Download Not for distribution - The Iowa Physical Therapy Association

IPTA Spring Conference
April 25, 2014
G. Beecher, G. McGaughy, K. Mercuris
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Includes head righting reactions, equilibrium
reactions, and maintaining a stable position over
the COM, and anticipatory control
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Involves controlling the body’s position in space for
the purposes of stability and orientation and
emerges from the interaction of multiple systems
that are organized around a task and constrained
by the environment
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Atypical alignment and abnormal patterns
of weight bearing
Abnormal muscle
Motor/coordination problems (neuro-motor
component)
Changes in sensory systems:
somatosensory, visual, vestibular
Task and/or environment
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1.
2.
3.
4.
Changes in muscle strength
Changes in muscle/postural tone
Changes in muscle activation
Sensory changes
3.
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4.
Orthopedic changes- alignment, joint
mobility (hypo/hyper mobility)
Changes in muscle and soft tissue length
Pain (joint, muscle, altered sensitivity,
shoulder/hand syndrome)
Edema
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1.
Primary Impairments
Secondary Impairments
Movement Deficits
Composite impairments
Atypical movements
Compensations
2
Neuromuscular
Sensory-Perceptual
Musculoskeletal
Cognitive-Behavioral
Cardiopulmonary
and
other
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Velocity dependent increases in tonic stretch
reflexes
Exaggerated tendon-jerks or clonus resulting
from hyperexcitability of the stretch reflex
Confirmed by increased resistance to RAPID
passive lengthening of muscles at rest
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Excessive Co-Activation- simultaneous
activation of agonist and antagonist muscle
groups crossing the same joint, increasing
joint stiffness.
Impaired muscle synergies- limited
movement patterns that would otherwise
allow an individual to act in a variable and
efficient way to meet specific requirements
of task.
3
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Impaired Modulation and Scaling of Forcesgenerate an inappropriate amount of
force/acceleration/deceleration with
performance of a task
Timing/Sequencing Impairments- slowness in
initiation, performance, and difficulty
terminating action during a task
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Weakness- dependent on number and type
of motor units that are recruited
Inability to activate and sustain muscle
activity to complete action/movement
Lock of postural muscle control to provide
stable base for UE or LE movement
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Ability to perceive, interpret, adjust, and
organize sensory input for use in eliciting a
motor response
Poor stability if difficulty in processing input
Poor processing may be due to:
◦ Detection
◦ Interpretation
◦ Modulation
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Decreased ability to plan and perform
movements automatically
For example, patient with left neglect does
not utilize left side of body, even when ability
to move is preserved.
Hyporesponsive- have a high threshold to
sensory stimulation, appear unmotivated,
forget to use one side of body even with
tactile stimulation.
Hyperresponsive- have a low threshold to
stimulation, distractibility, easily
overwhelmed, perceived input as
uncomfortable, overreaction to postural or
balance displacements.
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Affects stability and adaptation aspects of
mobility. Peripheral vision needed for balance
control
Isolates people from gaining information
from environment, producing a sense of
insecurity
Visual Acuity, visual field deficits, diplopia,
eye movement limitations
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Kinesthetic Memory- what a movement should
feel like and how to perform it correctly.
Inability matching sensory information with
experience/memory
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Joint and Soft Tissue Flexibility (hypo or
hypermobile)
Skeletal impairments- osteoporosis, DJD,
atypical bone structure
Muscle weakness
Decreased muscular endurance
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Expressive/Receptive aphasia
Apraxia
Impaired insight, judgment, attention, safety
awareness
Limited comprehension
Difficulty with carryover
Decreased motivation
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Respiratory System
Regulatory System (arousal and attention)
Cardiopulmonary System
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3 Typical Patterns of Recovery Exist
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Most influenced by gravity
Least muscle activity
Postural control is not adequate enough to
support the weight of the body against
gravity
Examples: Usually have a heavy, hanging UE,
with scapula pulled into downward rotation.
Intercostal muscles may be inactive. Pelvis
‘falls’ into posterior tilt in sitting and anterior
tilt in stance.
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Rotation typical due to unbalanced muscle
activity.
Pt fires extensors with unbalanced flexors.
With unilateral extension, increased
asymmetry resulting in rotation.
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The body appears very stiff due to over firing.
May need to cue patient to ‘work less’,
reassess task and environment
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Unable to selectively recruit desired patterns.
Therefore, the pt fires many muscles and
works very hard but does not achieve the
desired outcome.
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1. Starting position of movement & BOS.
Asymmetry in weight distribution, head, upper
and lower trunk alignment as unit.
2. Initiation of phase of movement. What body
part moves first, direction of weight shift and
change in BOS.
3. Transition point of movement, position of
body, BOS and new direction of movement.
4. Completion of movement with position of
body, limbs and BOS.
5. Range of movement control
6. Quality of movement- control of speed,
smoothness, grading, able to sustain, and ease
of movement.
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1. Is the UE heavy and pulling pt unilaterally or
forward?
2. Is the UE partially active, but the scapula is
elevated or the pt is utilizing abnormal
patterns thus changing the pelvis, trunk, and
head alignment?
3. Is the UE overly active, thus causing stiffness
and asymmetry throughout?
1.
2.
3.
4.
Is the LE flaccid?
Are both feet touching the floor and even?
Is the patient pushing with one LE in plantar flexion?
Can the patient activate LE’s to stabilize or weight
shift?
5. Can the LEs muscles generate force for sit/stand or
scooting to the side?
6. Do the LEs adapt to postural changesweight shift with reaching or movement
of the trunk?
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1. Correct problems in alignment and postural
asymmetries
2. Assist difficult movement patterns
3. Block undesirable movement patterns
Remember to include assessment of primary and secondary
impairments contributing to movement dysfunction, atypical
or compensatory movement patterns.
Examples: muscle strength, alignment, orthopedic changes,
shortening, abnormal muscle tone- interference with normal
movement patterns.
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1. Create a problem list of functional limitations and
movement problems.
3. Need to analyze which system is most affecting
abnormal movement and which system you may be able
to control!
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2. Note atypical or compensatory movement patterns,
significant movement deficits and relevant impairments
for the trunk, UE, and LE.
•Unifunctional
•Multifunctional
•Rhythmical
•Discrete
Task
Individual
•Neuromuscular
•Musculoskeletal
•Sensory Perceptual
•Cognitive Behavioral
•Cardiopulmonary &
•other
Environment
•People
•Place
•Things
•Time
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Treatment of Impairments
Movement Reeducation
Task Specific functional training
Use of facilitating movement and normal movement
patterns can assist in decreasing secondary impairments
(joint mobility, tissue shortening/lengthening).
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Once normal alignment is attained, can utilize bracing,
splinting, positioning as an adjunct to the treatment of
impairments
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Sensory Education: Assists with sequencing,
timing, speed, and force of movement, i.e.
Treadmill training
Muscle Activation: strengthening with isometric,
eccentric, concentric contractions
Independent Movement/Practice: kinesthetic
memory reestablished. Assist is gradually
decreased so the pt performs the activity in the
best possible normal movement patterns.
Functional Training- Now pt can achieve desired
normal movement, pt now needs to practice with
functional activity.
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Retraining task performance- break down
components of the task for normal movement
patterns (recognizing that there are variable
ways people can “normally” complete a
functional task).
Practice of ‘whole task’
Avoid compensatory patterns and ‘learned
non-use’. i.e. asymmetrical movement and
poor alignment of segments.
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Attempt to realign pt with facilitation on region
with mal-alignment.
Example:
1. Ask the patient to sit erect with verbal cues or
demonstration
2. If unable then facilitate into position
3. If unable consider impairments- need for soft tissue
mobilization
4. If still unable, consider environment (later slide)
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◦ Assess trunk flexion/extension, rotation and lateral
trunk flexion. Facilitate ribs, pelvis for
symmetry/realignment. Facilitate UE for weight bearing
to increase stability of trunk. Work proximal to distal but
look at entire body
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Once static realignment has been achieved,
assess patient comfort with and ability to
maintain realigned position with movement
inside BOS (progressing to outside BOS) with
multi-planar movement.
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May be beneficial to change environmental set up
to achieve desired outcomes
Examples- Mat table/bed adjusted high/low, use of
wall as a goal directed target for “pusher’s”,
therapist assisting from right/left/in front/behind,
changed position of tray table or reaching target
to achieve improved quality of weight shift or to
allow more room for anterior weight shift
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Postural control is the foundation to movement
within normal movement patterns.
The therapists role is to facilitate a patients ability
to obtain, maintain, and sustain trunk/postural
control during functional tasks.
If the patient performs transfers, bed mobility,
ADLs, and gait training without proper postural
control and alignment, the task, energy
expenditure, and quality of movement can be
compromised for the patient and therapist.
If you do not facilitate postural control, a patient
may develop compensatory patterns that will
restrict quality of life.
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Material adapted from:
◦ NDT Bobath 3 week Course - Treatment in Adults
with Hemiplegia by Monica Diamond
◦ Functional Movement Reeducation by Ryerson and
Levit
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Initial Contact: Heel contacts the ground first.
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Loading Response: Hip stability, controlled
knee flexion and ankle plantarflexion
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Initial Contact: the
point in time when the
foot strikes the ground.
Trunk: erect/neutral
Pelvis: level: maintains
forward rotation
Hip: 30° flexion; neutral
rotation, abd/adduction
Knee: 0° ext.
Ankle: 0° / neutral
Toes: neutral
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4/10/2014
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Loading Response:
shock is absorbed as
forward momentum is
preserved. A foot flat
position is achieved.
Trunk: erect/neutral
Pelvis: level: less forward
rotation
Hip: 25° / 30°; neutral
rotation, abd/adduction
Knee: 0°- 15°
Ankle: 0° - (-)15° plantar
flexion
Toes: neutral
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Ankle and Foot:
Forefoot or foot flat- compensation for weak
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quads to avoid normal loading response or
inadequate knee ext in terminal swing
Foot Slap-weak anterior tibialis
Excess plantar flexion- plantarflexion
contracture
Excess dorsiflexion- excess hip/knee flexion
Knee
Limited flexion- At loading response, impaired
proprioception, foot flat or forefoot contact or knee
pain
Excessive flexion- Impaired proprioception, knee
flexor hypertonicity due to excess hip flexion and
ankle dorsiflexion, weak quads, or knee flexion
contracture
Hyperextension- impaired proprioception, forefoot
contact, intentional to increase limb stability
(weakness) or weak hamstrings, due to excess
plantarflexion
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Hip
Excess flexion- excess ankle dorsiflexion and/or
knee flexion or hip flexion contracture
Limited flexion- intentional to decrease the demand
on hip extensors, limited hip flexion in terminal
swing, or past retraction in terminal swing
Abduction- impaired proprioception, or abduction
contracture, or to increased the base of support
Adduction- weak abductors, adductor hypertonicity,
or to decrease the base of support
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Trunk
Backward lean- Intentional to decrease the demand
on hip extensors
hip flexion
Lateral lean- Weak hip abductors
Backward rotation- Inability to disassociate trunk
movements from pelvis/limb movements
Forward rotation- Inability to disassociate trunk,
intentional to advance limb or excessive use of
assistive devices
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Forward lean- Inadequate hip extension or excess
Pelvis
Excess forward rotation-
intentional to advance the limb, or
increase step length during
terminal swing
Lack of forward rotation- retracted
pelvis or to decrease step length
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4/10/2014
MIDSTANCE: Controlled tibial advancement
forward with knee extension and hip
stabilization in the frontal plane
TERMINAL STANCE: ankle stabilization with
heel rise and achieving trailing limb
PRE-SWING: Knee flexion to 40 degrees (bridge
between Stance and Swing)
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Mid-stance: controlled
advancement of the body from
behind to ahead of the ankle.
Contralateral swing limb
provides the momentum
Trunk: erect / neutral
Pelvis: level: neutral rotation,
abd/adduction
Hip: 30° - 0°: neutral rotation,
abd/adduction
Knee: 15° - 0°
Ankle: 15° plant. - 10° dorsi.
Toes: neutral
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Terminal Stance:
extreme progression
of the body past the
MTP heads.
Trunk: erect / neutral
Pelvis: level: backward
rotation 5°
Hip: 0° - 10°ext. ; neutral
hip rotation,
abd/adduction
Knee: 0°
Ankle: 10° dorsi. - 0°
Toes: 0° - 30°ext.
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4/10/2014
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Preswing: the foot
remains on the floor
while weight shifts to
the other limb.
Trunk: erect / neutral
Pelvis: level: backward
rotation 5°
Hip: 10° ext. - 0°; neutral
rotation, abd/adduction
Knee: 0° - 35°
Ankle: 0° - 20°plant.
Toes: 60° ext.
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Ankle and Foot
plantarflexion hypertonicity, plantarflexion
contracture, weak dorsiflexors, inadequate
ankle ROM
Excess dorsiflexion- weak calf muscles,
inadequate knee/hip extension
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Excess plantar flexion- weak quads,
Knee
Inadequate Extension- Excess dorsiflexion,
inadequate hip extension, posterior pelvic tilt, knee
flexion contracture, pain or hypertonicity
Hyperextension- Secondary to forefoot contact,
excess plantarflexion, weak quads, impaired
proprioception, quads hypertonicity, trunk
alignment, intentional to increase limb stability
Causes: decreased shock absorption, decreased
forward progression of the tibia, potential injury to
the posterior aspect of the knee joint
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4/10/2014
Hip
Inadequate extension- inadequate knee
extension or excess dorsiflexion, weakness,
or hip flexion contracture (or tight hip
capsule)
Adduction- secondary to contralateral pelvic
drop, weak abductors
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Trunk
Forward lean- intentional to stabilize the knee and
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ankle in extension, intentional to substitute visual
input, or to progress over an excessively
plantarflexed ankle
Lateral lean- Weak hip abductors (compensated
Trendelenberg)
Backward lean- intentional to decrease the demand
on the hip extensors
Rotates backward/forward- inability to disassociate
trunk movements from pelvic or limb movement
Pelvis
Contralateral pelvic drop- (Uncompensated
Trendelenberg) weak hip abductor on the
reference limb, or intentional to lower the
opposite limb for initial contact, may
decrease stance limb stability
Lacks backward rotation- impaired motor
control of the trunk and pelvic muscles
Excess backward rotation- inability to
disassociate the pelvis from limb movement
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INITIAL SWING: Knee flexes further to 60
degrees aided by hip flexion
MID SWING: Ankle positioned to neutral
TERMNAL SWING: Knee extension to neutral
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Initial Swing: the foot
is cleared from the
floor as the thigh
begins to advance.
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Trunk: erect / neutral
Pelvis: level; backward
rotation 5°
Hip: 0° - 20°flex; neutral
rotation, abd/adduction
Knee: 35° - 60°
Ankle: 20° plant. - 10°
plant.
Toes: neutral
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Mid-swing: the
thigh continues to
advance as the knee
begins to extend,
foot clearance is
maintained.
Trunk: erect / neutral
Pelvis: level; neutral
rotation
Hip: 20° - 30°
Knee: 60° - 30°
Ankle: 10° plant. - 0°
Toes: neutral
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Terminal Swing: the
leg reaches out to
achieve full step
length.
Trunk: erect / neutral
Pelvis: level: forward
rotation 5°
Hip: 25° - 30°; neutral
rotation, abd/adduction
Knee: 30° - 0°
Ankle: 0°
Toes: neutral
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Ankle and Foot
Excess plantar flexion- weak anterior tibialis
Contralateral Vaulting- compensatory for limited flexion of the
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swing limb, weak dorsiflexors, plantarflexion contracture
Knee
Limited flexion- at preswing/midswing, inability to rapidly flex
the knee (motor control), inadequate hip extension, no heel
off in terminal stance or excess extensor tone
Inadequate extension- inability to selectively extend the knee
while maintaining a flexed hip, intentional to decrease the
demand of hip extensors, intentional to allow forefoot or foot
flat contact or weak quads
Hip
Limited flexion- weak hip flexors, inability to rapidly flex hip (motor
control), intentional to decrease the demand on hip extensors
during loading response, secondary to foot drag
Excess flexion- intentional to clear the floor, or excess plantar flexion
Past retract- ( defined as a visible backward movement of the thigh
during terminal swing) inability to selectively extend the knee while
the hip is flexed, impaired proprioception, intentional to help
achieve a stable knee at loading response, or intentional to decrease
the demand on the quads and hip extensors at loading response
Adduction- secondary to contralateral pelvic drop
Abduction- compensatory to clear a longer swing limb, abduction
contracture
Circumduction- (a composite movement of abduction/external
rotation followed by adduction/internal rotation) intentional to
advance limb, impaired motor control, weakness
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4/10/2014
Trunk
Backward lean- intentional to advance the
limb
Lateral lean- intentional to clear the swing
limb or use of assistive devices
Backward rotation- excess ankle
plantarflexion in terminal stance or use of
assistive devices
Forward rotation- intentional to advance the
limb, excessive use of upper extremity aids
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Pelvis
Hikes- intentional to clear the swing limb
Lacks forward rotation- compensatory to decrease the demand
on the quadriceps and hip extensors at loading response
Excess backward rotation- inability to disassociate the pelvis
from limb movement, or excess plantarflexion
Ipsilateral pelvic drop- weak hip abductors on the opposite
limb, intentional to lower the opposite limb for initial contact
Posterior pelvic tilt- advance the limb if hip flexors are weak,
low back pain or limited lumbar extension
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Alignment
◦ Proximal
◦ Distal
Mobility/range
◦ Closed chain
◦ Open chain
Strength
◦ MMT
◦ Postural/synergistic/neurologic
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4/10/2014
1. Get an overall picture:
◦ -Speed, stability, step length, trunk and UE
positioning
◦ -Observe overall gait pattern with and without:
 Braces
 Shoes
 Assistive devices
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2. Develop an orderly assessment strategy
◦ For example, start assessment from bottom and
work your way to the top or vice versa
◦ Observe from all directions
 Front view
 Lateral view
 Rear view
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 Remember, often times early on many distal impairments
can stem from proximal instabilities or impairments. If
these proximal impairments are addressed early on, many
times secondary impairments of pain, stiffness, and poor
positioning can be avoided or minimized.
3. Observe the effects of varying
environment/demand on system.
◦
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How is gait affected by varying speed?
How is gait affected by varying walking surfaces?
How is gait affected by varying directions?
How is gait affected by varying cognitive
involvement? Dual task performance? Talking?
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4/10/2014
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Specific gait considerations to observe:
◦
◦
◦
◦
◦
◦
◦
Trunk position and movement over stance LE
Amount and direction of weight shift
Duration of stance on each LE
Sequencing and timing of LE and trunk movement
Step length
Time spent in double/single limb support
Swing initiation- passive with momentum of gait
or active and effortful?
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Need to assess what is happening at all joints
and hypothesize and prioritize which body
systems are most likely the cause of gait
deviations to efficiently and effectively treat
patients.
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Bend and straighten both knees
Weight shift to affected side and
maintain while:
◦ relaxing the opposite knee
◦ stepping forward with the opposite lower
extremity
◦ stepping back
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4/10/2014
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Squats
Reciprocal stairs
Retro-walking
Single limb bridge (LE off mat)
Modified bridge (sitting on edge of mat)
Working at a wall
◦ Pushers
◦ Tapping toe
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Sitting on a high low mat with weight loaded
through the LE
Climbing a ladder
Hopping
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Single limb stance
◦ Step ups
◦ Step ups to a ball
◦ Step up and move the surface
Slider for swing (paper, slider, ACE Wrap)
◦ Swiss Ball
Incorporate the UE(foam roll, ball, flat surface,
pole)
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4/10/2014
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For transfers, keep patient in anterior weight shift
and low. Limit patients ability to extend uninvolved
LE. (Cue to reach to the floor, touch the back of
therapist calf, hold other UE) Consider use of
sliding board.
Initial goal is to orient to midline and decrease
pushing tendency. Start with weight shift to the
strong side. (Sitting to lateral forearm weight
bearing or sidelying to sitting, reaching to strong
side, placing hand on “X” excessively outside BOS)
Standing with weight shift to the strong side with
use a hi-lo mat table, wall or elevated hemi bar for
tactile input on uninvolved hip. Use visual cues.
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If using uninvolved UE, limit ability to grasp
bar or object. Use variable non-stable support
surface to limit pushing. (Flat hand on mat
table, foam roll, small ball, tall pole)
Consider mat activities. Tall kneeling (with
reaching/weight shift), 4 point, rolling for
increased tactile input.
From OP standpoint, patient might present
with secondary impairments (trunk
asymmetries, knee buckling, back/neck
pain/stiffness) Consider mat activities,
standing weight shift ideas in normal
alignment.
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Continually trial various devices to optimize normal
alignment and most effortless gait. Always trial
gait with and without extraneous devices.
Braces
◦ Dorsiflex assist ace wrap
◦ Knee hyperextension ace wrap (figure 8 on back of knee)
◦ Air splint

Assistive devices
◦ Choose device that will optimize normal BOS, increase
postural control bilaterally, increase trunk stability,
normalize automaticity of gait cycle and speed.
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1.
2.
3.
4.
5.
6.
7.
Davies PM. Steps to Follow. New York: Springer- Verlag,
1985.
Davies PM. Steps in the Middle. New York: SpringerVerlag,1990.
Perry J. Gait Analysis Normal and Pathological Function.
New Jersey: SLACK Inc, 1992.
NDT Three-Week Adult Course in the Treatment of
Hemiplegia. Course Notes. Instructor: Monica Diamond,
2002 and 2006.
NDT Advanced Course-Advanced Gait. Course Notes.
Instructors: Teddy Parkinson and Cathy Hazzard, 2004.
Ellis, P. Physical Therapy Management of Lower Extremity
Amputation. Aspen Publications, 1986.
Ranchos Los Amigos Medical Center. Observational Gait
Analysis. Pathokinesiology Department and Physical
Therapy Department, 1996.
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