Knee-Ankle-Foot Orthoses)
KAFO Indications:
- Most commonly used for ___________
- Can be used with hemiplegia (Severe knee hyper____________, ___/____ instability at knee)
- paraplegia
- (extension, M/L)
KAFO Considerations:
- Most can be progressed to _____ AFO
- Knee joint can be ________ to provide maximal sagittal plane support during standing/walking tasks (Unlocked for sitting)
- VERY heavy and clunky (High reliance on ____ musculature to move forward)
- solid AFO
- locked
- hip
What is the biggest problem with KAFOs not being appropriate for significantly hemiplegic patients?
They are heavy, clunky, and uncomfortable. Won’t be able to advance limb with the KAFO on.
Considerations of Orthoses:
- Each AFO will have a different impact on _________.
- Goas for choosing a brace should be the _____-_________ orthoses; is also most reflective of both patient ___________ and _________ for recovery.
- ______ to brace.
- 1 brace/__-__ years unless significant change in function. Medicare B: __% coverage.
- function
- least-restrictive, presentation AND prognosis
- When
- 3-5 years, 80%
Management for Orthoses:
- Must always be worn with __________ shoes.
- Ideally should not be donned against _____ _____.
- Wear schedules
- Skin checks
closed-toed
-bare skin
Upper Extremity Splints/Orthotics Indications:
- Management or prevention of _________ at fingers, wrist, or elbow
- Hypotonia, hypertonia
- Often used as “resting splints”
Upper Extremity Splints/Orthotics Considerations:
- When donned, eliminates __________ use splinted joints from
- Skin checks important
- RN, patient education
- contractures
- functional
PART 4: CVA MODALITIES (BWSTT)
PART 4: CVA MODALITIES (BWSTT)
What is the primary line of defense for addressing post-stroke gait dysfunction?
over ground walking
What is BWSTT?
Body Weight Supported Treadmill Training
What are the benefits of walking on a treadmill?
- increased stride length
- increased step length
- improved symmetry
- improved activity tolerance
- improved gait speed
What is the biggest concern with treadmill training post-stroke?
FALL RISK
What are the benefits of harness system/BWSTT?
- effectively removes fall risk
- has an unloading effect
BWSTT is recommended for _________ patients, but not _____________ patients.
- acute/sub-acute
- chronic
BWSTT Acute to Subacute:
What does research show today?
-Improvements seen in gait _____, ______, ______________.
No significance found in gait ___________.
- speed, endurance, fear of falling
- mechanics
BWSTT Acute to Subacute Indications:
- Ambulatory patient with stable ___ status
- Stable upright tolerance
- Gait goals including gait ______ and/or reducing fall risk with gait
- Eliminate ____ risk, many safety concerns
- Decreased physical load on _________
- CV
- speed
- fall
- therapist
BWSTT Acute to Subacute Considerations:
- Allows for more ______/__________
- Be aware of _____________ status
- Be cautious with ________ or _________ deficits
- steps/session
- cardiovascular
- behavioral or cognitive
BWSTT Acute to Subacute:
What should it look like?
-Benefits are found at _______ treadmill speeds
-BWS should remain less than __%
-Should always be followed by ____ _______ ambulation to promote carryover.
- higher
- 40%
- over ground
What are some ways to progress BWSTT?
- increase speed
- reduce BWS
- reduce assist and facilitation
- add incline
- increase duration, lessen rest breaks
PART 5: ADDITIONAL MODALITIES
PART 5: ADDITIONAL MODALITIES
What is NMES?
The use of electrical stimulation to activate muscles through stimulation of intact peripheral motor nerves.
NMES Indications:
- ______ injuries ONLY
- UE: pain, subluxation, spasticity (short-term effects), strengthening
- LE: spasticity, strengthening
UMN
NMES-mediated task must be repetitive, novel, volitionally controlled, and __________ relevant.
functionally
NMES Precautions:
-Impaired or absent _______ to area being stimulated.
sensory
NMES Contraindications:
- internal _________ or ______ implant
- Open wounds, ________, cancerous lesions near site or stim.
- electrical or metallic
- fractures
What is the use of NMES to promote specific functional activity with devices called?
Functional Electrical Stimulation (FES)
- What are the most common FES we will work with as PTs?
- What are their indications?
Bioness L300
- foot drop
- poor foot clearance
Bioness L300+
- knee instability
- poor foot clearance
How do the Bioness FES devices work:
- Sensor placed in sole of shoe to detect when extremity is in ________ phase
- Stims muscles in response to normal physiological activation of targeted muscles throughout gait cycle
stance
Bioness Muscle Activation:
- ________: stim during stance and 2nd half of swing
- __________: stim during first half of swing
- ___________: stim throughout swing
- Quads
- Hamstrings
- Anterior Tibialis
Bioness devices are good for ____ level functioning patients.
high-level
EMG Biofeedback:
- Most evidence surrounding use on __s (Shown to result in improvements in strength and motor control)
- Requires some active movement of targeted muscle groups
- Limitation: No standardized recommendations for treatment prescription (Typical rx: 3-5x/week over several weeks )
- Insufficient evidence to suggest superiority over other forms of treatment in __
- UE
- UE
List some alternative therapies in addition to what has been described.
- Partial Body-Weight Supported Overground Ambulation
- Aquatic Therapy
- Neurologic Music Therapy
- Robotics
- Virtual Reality
- Mental Imagery
PART 6: OUTCOME MEASURES
PART 6: OUTCOME MEASURES
What is the Stroke Impact Scale?
Subjective questionnaire evaluating disability and health-related QOL after stroke.
What are the 8 domains of the Stroke Impact Scale?
- Strength
- Hand function
- ADL/IADL
- Mobility
- Communication
- Emotion
- Memory and thinking
- Participation/role function
Stroke Impact Scale tends to be more helpful with ______ patients.
chronic
Stroke Impact Scale has excellent accuracy in predicting ______ post-stroke.
QOL
What outcome measure provides a uniform system of measurement for disability based on how much assistance is required for the individuals to carry out activities of daily living?
Functional Independence Measure (FIM)
The FIM is becoming obsolete, why?
Medicare has dropped it
The FIM is performed by multiple healthcare providers typically at admission and discharge. It is scored on a scale of 1-7 with __ domains.
18
What is the Orpington Prognostic Scale?
Provides an assessment of stroke severity via 4 domains?
What are the 4 domains the Orpington Prognostic Scale looks at?
- Motor Deficit
- Proprioception
- Balance
- Cognition
Orpington Prognostic Scale Scoring (1.6-6.8):
- Minor = Scores _____ have high likelihood of returning home.
- Moderate = Scores between ___-___ generally respond better to rehabilitation.
- Major = Scores _____ are typically dependent with increased risk of institutionalism.
- <3.2
- 3.2-5.2
- > 5.2
