What are the 3 components of the gait cycle?
- Stance phase: 58-61%
- Swing phase: 42-39%
- Double support: 8-11%
What is the purpose of the stance phase?
- Support upper body & prevent collapse
- Maintain balance by keeping COM over BOS
- Propulsion of the body
- Absorption of energy for shock absorption & control of the body’s forward velocity
What is the purpose of the swing phase?
- Clear foot from the ground
2. Prepare foot for heel strike
What are the important components of the stance phase? **Exam question
- Hip extension throughout
- Knee yield (15 deg flexion) on heel strike then extension in mid-stance & flexion prior to toe-off
- DF until end of stance then fast PF
- Lateral horizontal shift of pelvis & trunk
What are the important components of the swing phase?
- Knee flexion with hip initially in extension
- Hip flexion throughout
- Ankle DF throughout
- Slight lateral pelvic tilt downward
- Rotation of pelvis forwards
- Knee extension prior to heel strike
What are the common missing important components in the stance phase after stroke?
- Reduced hip extension
- Excessive lateral pelvic shift to affected side
- Loss of knee yield
- Knee hyperextension or flexion
- Absent knee flexion at end stance
- Reduced PF at toe off
What are the common missing important components in the swing phase after stroke?
Decreased
- Hip flexion
- Knee flexion mid swing
- Knee extension at heel strike
- DF
What are the common adaptive strategies in walking after stroke?
- Decreased amplitude of movement
- Decreased walking velocity
- Decreased stride & step length
- Uneven step & stride lengths
- Increased stride width
- Increased time in double support
- Increased cadence
- Use of arms
- Trunk inclined forward during stance
- Elevation of pelvis & abduction of leg
- Toes not clearing ground during swing
- Trunk inlined backwards at end of swing
How is normal step length calculated?
0.4 x height (or height divided by 3)
What is the normal cadence for a healthy adult?
120bpm
What is normal stride width for healthy adults?
3-6cm between heels or 0cm between medial malleoli
What are some of the changes in gait variables in frail elderly?
Decreased - Step length - Balance - Ankle PF ROM & strength - Hip extension Increased double support phase
What evidence is there for the importance of the PFs in gait?
Unilateral tibial nerve block paralysing PFs lead to
- Decreased weight transference to front of foot
- Decreased single leg stance
- Decreased step length on intact side
- Decreased walking speed
- Increased ankle DF & knee flexion in stance (as PFs couldn’t control DF)
- Increased quads activity
- Exaggerated fall of centre of gravity, resulting in excessive work output to lift with it the intact leg
What are the clinical implications of the findings regarding PFs in gait?
- Train PFs
- PFs are important for step length on both sides & walking speed
What does the assessment of walking include?
- Observation from in front & side
- Note deviations from important components
- Note adaptive strategies
- Determine impairments
- Consider safety (harness, physio assistant)
What measurement tools are used for walking?
- MAS
- 10m walk test (for walking speed, cadence, step length/width)
- 6 minute walk test
- Rivermead gait assessment
What does training in preparation for walking include?
- Strength training
- Dexterity training (part practice)
- Management of other impairments
What are the strategies for training walking as a whole activity?
- Treadmill with/without body weight support
- Overground training with/without body weight support
- Use of cues for symmetry & speed
- Stairs
How do you train flexibility of walking?
- Obstacles
- Uneven surfaces
- Crowded environments
- Add cognitive demands
What evidence is there for the likelihood of patients who are non-ambulatory in the first month after stroke regaining independent walking?
- Systematic review
- Measures taken at 3, 6 & 12 months
- Rehab unit: 91% at 12 months
- Acute unit: 74% at 12 months
- Clinical implications: Advocate for rehab
What evidence is there for body weight support & treadmill walking?
- Compared muscle activity in lower limbs at different levels of BW support
- Increased single stance in stroke patients
- But > 30% BW reduced muscle activation in lower limbs
- Clinical implications: Use BW support with treadmills, but no more than 30%
What evidence is there for treadmill training in acute stroke patients?
- Systematic review of treadmill training in acute stroke patients
- Significantly more patients walked independently at 4 weeks/6 months in treadmill groups
- Patients in treadmill groups walked significantly faster & further at 6 months
What evidence is there for treadmill training in chronic stroke patients?
- Randomly assigned to treadmill training or control
- Training: 30 mins 3/week for 4 weeks
- Control: Low intensity home exercises
- Treadmill group had significant improvement in speed, increased step length & endurance, maintained at follow up
What evidence is there for the use of ankle/foot orthosis (AFO) in walking training?
- Examined effects of AFO in normal walking
- Use of AFO resulted in decreased stance, increase vertical force at push-off & lateral shift of centre of pressure
- AFO restricts PF
- Doesn’t encourage patient to clear their foot
- Wouldn’t use in stroke patients in first few months of recovery
