Louisiana Physical Therapy Association 2015 Fall Meeting. Functional Gait Training for the Neurologically Impaired Client

Transcription

1 Louisiana Physical Therapy Association 2015 Fall Meeting Functional Gait Training for the Neurologically Impaired Client Lecture: Normal Human Gait Nicky Schmidt, PT, NDTA TM Instructor Saturday, September 12,

2 Normal Human Gait Nicky Schmidt, PT, C/NDT NDTA Coordinator Instructor Walking is the complex interplay between gravity, momentum changes, and muscle action. In Normal Gait appropriate timing and intensity of mm contraction act in response to the influence of gravity and inertia to meet the functional requirements placed on the stance limb (Skinner) 240

3 Goal of Locomotion To Transport the body with the least energy and the greatest stability This demands that the head and trunk be a relatively stable passenger over the LEs Functional Ambulation Requires coordination of Multiple Systems Somatosensory System Visual System Vestibular System Musculoskeletal System Neuromotor System Functional Gait is maneuvering Over continuously changing bases In different and/or changing directions At different and/or changing speeds With an automaticity that allows no conscious effort With an efficiency that allows combining walking with other activities 241

4 Do our patients achieve functional gait???? Can your clients walk indoors, outdoors, on different surfaces, change directions, and walk at different speeds even when fatigued? Can they multitask and walk - carry, push/pull objects while walking - talk and walk - eat/chew and walk - reach for an object while walking These are concerns for PT, OT and SP/L! Gait Cycle Divided into a stance phase (60%) and a swing phase (40%) and is equal to one stride length. Stride Length at normal speeds Avg = 1.41m or 4.5ft Males = 1.46 m Females = 1.28m Stride and Step Length Stride length Distance from one heel contact to the next heel contact of the same limb Step length Distance from heel contact of the right heel to heel contact of the left heel 242

5 Stride and Step Velocity Velocity is a distance per time relationship Velocity = step length x cadence Avg = 82 m/min or 275 ft/min Males = 86 m/min Females = 76m/min CVA Pt. = 9.6 to 39 m/min Cadence Cadence is the number of steps taken in a given amount of time. Medium walking speed = steps/min Avg = 113 steps/min Males = 111 steps/min Females = 117 steps/min 243

6 Step Width Varies in the literature depending upon the reference point Mid-section of the right foot to midsection of the left foot = 7-10 cm or inches Guidelines for Functional Community Ambulation(FCA): 10,000 steps/day is target for healthy, active, adult lifestyle and for weight loss steps/day recorded for older, healthy adults steps/day for community dwelling individuals with disability or chronic illness Adults must walk 300 meters continuously to be considered a FCA Ground Reaction Force GRF= a force that is equal in magnitude and opposite in direction to the force exerted on the floor by the body through the stance limb. GRF can render a joint inherently stable or unstable. 244

7 GRF Range Requirements Pelvis: 0 to 5 degrees of rotation Hip: 20 degrees EXT to 30 degrees FL Knee: 5 degrees to 60 degrees FL Ankle: 20 degrees PF to 10 degrees DF Toes: 0 to 60 degrees of MTP extension Role of the Head Stabilized on the shoulders Adequate postural mm activity to stay aligned Selective movement for scanning the environment, conversing and engaging socially 245

8 Role of the Upper Extremities Rest at the side of the trunk with active muscle control: Isometric muscle activity stabilizes the limb on the trunk and out of the way of the advancing lower limb As cadence increases above 90 steps/min. momentum initiates arm swing Role of the Trunk Trunk is co-activated and stable during gait Anticipatory muscle activity varies: - Isometric mm activity holds the rib cage stable over the pelvis - This muscle activity grades up/down depending on demands for stability In single limb stance peak mm activity increases stability over the smaller BOS During efficient gait at moderate speeds trunk movement is not visually appreciated Achieving Trunk Stability Muscles of the trunk provide core stability to the trunk and therefore to the body as a whole. Stability allows the trunk to hold a static posture even under the influence of destabilizing external torques. (Donald A. Neumann). 246

9 Role of the Trunk Trunk control is critical for posture and balance because two thirds of the body mass lies above the waist. Trunk serves as a stable base of support for mms attaching from the pelvis to the femur Trunk mms stabilize the head, arm and trunk and maintain a stable COM over the BOS Trunk augments LE movements by contributing to smoothness of gait, step length, and forward progression Role of the Lower Extremities Produce adequate isometric muscle activity to stabilize the body in single limb stance Produce efficient eccentric muscle activity to decelerate the body against the forces of gravity and momentum Produce adequate concentric muscle activity to accelerate and propel the body forward Rockers of the Foot 1 st (heel) rocker Decelerates and absorbs shock at initial contact to loading. 2nd (ankle) rocker -- Decelerates forward movement of the tibia during single limb stance. 3rd (forefoot) rocker -- Tightens the plantar aponeurosis and allows roll off the toes in terminal stance to pre-swing. 247

10 Rockers of the Foot Phases of Gait Stance Phase is divided into: Weight Acceptance - Initial contact Loading response Single Limb Support mid-stance terminal stance Phases of Gait Swing phase is a period of: Swing Limb Advancement that includes: Pre-swing Initial swing Mid-swing Terminal swing 248

11 Phases of Gait Weight Acceptance Weight is accepted on an outstretched limb while forward momentum and limb stability are maintained. Initial Contact Loading response Shock absorption, hip stability, and foot contact are key as the body moves forward Initial Contact When the heel strikes the ground Hip flexion Knee 0-5 flexion Ankle 0 Heel rocker occurs 249

12 Loading Response Shock is absorbed and forward momentum is preserved Pelvis 3-5 fwd rotation Hip 20 flexion Knee moves from 0-15 flexion Ankle 0-10 plantarflexion Concentric hip extension with controlled knee flexion as the ankle plantarflexes and the forefoot lowers to the ground Single Limb Support Body progresses over and then ahead of a single stable limb. Mid-stance Terminal Stance Momentum is created by the advancing contralateral limb as it swings forward. Midstance Body advances from behind to ahead of the ankle Pelvis 0 rotation Hip 0 flexion Knee 0-5 flexion Ankle 5 dorsiflexion Ankle rocker is established with strong eccentric demand on gastroc and soleus as the body advances 250

13 Terminal Stance Body progresses forward and past the forefoot Pelvis 3-5 backward rotation Hip 20 extension/hyperext. Knee 0-5 flexion Ankle 10 dorsiflexion Toes 30 hyperextension Critical for establishing trailing limb for swing initiation and step length of contralateral limb Swing Limb Advancement The swing leg flexes behind the body to clear the foot off the ground, then advances forward ahead of the body by flexing at the hip and extending at the knee to achieve step length. Pre-swing Initial swing Mid-swing Terminal swing Preswing Weight shifts to the other limb as the knee rapidly flexes (a period of double limb support). Hip passively goes from10-0 extension Knee passively flexes Ankle plantarflexion Toes 60 MTP hyperextension Toe rocker assists balance and prepares the foot to leave the ground 251

14 Rockers of the Foot Initial Swing The thigh advances forward as the knee continues to flex and the foot clears the floor. (Note: the foot comes off the floor while behind the body) Pelvis 3-5 backward rotation Hip 15 flexion Knee 60 flexion Ankle 10 plantarflexion Hip and Knee concentric flexion are critical events Mid Swing Thigh continues to advance forward as the knee begins to extend Pelvis 0 rotation Hip flexion Knee moves from 60 to 25 flex Ankle moves from 10 PF to 0 Hip flexion will have to be restrained and the foot set up for IC. 252

15 Terminal Swing The leg is extended for step length and heel strike. Pelvis 5 forward rotation Hip flex Knee 0-5 flex Ankle 0 Knee extension near neutral allows the foot to reach the ground Lateral Displacement Range Requirements Trunk Erect with 0-5 counter rotate of upper trunk to pelvis Pelvis 0-5 rotation and 0-5 obliquity Hip 20 ext to 30 flex Knee 0-60 flexion (only 20 active flex) Ankle 20 PF to 10 DF Toes 0 to 60 MTP hyperextension 253

16 Muscle Activity Requirements At normal velocity of gait the muscle action is predominately eccentric. Two high torque demands in gait occur at: 1) Loading - with concentric hip extensor activity to propel the body forward 2) Terminal stance - with eccentric plantarflexor activity to restrain the body against the force of momentum At slower velocities than normal gait there is less momentum thus demand for concentric mm activity increases. References Donatelli, Robert. Biomechanics of the Foot and Ankle. FA Davis Co., Philadelphia Neumann, Donald. Kinesiology of the Musculoskeletal System: Foundations for Physical Rehabilitation. Mosby, Inc. St.Louis, Missouri, Perry, Jacquelin and burnfield, JM. Gait Analysis, Normal and Pathological Function 2nd ed. Slack Inc., NJ, 2010 ISBN Gait Summary, Physical Therapy Department, Rancho Los Amigos Medical Center Ankle: Plantarflexion / Dorsiflexion 254

17 Inversion / Eversion Forefoot: Adduction / Abduction 255

18 Louisiana Physical Therapy Association 2015 Fall Meeting Functional Gait Training for the Neurologically Impaired Client Lab Handout: Treatment Strategies to Improve Gait Nicky Schmidt, PT, NDTA TM Instructor Saturday, September 12,

19 Treatment Strategies to Improve Gait Post Brain Lesion Nicky Schmidt PT/CNDT 2012 Achieving Stability for Single Limb Support 3 Motor Components are Critical The trunk must be stable and well aligned in all planes with active muscle contraction to prevent excessive movement. The body must progress forward over the foot as shock is absorbed and momentum provided by the advancing swing limb. Hip and knee extension must be completed early in mid stance. General Handling Guidelines for Assisting the Patient in Stance If the therapist needs to monitor the muscle activity of the trunk and assist in maintaining trunk stability by providing feedback to the trunk extensors or the abdominal muscles, then there is at least one hand somewhere on the trunk to assist contraction of the appropriate muscles. If the patient has weakness of the hip extensor or hip abductor muscles and does not adequately initiate or sustain contraction of these muscles after initial contact, then manual facilitation over the muscle mass with approximation down toward the foot maybe given to assist with loading of the limb. 257

20 General Handling Guidelines for Assisting the Patient in Stance To assist the patient in advancing over the stance foot with adequate forward weight shift the therapist must assume the identical stance leg as the patient, with a step length most appropriate for the patient, while shifting his/her body in sync with the patient similar to dance partners. If the therapist wants to assist the patient in increasing the velocity of gait, then the therapist will need to position himself/herself directly behind the patient or beside the patient on the more involved side. General Handling Guidelines for Assisting the Patient in Stance The therapist may walk more slowly with the patient at first to practice control of a specific component, but within every session the therapist must reduce or remove manual cues and feedback and practice gait at faster and more normal velocities. The patient must be challenged in gait through a variety of functional movements, directional changes and tasks, such as stepping backwards; turning in all directions; stepping up, down and over various height steps and objects; walking on various terrain; carrying, pushing, or pulling objects with the upper extremities while walking; transitioning from walking to squatting to pick up, reach, or move objects. The tasks should be purposeful and meaningful to the patient. Strategy One: Facilitating trunk and hip stability through the abdominal and hip muscles while walking behind 258

21 Strategy One: Facilitating trunk and hip stability through the abdominal and hip muscles while walking behind the patient. Graded tension is applied over the skin and muscle by both hands to assist muscle contraction as weight shift onto the stance leg is initiated. The therapist shift his/her body over the same stance leg as the patient and both therapist and patient move in synchrony. Tension gradually increases over the hip extensor and/or hip abductor muscles from initial contact through loading. The therapist gives a directional cue down toward the ankle and foot to provide approximation through the joints to help sustain muscle activity required to meet the GRF and achieve mid stance alignment. Strategy One: Facilitating trunk and hip stability through the abdominal and hip muscles while walking behind the patient. The hands are open with fingers extended. The pads of the fingers contact the skin of the patient not the palm. The posterior hand over the hip and/or pelvis will assist the pelvis to achieve and sustain a neutral alignment as the hip extends. As the patient shifts onto the leg the therapist increases isometric tension in his/her hand and a directional cue to help tuck the pelvis to neutral. The anterior hand will assist to stabilize the rib cage and pelvis ventrally by increasing isometric tension over the abdominal muscles. A slight down cue maybe given proximally to tuck the rib cage and a slight up cue distally to stabilize the pelvis. 259

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23 Assisting swing of the weaker lower extremity while maintaining trunk stability as you walk behind the patient in gait. Once mid stance is achieved the isometric tension in the therapist hands that was added during loading is relaxed. The therapist continues to shift in synchrony with the patient through terminal stance. As the body weight shifts off this leg the therapist can give a gentle down cue on the pelvis or hip with the posterior hand to assist the leg to passively release into hip and knee flexion for pre swing. O th li b i fl d th th i t 261

24 Strategy Two: Facilitating trunk and hip stability through the abdominal and hip muscles while walking from the side 262

25 Strategy Two: Facilitating trunk and hip stability through the abdominal and hip muscles while walking from the side This strategy may be chosen over walking behind because the patient needs assist to stabilize the upper extremity on an object or at the side for balance. This strategy may be chosen if the patient requires more assist to clear the foot in swing. This strategy may be chosen if the patient tends to excessively supinate the foot at Strategy Two: Facilitating trunk and hip stability through the abdominal and hip muscles while walking from the side The anterior hand will facilitate the abdominal muscles to stabilize the rib cage and pelvis ventrally at neutral just as in the previous strategy. The patient s hand may be on a object or contacting the therapist forearm or arm for stability. The therapist posterior hand remains over the pelvis and hip primarily, but part of this hand or forearm can also provide approximation to the the back of the 263

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28 Assisting the foot to move from first to second rocker for weight acceptance Once the heel contacts the ground the therapist will place his/her heel on the ground and his/her toes laterally on the patient s foot along the proximal row of tarsal bones next to the ankle joint and give a gentle pressure medial to help the foot move towards pronation. The therapist can also give a pressure down and back towards the calcaneus for approximation to assist loading as the body progresses over the foot. 266

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30 Louisiana Physical Therapy Association 2015 Fall Meeting Functional Gait Training for the Neurologically Impaired Client Lab Handout: Pre-Gait Activities Nicky Schmidt, PT, NDTA TM Instructor Saturday, September 12,

31 PREGAIT PREPARING TO STAND ON ONE LEG AND STEP IN STRIDE Nicky Schmidt PT, C/NDT 2014 REQUIREMENTS FOR NORMAL HUMAN GAIT 1. A stable trunk in which the muscles of the upper and lower trunk are co contracting to support the head and upper extremities and prevent any destabilization. 2. Concentric hip and knee extension to load the body mass of the trunk, head, and upper extremities over the weight bearing foot in time to match the magnitude and direction of the GRF in loading to mid stance. 3. Isometric hip abduction control from initial contact through terminal stance to prevent lateral displacement of the body. 4. Eccentric plantar flexion muscle control to decelerate the forward advancement of the body over the stance leg in mid to terminal stance. 5. Adequate hip and knee flexion to clear the foot in swing. Range Requirements Trunk upper Pelvis Hip Knee Ankle Toes Erect with 0 5 counter rotation of trunk to pelvis 0 5 rotation and 0 5 obliquity 20 ext to 30 flex 0 60 flexion (only 20 active flex) 20 PF to 10 DF 0 to 60 MTP hyperextension 269

32 When is the Patient Ready For PREGAIT Activities? When the patient can maintain midline sitting with reasonable facilitation on the trunk from the therapist. When the patient can initiate minimal hip or knee extension from a high perched sitting position with hands supported to rise to standing with reasonable facilitation from the therapist. When the patient can sustain bilateral stance with hands supported on a surface with hip and knee extended to neutral with reasonable facilitation from the therapist. Reasonable facilitation does not mean 100% support. It does not mean that the knee is locked in hyperextension, the hips flexed, the ankle plantar flexed, the trunk leaning or the pelvis displaced! PREGAIT: An Assessment Tool for Normal Gait All 8 sub phases of gait can be assessed while working with the patient in pregait. The patient s ability to generate adequate muscle force in the various muscle groups of the trunk and lower extremity, as required to achieve and sustain single limb stance control and swing of the affected lower extremity, can be assessed in pregait. ROM requirements of the hip, knee, ankle and toes for normal gait can be assessed in pregait. Phases of Gait 270

33 What must be assessed prior to starting PREGAIT? Evaluate the limbs for swelling, redness and pain to rule out any circulatory or musculoskeletal compromises. Determine and treat any ROM limitations in the trunk and foot and ankle that will require joint mobilization or soft tissue stretching to achieve a mid stance alignment. Note: some range limitations of the foot and ankle can be resolved in weight bearing as the patient moves over the foot in pregait. Assess for and begin to treat abnormal muscle tone in the trunk that prevents the patient from sustaining adequate co contraction of the trunk for sitting, scooting, sit to stand, and standing. Assess the patient s ability to generate active hip and knee extension as well as hip abduction in scooting, transfers, sit to stand, and weight shift in standing. PREGAIT: A Training Program To Teach Components of Normal Gait 1. Teach the patient to support the body mass in single limb stance over the affected lower extremity by challenging trunk and lower extremity stability through closed change strategies. (Isometric muscle control) Increase the duration and time the client must sustain SLS Challenge balance through perturbations created by the other limb on moveable surfaces. (Eccentric/concentric muscle control in small ranges) Increase the ROM the hip and knee must move through while in FWB. (Eccentric/concentric muscle control in larger ranges) PREGAIT: Training program cont. 2. Teach the patient how to weight shift the body in a stride position with the less affected lower extremity forward. Challenge the distance of the weight shift in the forward direction by gradually increasing the step length of the less affected leg. Sustain trunk, hip, and knee extension while moving the body over the foot with the heel on the ground and the ankle moving towards increased dorsiflexion. 271

34 PREGAIT: Training program cont. 3. Teach the patient how to passively release the affected lower extremity into hip and knee flexion for pre swing. Assist the pelvis to drop slightly (about 5 ) to initiate 40 of passive knee flexion for pre swing. Patient is standing in stride position with the more affected lower extremity behind the other leg. The heel of the affected lower extremity should rise with the toes remaining in contact with the ground for toe rocker position. The therapist can assist the more affected LE through swing. PREGAIT: Training program cont. 4. After the patient has been assisted to advance the more affected lower extremity forward and is in stride stance, teach them how to weight shift forward onto the more affected limb from loading to mid stance when that foot is ahead of the less affected leg. The patient must be trained to activate the hip extensors from a position of hip and knee flexion in loading so that the body advances forward over the foot. The hip must achieve a position of neutral hip extension and hip abduction prior to neutral knee extension to avoid mechanical knee hyperextension in single limb stance. 272

35 Louisiana Physical Therapy Association 2015 Fall Meeting Functional Gait Training for the Neurologically Impaired Client Lab Handout: A Leg to Stand On Nicky Schmidt, PT, NDTA TM Instructor Saturday, September 12,

36 A Leg to Stand On Facilitating Single Limb Stance in Gait and on the Stairs Nicky Schmidt PT NDTA TM Instructor Critical Movement Events for Single Limb Stance Forward weight shift of the body over the foot with ankle dorsiflexion Stable,co-activated trunk Stable head with free movement for scanning Achieving neutral hip extension and abduction prior to knee extension Closed Chain Strategies to Challenge Trunk and LE Stability in Stance Increase the duration and time the client must sustain SLS Challenge balance through perturbations created by the other limb on moveable surfaces Increase the ROM the hip and knee must move through while in FWB 274

37 Increasing Duration of Single Limb Stance Stepping onto a step Stepping onto progressively higher surfaces Stepping over objects of various sizes Challenge Balance Move an object on the ground with the less affected LE Move the less affected LE on a stable raised surface Move the less affected LE on a multidirectional mobile surface Increase the Range of Hip and Knee Motion in SLS Train in transitions like stand to stride squats, stand to half kneel, and stepping from a squat or sit position Ascend stairs reciprocally Descend stairs reciprocally 275

38 Why Teach Reciprocal Stair Climbing? It is part of normal function. It is a way to force the use of the more affected limb. Stairs provide a stable environment with definite parameters for motor learning. It presents a natural challenge to motor recruitment, strength, grading, ROM, and balance that can enhance function in gait. How is Stair Climbing Similar to Walking on Level Ground? Mid stance alignment is the same Generally the demands on the head, neck, and trunk for stability and coactivation are the same. Same muscle groups working in similar muscle contractions from loading through terminal stance. How is Stair Climbing Different from Walking on Level Ground? Initial contact on the stairs is on the forefoot Loading phase requires a greater ROM into hip and knee flexion and ankle DF. Thus there is a greater demand on the extensor muscles and plantar flexors to reach mid stance. Initial swing requires more active hip and knee flexion to clear the foot to the step above. 276

39 References Krebs, D.E., Wong, D., Jevsevar, D. et. al. Trunk Kinematics During Locomotor Activities. Physical Therapy, 1992: 72: McFadyen, B.J., Winter, D. An Integrated Biomechanical Analysis of Normal Stair Ascent and Descent. Journal of Biomechanics, 1988: 9: Perry, J. Gait Analysis: Normal and Pathologic Function. New York, McGraw Hill Book Co.,

40 Louisiana Physical Therapy Association 2015 Fall Meeting Functional Gait Training for the Neurologically Impaired Client Lecture: Gait Assessment and Common Deviations Nicky Schmidt, PT, NDTA TM Instructor Sunday, September 13,

41 Gait Assessment Assessing Deviations in Gait and Identifying Possible Impairments Nicky Schmidt, P.T., C/NDT NDTA Coordinator Instructor Behavioral Objectives Identify the role of trunk and pelvis stability in gait and the impact on LE movements. Correlate observed malalignments of the trunk, pelvis, hip, knee, and foot during gait to potential musculoskeletal and neuromotor impairments. Discuss how potential impairments create specific movement strategies used in gait. General Assessment Guidelines Observe the person performing gait activities/skills in function. Determine the overall alignment of the head, trunk and all 4 limbs over BOS. Compare weight acceptance, single limb stance, and swing of each LE. Measure velocity, cadence, and step/stride lengths. 279

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43 Contributing Impairments Musculoskeletal Skeletal malalignment Contracture Weakness Neurologic impairments Disuse Contributing Impairments Impaired Motor Control/Problems with spatial and temporal components Sensory Pain Specific Assessment Considerations Body Alignment Mobility/ROM Strength and Postural Tone Muscle Coordination Weight Transference/Stance Limb Stability Initiation and Termination of Swing Motor Sequencing and Timing Foot contact and balance control 281

44 Alignment Identify the base of support and determine if it is appropriate for the phase of gait observed. Observe the trunk and check that the shoulders and pelvis are sustained in a relatively stable alignment at all times. Observe the limb alignment and determine if appropriate to the trunk, the phase of gait and the task being performed. Stance Stability and Weight Transference If the shoulders and pelvis deviate from each other in any plane, does this compromise LE alignment or muscular control? Is ankle rocker achieved with full foot contact? Is the body weight transferred from behind to in front of the ankle joint with maximal Limb Stability in hip and knee extension and a stable trunk? Does the patient achieve mid stance alignment on either LE? Mobility or Range of Motion Must include evaluation of thoracic, lumbar, pelvis, hip, and knee in conjunction with the ankle and foot. Must examine active or functional mobility as well as passive. This requires evaluating the joint movements in weight bearing as well as non-weight bearing. 282

45 Muscle Strength and Tone What do you feel as you move the client passively (resistance/muscle activation/lack of muscle activation)? What are the observable changes in alignment and symmetry that occur as you move the client or as the client moves through function? Do the muscles of the hip, knee and ankle adequately advance the swing LE and clear the foot in gait? Is arm swing natural and occurring spontaneously with normal velocity gait? Muscle Coordination Is there excessive or exaggerated movement of the shoulders or pelvis in any plane? When in gait does this occur? How does this compromise LE alignment, stability, or muscular control? Do the muscles in the LE adequately and automatically clear the foot through swing and prepare it for contact with the ground? Do you observe vaulting, hiking of the pelvis, circumduction, or dragging the foot? Observed Asymmetry within the Trunk During Stance If the trunk is not co-activated and stable during gait then the upper trunk will generally shift in the opposite direction of the pelvis in order to maintain COM balanced over the base of support. This is complicated by the fact that the trunk can move in all 3 planes of motion, and movement can be initiated by either upper or lower trunk. 283

46 Asymmetrical Pelvic Alignment Sagittal Plane Pelvis anteriorly tilted with increased lumbar extension and associated: Forward trunk lean, hip flexion, knee hyperextension, and ankle plantar flexion or Hip and knee flexion, hip adduction, subtalar pronation with either increased ankle plantar flexion or dorsiflexion in stance Forward Trunk Lean Potential Impairments Adaptive shortening of lumbar extensors, hip flexors, hamstring, or ankle plantarflexors Insufficient mm activation of the abdominal mms. hip extensor mms, eccentric plantar flexors, quadriceps Increased force production in lumbar extensors, hip flexors, knee extensors, or ankle plantar flexors Inability to sufficiently co-contract the erector spinae and abdominal mms 284

47 Asymmetrical Pelvic Alignment Sagittal Plane Posterior tilt of the pelvis with lumbar flexion and backward trunk lean in stance can result in: Hip extension, knee flexion, and ankle dorsiflexion or A crouched gait with hip and knee flexion and ankle dorsiflexion Crouched Gait From Perry, J. Contractures: A historical perspective: Clin Orthop 219:8, 1987 Potential Impairments Decreased ROM in thoracic or lumbar extension Adaptive shortening of the hamstring or ankle plantar flexors mms. Insufficient mm activation of the thoracic or lumbar extensor mms., hip or knee extensors, and ankle plantarflexors Excessive force production in the knee flexors 285

48 Asymmetrical Pelvic Alignment Frontal Plane Pelvis shifted laterally with resulting femoral adduction on the stance LE and shoulders shifted away from the stance leg. Excessive pelvic drop on the stance LE resulting in trunk elongation on the stance limb and increased lateral pelvic displacement of the contralateral side Lateral Pelvic Displacement 286

49 Potential Impairments Decreased ROM in lumbar lateral flexion, hip adduction or hip abduction Insufficient mm activation of the lumbar extensors and abdominals unilaterally Insufficient mm activation of the hip abductors or hip adductors Excessive mm activation of the trunk extensors on one side, or hip adductors Asymmetrical Pelvic Alignment Horizontal Plane Backward rotation of the pelvis on the stance LE will likely result in forward trunk lean, hip flexion and external rotation, knee hyperextension, and ankle plantar flexion 287

50 Potential Impairments Decreased lumbar flexion, thoracic extension, or lateral flexion ROM Adaptive shortening of the hip flexors or ankle plantar flexors Insufficient mm activity in the erector spinae, or abdominal mms of the trunk Increased force production of the erector spinae unilaterally Insufficient mm activity in the hip extensors, adductors, quadriceps, ankle plantar flexors Asymetrical Pelvic Alignment Horizontal Plane Forward rotation of the pelvis on the stance LE may occur with hip extension and internal rotation, knee flexion or extension, and ankle dorsiflexion 288

51 Potential Impairments Insufficient mm activity in the abdominal mms Insufficient mm activity in the hip extensors, hip abductors or adductors, knee extensors, ankle plantar flexors Increased force production in the hip and knee flexors of one LE and hip and knee extensors of the opposite LE Upper Trunk Deviations that Influence Trunk Symmetry Increased scapula elevation and abduction with apparent elongation of the trunk may result in: Excessive trunk lateral flexion, forward rotation of the upper trunk, or increased forward lean of the trunk with thoracic flexion Potential Impairments Decreased ROM in thoracic extension, or posterior rotation of the ribs Insufficient mm activation of the, thoracic and lumbar extensors, scapular depressors, or scapular adductors Adaptive shortening of the pectoralis, latisimus dorsi, upper trapezius or levator scapulae mms 289

52 Upper Trunk Deviations continued Upper trunk and rib cage collapsed down and forward or down and back creating an apparent shortening of the trunk may result in: Excessive lateral pelvic displacement or rotation of the pelvis in the opposite direction of the upper trunk with downward rotation of the scapula Potential Impairments Decreased ROM into lateral trunk flexion in the opposite direction or rib cage expansion on the same side Hypotonicity of the scapula and shoulder muscles generally especially trapezius, serratus anterior, deltoid Insufficient mm activity in the abdominals, trunk extensors Decreased Hip Extension During the Stance Phase If the trunk is relatively stable then the LE alignment at mid stance will be: Hip flexion with knee hyperextension and ankle plantar flexion or Hip and knee flexion and ankle dorsiflexion This results in decreased stance stability, decreased forward progression, loss of trailing limb which leads to decreased contralateral step length, and decreased hip and knee flexion for limb advancement 290

53 Potential Impairments Adaptive shortening of the hip flexor or ankle plantar flexors Insufficient mm activation of the hip extensors, knee extensors, or ankle plantar flexors Increased anterior pelvic tilt due to insufficient or delayed firing of the abdominal mms Potential Impairments continued Inappropriate timing and sequencing of hip and knee extension from loading to mid stance Excessive force production in the hip flexor or ankle plantar flexor mms Pelvic Hike or Hip Circumduction During Swing Compensatory strategies used to advance the swing leg that generally result in initial contact on a supinate foot. If the foot becomes rigid due to increased mm tone or decreased mobility of the foot and ankle then weight shift is inhibited and momentum for forward propulsion is diminished. This movement strategy can occur with posterior pelvic rotation or posterior tilt to assist limb advancement. 291

54 Circumduction of the Lower Extremity Potential Impairments Insufficient mm activation of the hip flexors, knee flexors, ankle dorsiflexors, peroneal mms during swing Adaptive shortening of the ankle plantar flexors, hip abductors or external rotators Hypertonicity of the hip external rotators, hip abductors, knee extensors, ankle plantar flexors or supinators of the foot. 292

55 Rapid Knee Extension or Genu Recurvatum in Stance Generally associated with malalignment or muscular instability at the pelvis and/or hip joint, or weakness or decreased mobility at the ankle joint. It does not occur as an isolated impairment of the knee in a patient with TBI or CVA. 293

56 Potential Impairments Insufficient activation of the trunk, hip or, knee extensors, or abdominal mms Hypertonicity of the ankle plantar flexors at initial contact and early stance Adaptive shortening of the hip flexor or ankle plantarflexors Inappropriate timing and sequencing of hip and knee extension from loading to midstance Increased Knee Flexion During Stance If there is normal ROM at the knee then there is impairment at the pelvis, hip, or ankle associated with this increased knee flexion. Potential Impairments Adaptive shortening of the knee flexors with associated tightness in the hip flexors or plantar flexors, Insufficient activation of the hip extensors, knee extensors or trunk extensors Hypertonicity of the knee flexors 294

57 Excessive PF During Swing, Initial Contact and Loading If due to weakness (Drop Foot): Hinders foot clearance, but does not prevent normal pre-swing. May influence foot or knee control at IC & loading, but does not have to interfere with mid and terminal stance phases. It should be accommodated for without immobilizing the ankle jt. and limiting progression of the body over the foot. Excessive PF If due to excessive force production in the ankle PF, inverters of the hind foot, and supinators of the mid foot or contracture of PF: Patient may require bracing to restrict PF and calcaneal inversion during loading so forward progression over the foot can occur. Hip hiking, contralateral vaulting, lateral trunk lean, or circumduction may be used in swing for foot clearance. Velocity and step length are decreased. Potential Impairments Insufficient activation of the ankle dorsiflexors and toe extensors Adaptive shortening of the ankle plantar flexors and hamstrings Excessive force production in hip and knee flexors, hip abuctors, ankle PF, inverters or supinators of the foot 295

58 Pronation of the Foot During Stance Critical to determine the integrity of the midfoot, particularly the midtarsal and subtalar jts. Because there is a tendency to develop hypermobility. Observe for collapse of the medial longitudinal arch. Evaluate whether the hindfoot is also pronated Potential Impairments Hypotonic = overly stable, nondynamic foot. Associated with excessive range into ankle dorsiflexion, and increased hip and knee flexion with hip adduction in stance. Can result from: Insufficient activation of the hip abductors, hip and knee extensors,or ankle plantar flexors 296

59 Pronation of the Foot During Stance Hypertonic = stiff, immobile foot with small weight bearing surface. Associated with forefoot abduction and severe potential for deformity. Can result from: Hypertonicity in the trunk extensors, hip adductors, hip medial rotators, knee extensors, ankle plantar flexors, peroneals Decreased Toe Hyperextension for Terminal Stance Can occur with a drop foot, with either type of pronated foot, or with a high tone supinated foot. May be related to decreased or increased active mm tension any where in the trunk or LE which challenges postural control. Potential Impairments Excessive mm tension in the toe flexors, along with hypertonicity of the forefoot inverters and/or ankle plantar flexors Insufficient activation of the toe extensors or ankle plantar flexors Adaptive shortening of the toe flexors A shortened step length with no trailing limb position achieved in stance. 297

60 Louisiana Physical Therapy Association 2015 Fall Meeting Functional Gait Training for the Neurologically Impaired Client Bibliograpy Nicky Schmidt, PT, NDTA TM Instructor Saturday, September 13,

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