Week 4 Gait 1 Flashcards
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Where to start with pts with neurological gait? – Look to see where there deviations are and start to address those
People want their walking to improve – aesthetically, physically, etc
If people aren’t able to walk there is a psychological burden. Pts can feel useless as well.
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Ambulation: A Prerequisite for Daily Activity
Requirements of community ambulation:
Cross streets, step on/off moving walkways, up/down curbs, go in/out of automatic doors, walk around furniture, etc.
Speed of - m/s allows function in varying environmental and social contexts
***Only 7% of patients post stroke can walk 500m at this speed!
We as able body humans have to walk at least 1.1-1.5 m/s to be able to do these things in the community to do these things in a safe and healthy manner.
1.1-1.5;
VIDEO
When assessing neurological gait, start simple and just list deviations.
Absent L heel strike – heel never hits the ground
Forward trunk lean throughout the GAIT cycle
Shortened step length bilaterally – right foot doesn’t take as big of a step compared to the left
Left foot supination during swing
Decreased left knee flexion during swing
Decreased left hip flexion during swing
Decreased bilateral hip extension in stance phase
Potential compensatory Trendelenburg when right limb is in stance
Increased left knee flexion in stance
Normal BOS is roughly 12 cm, his is increased.
He probably takes 16 steps / min – most people take 90-100 steps / min
When looking at step length, compare how much further one foot goes compared to the other foot. Ex – does the left foot get a lot further than the right foot when walking?
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Basic Tasks of Gait
Weight acceptance Single limb stance ~(40/60)% of gait Limb advancement ~(40/60)% of gait
These tasks are a production of a locomotor rhythm
The major requirements for successful walking include (1) support of body mass by the LEs, (2) production of locomotor rhythm, (3) dynamic postural control of the moving body, (4) propulsion of the body in the intended direction, and (5) adaptability of the locomotor response to changing environmental and task demands.(401)
Have to be able to accept weight on your limb or you buckle.
Walking by nature is supposed to be effortless and have a rhythm to it and you need these three components ^^^
60; 40;
Terminology used in the clinic and during documentation
Stance phase is roughly 60% of gait
A lot of the gait cycle is (concentrically/eccentrically) based.
A lot of gait issues are in the (swing/stance) component of their GAIT.
eccentrically; stance;
(Stride/Step )– one foot compared to the other
(Stride/step) – right foot distance covered compared to the next step with the right.
Step; stride
ROM Requirements:
Hip:
_ degrees extension (terminal stance) > _ degrees flexion (prior to initial contact)
20; 30
ROM Requirements:
Knee:
_ degrees of extension (terminal stance) > _ degrees flexion (mid-swing)
0; 60;
ROM Requirements
Ankle:
_ degrees plantarflexion (pre-swing) > _ degrees dorsiflexion (mid to terminal stance)
20; 10
ROM Requirements
MTP:
_ degrees of extension (pre-swing)
60
COMMIT THIS SLIDE AND NEXT SLIDE TO MEMORY
Rom is a huge factor in peoples walking.
Big ticket ROM requirements ^^
Roughly get 50 degrees of total motion in the hip during gait
You need roughly 60 degrees of motion at the knee. Have to get _ degrees of knee extension when walking. Walking will be impaired if you lack the motion to do the task.
Individuals that have a stroke or SCI have ROM deficits. They may show signs of contracture/pain that may limit their ROM.
(Ankle/Knee) is the highest of priorities for joints when it comes to walking.
Lacking (PF/DF) ROM is when pts start to get in trouble with walking.
0; Ankle; DF
Strength Requirements
Hip
Stance:
Glut max - (concentric/eccentric)
Glut med - (concentric/eccentric)
Hamstrings - (concentric/eccentric)
Swing:
Iliopsoas - (concentric/eccentric)
eccentric; eccentric; eccentric; concentric
Strength Requirements
Knee
Stance:
Hamstrings - (concentric/eccentric)
Quadriceps - (concentric/eccentric)
Swing:
Hamstrings - (concentric/eccentric)
eccentric; eccentric; eccentric
Strength Requirements
Ankle
Stance:
(Dorsiflexors/Plantarflexors)
Midstance - (concentric/eccentric)
Terminal stance - (concentric/eccentric)
Swing:
Tibialis anterior - (concentric/eccentric)
Peroneals - (concentric/eccentric)
Plantarflexors; eccentric; concentric; concentric; concentric;
Take home message of this slide – Need more (concentric/eccentric) strength to be able to walk
If you are doing strengthening with someone to improve walking, bias the strength training to (concentric/eccentric).
Majority of stance phase is (concentrically/eccentrically) loading – controlling a fall.
Plantarflexors – PFs are working (concentrically/eccentrically) when it is mid-terminal stance. When the tibia has to advance over the ankle during mid-terminal stance they are being lengthened. They are (concentrically/eccentrically) working during push off. They have to double dip – strong enough to eccentrically be loaded and they switch to concentrically pushing into swing phase.
eccentric; eccentric; eccentrically; eccentrically; concentrically;
Cardiovascular - When someone has a stroke they have to pump out 2x the metabolic output to do the same things as someone who is healthy. With walking they will be challenged from a fatigue perspective.
Orthopedic – individuals are at risk for pain – think of compensations that can occur with someone
Integumentary – think of the skin and how if an individual places all of their weight on the ball of their foot and the demands that are placed on their integumentary system based on compensations
Classic – shuffling gait in Parkinson’s
Hemiplegic stroke – walk like Ronnie (dude in the video)
When you think of the deviation, ask yourself why do they have those deviations?
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“the nervous system is trying to solve a problem”
Systems – people look at ankles > knees > hips > trunks or you can do it the opposite manner, just stay consistent with yourself
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If someone doesn’t have the ROM, that is where a potential deviation can come from.
Look at GAIT deviations on an impairment level and then look to see how you’d treat that.
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Ankle - Weak Plantarflexors
Stance:
(Control tibial advancement/Achieving a positive step length)
Deviations - Excessive knee (flexion/extension) due to weak quads or (hyperextension/hyperflexion).
Delayed or absent (toe off/heel off) in terminal stance
Swing:
(Control tibial advancement/Achieving a positive step length)
Deviations - (Increased/Reduced) foot clearance, step length, and propulsion
*Ankle power generation at push-off supplies >_ % of all the power generated for forward propulsion during walking. (Williams et al, 2019)
What aspect of gait do these muscles work?
What part of stance phase do you notice the deficits?
When you are in stance phase the PFS have to (concentrically/eccentrically) control the tibia from going forward.
Hyperextension – cant control the knee eccentrically.
Weak quads – excessive knee flexion – buckling
Looking solely at these issues - If you see buckling in stance it is probably weak (plantarflexors/quads). If you see hyperextension it is probably (quad/plantar flexor) issue.
(DFs/PFs) do the majority of the work to push your foot forward. If you can’t do that you can’t ^^^
Ankle PFs – 60% ^
When someone isn’t covering enough ground – they aren’t pushing through those ankle (dorsi/plantar) flexors, it isn’t about the quads.
(DFs/PFs) are arguably the most important muscle when you walk.
flexion; hyperextension; heel off; Achieving a positive step length; Reduced; 60; eccentrically; quads; plantarflexor; PFs; plantar; PFs
Ankle - Weak Dorsiflexors
Stance:
(Accelerate/Decelerate) forefoot lowering and draw tibia forward following initial contact.
Deviation - “___ slap”
Swing: Foot clearance (~1cm to clear ground) Deviations - (Ipsilateral/contralateral) hip hike, (minimal/excess) hip flexion or abduction to assist with limb clearance, or (ipsilateral/contralateral) vault
Stance - (Concentrically/Eccentrically) loaded to bring foot into loading phase
Swing – can’t clear your foot.
Deviations – if can’t clear the ankle have to get motion from somewhere else
Decelerate; foot; ipsilateral; excess; contralateral; Eccentrically
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Knee - Weak Knee Extensors
Stance:
Provide stability and prevent collapse
Deviations - Knee hyperextension or knee flexion during (midstance/loading response)
Midstance and terminal swing have negligible impact due to quad activity cessation
Swing:
Modulates rates of knee (flexion/extension)
Deviations - Negligible
Stance –
Collapse/buckling
Knee hyperextension- when knee is hyperextended in stance, the quads can be 0/5 strength because the quads don’t have to work. Individuals who are weak will get some level of flexion.
A knee is not meant to be slammed into hyperextension. People will start to notice orthopedic pain because they are stretching the (anterior/posterior) part of that knee more than it is supposed to be.
Swing –
You get knee flexion from the (dorsi/plantar) flexors to give us passive knee flexion
loading response; flexion; posterior; plantar
Knee - Weak Knee Flexors
Stance:
Resisting knee (hyperflexion/hyperextension) during initial contact and early loading phase
Deviation- Knee hyper (flexion/extension)
Swing:
Controlling thigh advancement and prepare limb for loading response
Deviation - Compensatory hip (drop/hike), (reduced/excess) hip flexion, or abduction to assist clearance.
Stance – hamstrings are responsible for resisting the amount of hyper extension
A lot of deviations in general are based around hyperextension
Swing –
If hamstrings aren’t working in swing phase have to get motion from somewhere else – prob the hips.
hyperextension; extension; hike; excess;
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Hip - Weak Hip Flexors
Only need (2+/3)/5 MMT in gait (~- degrees of flexion required)
Stance:
(Mobility/Stability) of joint
Deviations - N/A
Swing:
Thigh advancement
Deviations - Poor foot clearance, placement of limb, or step length
Only need 2+/5 MMT in gait to have normal GAIT. You only need 30 degrees of hip flexion in walking. 3 in MMT – full range of motion against gravity.
You (need to/don’t need to) strengthen the hip flexors for normal GAIT (his pet peeve).
If you truly have weak hip flexors – it might lead to poor foot clearance
Hip flexors help control the thigh and if you don’t’ have that you’ll see those deviations.
2+; 25-30; Stability; don’t need to
Hip - Weak Hip Extensors
Stance:
Single joint hip extensors and abductors contract vigorously to (mobilize/stabilize) pelvis and trunk over femur
Deviations - Forward trunk lean or (reduced/excessive) posterior lean
Swing :
Deviations - n/a
Stance – provides stability
A lot of people have weak hip extensors
Forward trunk lean or excessive posterior lean – if you are excessively leaning posteriorly they are hanging on the y ligament so the muscles don’t have to work. If they lean forward – probably adopted an AD because they know if they lean too far forward without an AD they’ll fall.
stabilize; excessive;
Hip - Weak Hip Abductors
Trendelenburg gait:
Dropping of the (ipsilateral/contralateral) pelvis during (stance/swing)
Lateral lean towards (stance/swing) leg
(Increased/Decreased) step width, which can interfere with medial-lateral stability during ambulation
Weak hip abductors – will get Trendelenburg gait
Poor step width can interfere with stability.
contralateral; stance; stance; Decreased
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Spasticity
Spasticity highlights impaired control of movement that can show up in gait
Poor activation timing of affected muscle during the gait cycle
Excess activation of affected muscle throughout the gait cycle
(Decreased/Increased) stiffness of affected muscles which impacts transfer of momentum during gait
Resting tone or spasticity (is/is not) related to volitional movement capability:
Active and Passive Assessments are Different
Reducing “Tone” (Does/Does Not) Improve Movement
Spasticity – Velocity (independent/dependent) (AROM/PROM)
GAIT is an (passive/active) movement.
Passive phenomenon in spasticity with an active process in gait – something to think about
Increase stiffness – can present as ROM issues like Ronnie
When you reduce spasticity it doesn’t mean GAIT gets better.
People with spasticity - have to teach people how to work with it, compensate around it, or power through it.
Increased; is not; Does not; dependent; PROM; active;
Common Spastic Deviations
Plantarflexors
knee (hyperflexion/hyperextension) during stance
Shortened step length on (ipsilateral/contralateral) side and (late/early) initiation of swing
Poor push off
Lack of heel strike
Quadriceps spasticity and/or contracture?
Knee (hyperflexion/hyperextension) during stance
Disordered weight acceptance at loading response
Limited (flexion/extension) during swing
Hamstring spasticity and/or contracture?
Prevents full knee (flexion/extension) at terminal swing - muscles are so tight
Excessive knee (flexion/extension) in all stance phases
Shortened step length
hyperextension; contralateral; early; hyperextension; flexion; extension; flexion;
Impairments – (strength/ROM / vision/pain) will be for 90% of gait impairments
Vision – individuals with strokes may have vision deficits
Balance
Pain – if something hurts or you tore something you probably walk differently – if someone has pain contributing to their gait impairments, have to address it.
Cognition – what they believe they can or can’t do has a huge impact on their walking
Sensation – if you can’t feel where your limb is at it is hard to take appropriate lengths
strength/ROM
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Biomechanical Subcomponents
Propulsion - (Positive step length/Directional movement)
Limb swing - (Positive step length/Directional movement)
Stance stability - (prevent limb collapse/maintain upright)
Postural control - (prevent limb collapse/maintain upright)
As an individual walks they need these components
Limb swing – need to be able to advance their limbs.
Stance stability – as their leg hits on the ground it isn’t collapsing
If someone has weak dorsi flexors and they are taking decreased step lengths they might not be able to have a positive step length
If someone is shifting their body as they walk their postural control is off.
These components are funneling all of the info into one or more of these categories which will lead to interventions.
Directional movement; Positive step length; prevent limb collapse; maintain upright
Biomechanical Subcomponents
Video
Propulsion – can she propel her body in a forward direction ? Yes! Is it normal? Is she propelling forward or is there an awkward start/stop going forward? For her there is a start-stop ataxic component. She can propel her body forward but there is room for improvement.
Limb swing – can she advance each limb as she walks? She can achieve a positive step length
Stance stability – is she collapsing as she walks? Any knee buckling? No
Postural control – she is maintaining an upright posture, but she is catching herself from falling by increasing her BOS – her bos is a lot wider because she knows her postural control is off.
Her biggest areas of improvement – propulsion and postural control . Limb swing and stance stability are “less” of a concern compared to the other two.
Variable BOS , variable step lengths, reduced arm swing, doesn’t disassociate trunk from pelvis very well. These deviations limit her postural control and propulsion.
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Assistance levels – 50 feet max assist versus 50 feet supervision is different
As a therapist, if you’re going to start to look at GAIT, you need data to backup if someone is getting better or not.
Video benefits – deviations start to become habit for people and they’ll have no idea they are doing these things
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Jump in class system led to greater QOL improvement
Gait velocity is a (bad/powerful) predictor of function and prognosis post-stroke. (Schmid, et al., 2007)
The faster they walked the (less/more) likely they’ll be a participant in their community. The slower they walked the (less/more) likely that they’ll be home bound.
Most of us are walking 1.1-1.5 m/s.
powerful; more; more;
Article from the optional reading
If someone is walking at a slower speed, can make walking faster part of your goal.
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Need for Speed
Won’t walking faster make my patient’s gait deviations worse?
Tyrell et. al, 2011
Influence of Systematic Increases in Treadmill Walking Speed on Gait Kinematics After Stroke:
Improvement in many typical gait asymmetries after stroke when people walk on a treadmill at a (slower/faster) speed than self-selected speed, without increases in swing-phase compensations.
Tyrell:
N- 20 patients with chronic CVA, able to walk (I)
Intervention:
Outcomes: LE fugl meyer and 6MWT, gait kinematics with video anaylsis Vicon
Progressively increased speed an additional 3 times after baseline walking speed
Results: positive effect on some gait deviations while others were unchanged.
Gait asymmetries? – reduced step length asymmetry, increased SLS and decreased double limb stance, improved hip extension (using the hip extension reflex)
Conclusion: These results support the idea that facilitation of a more normal gait pattern through treadmill walking post- stroke can be enhanced by walking (slower/faster) on the treadmill.
Chronic stroke population?
Results may not apply to those who walk at less than 0.4m/s
Second, participants were permitted to ambulate both with their AFO and while holding on to a handrail during the testing
faster; faster;
2MWT – 2 minute walk test
6MWT – 6 minute walk test
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How far they walked, how much assistance they needed, over what surface
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Include all of the objective measures
Have to show that someone can get better –need baseline measures
Who, what, how much, why, and functional
Ex:
The pt will walk/ambulate 50 feet on a level tile surface to facilitate independecnce to participate in the community OR walk in the house without caregiver support.
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Prognosis
“When will I be able to walk?”
85% of all stroke survivors can walk independently by (3/6) months post stroke
HOWEVER—only 60% of those who require assistance to walk early after stroke regain independent walking ability
Independent – don’t need physical support/assistance
However – if they need a lot of physical support in the first place then they might never get back to independent walking
6;
This was an FYI
Coo
Prognostic Indicators for Ambulation
Walking endurance, motor function, and balance play important roles in home and community walking activity
6MWT, Fugl Meyer, BBS:
(Weakest/Strongest) predictors of home vs. community and limited vs unlimited community ambulation
6MWT is the (weakest/strongest) individual variable
>(205/288) m discriminates home vs community
>(205/288) m discriminates limited vs unlimited community
Once you get someone up and walking, if they start to walk more they have a better chance of success. The better some of these outcomes start and improve, the better off these pts will be when it comes to walking.
If a pt asks will I ever walk again? – provide evidence or statistics for the pt. Don’t make definitive statements. Utilize research. The reality is we don’t know even with the predictors we have. “it is my job to put you in the best position to be successful.”
Strongest; strongest; 205; 288;
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A – person will present with knee flexion in stance versus hyperextension
B - pre-tib – anterior tibialis –
C - Need 3+/5 to not buckle . If you have weak quads you might hyper extend. C is correct!!!!
C
