Uploaded byDr. Rima Jani (PT)
Neurological Gait Rehabilitation
This document discusses neurological gait and gait rehabilitation. It begins by defining normal gait and describing common pathological gaits that can result from neurological conditions, including hemiplegic, spastic diplegic, Parkinsonian, myopathic, and ataxic gaits. Specific characteristics and management approaches are described for each type. Rehabilitation approaches covered include traditional gait training exercises, use of assistive devices, high-tech options like body-weight supported treadmill training and electrical stimulation, as well as strength and balance training. Surgical management is also briefly discussed for some conditions.
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Neurological Gait Rehabilitation
- 1. NEUROLOGICAL GAIT REHABILITATION -By Dr.Rima Jani PT (B.P.T., M.P.T.)
- 2. CONTENTS • Introduction • NormalGait • Pathological Gait/Gait Deviation • Types of Neurological Gait • Gait Rehabilitation
- 3. INTRODUCTION • Gait islocomotion achieved through the mobility of limbs. • It is defined as bipedal, biphasic forward propulsion of the body, which includes alternate sinuous movements of different segments of the body with optimum energy expenditure. • Gait is a person's pattern of walking, it involves balance and coordination of muscles so that the body is propelled forward in a rhythm, called the stride. • There are numerous possibilities that may cause an abnormal gait.
- 4. PATHOLOGICAL GAIT • Problemsin the nervous system will show up in the way a person walks. • Pathologic gait patterns can be broadly divided into either neuromuscular or musculoskeletal etiologies. • Neurological Gait Deviations result from neuromuscular etiologies, because of underlying pathology associated to CNS or PNS.
- 5. TYPES OF NEUROLOGICALGAIT Basic pathological gaits that can be attributed to neurological conditions: • Hemiplegic, • Spastic Diplegic, • Parkinsonian, • Myopathic, • Ataxic.
- 6. HEMIPLEGIC GAIT • Hemiplegicgait is also known as Circumductory Gait. • It includes impaired natural swing at the hip and knee with leg circumduction. • The pelvis is often tilted upward on the involved side to permit adequate circumduction. • With ambulation, the leg moves forward and then swings back toward the midline in a circular movement.
- 7. COMPONENTS OF HEMIPLEGIC/CIRCUMDUCTORY GAIT •Hip Hike • Circumduction of the leg • Reduced hip & knee flexion • Decreased weight shift towards affected side • Foot drop, poor dorsiflexion, toe first or flat foot placement
- 8. HEMIPLEGIC GAIT REHABILITATION TraditionalGait Rehabilitation High Tech Gait Rehabilitation Additional Strength Training
- 9. TRADITIONAL GAIT REHABILITATION: • Gait Training in parallel bar • Gait Training exercises • Balance and core training • Use of Assistive devices &/or Orthotics • Task-specific training. • Treadmill Training
- 10. GAIT TRAINING INPARALLEL BAR
- 11. GAIT TRAINING EXERCISES •Seated Marching • Knee Extension Exercises • Toe Taps • Braiding Exercises • Side Stepping • Ankle Dorsiflexion Exercises • Assisted Toe Raise • Heel Raises
- 12. SEATED MARCHING • Thisbasic gait training exercise can be done from any seated position.
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- 15. BRAIDING EXERCISE • Braidingexercise is performed by crossing one leg in front of or behind the other in a continuous manner.
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- 20. BALANCE AND CORETRAINING • Balance and core training both help improve gait. But there is lack of significant evidences. • Walking is a full-body task that requires coordinated movement from the feet, legs, and core. • Reach outs in Standing • Walking on different surfaces • Balance Board Exercises • Weight Shifts on Affected side
- 21. USE OF ASSISTIVEDEVICES &/OR ORTHOTICS Ankle Foot Orthosis: • Solid AFO • Posterior leaf spring AFO (PLS)
- 22. TREADMILL TRAINING • Initiallytreadmill speeds are slow (0.23 m/sec) • Over a period of few weeks it is gradually increased up to (0.98 m/sec)
- 23. TASK-SPECIFIC TRAINING. • Thissimply refers to walking. • Walking in different environments. • Hurdle walking • Climbing small slope
- 24. HIGH TECH GAITREHAB : • Partial Body Weight Supported Treadmill Training • Functional Electrical Stimulation • Virtual Gait Training
- 25. BODY WEIGHT SUPPORTEDTREADMILL TRAINING (BWSTT)
- 26. • An overheadharness is used to support a portion of the patient’s body weight. • The harness controls the upright position of the patient in the absence of good postural stability & reduces fear of falling. • The use of harness also eliminates the need for adaptive UE support to compensate for LE weakness. BODY WEIGHT SUPPORTED TREADMILL TRAINING (BWSTT)
- 27. FUNCTIONAL ELECTRICAL STIMULATION. •Adding electrical stimulation to the affected muscles during gait training exercises can help boost results, according to studies. • NMES improves dorsiflexion and prevents foot drop • Significant improvement in gait is proven with use of FES.
- 28. VIRTUAL REALITY GAITTRAINING
- 29. ADDITIONAL STRENGTH TRAINING •Some muscle atrophy is common after a stroke. • Therefore, adding some strength training can help improve overall health and gait. • Keep in mind that this addresses the secondary complication of muscle atrophy, while rehab exercise addresses the primary concern
- 30. BENEFITS OF GAITTRAINING AFTER STROKE • Gait training exercises can help prevent falling after stroke, because strong legs can help with stabilization if patient loses balance. • Ultimately, a consistent rehab exercise program can help patient get back onto their feet and back to the activities that they enjoy. • Focus on high repetition of exercises to help rewire the brain. • Be sure to target core and feet along with legs to improve overall coordination and balance.
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- 32. DROP FOOT GAIT •A `drop foot' which is noted most clearly in the swing phase of gait due to the inability to selectively control the ankle dorsiflexors during this part of the gait cycle. • No calf contracture and therefore during stance phase, ankle dorsiflexion is relatively normal.
- 33. DROP FOOT GAIT •This gait pattern is rare, unless there has already been a calf lengthening procedure. • The only management maybe needed is a leaf spring or hinged ankle foot orthosis (AFO).
- 34. SPASTIC DIPLEGIC GAIT •Torsional deformities of the long bones and foot deformities are frequently found in spastic Diplegic CP. • Musculo tendinous contractures are also present • These are collectively referred to as `lever arm disease‘. • The most common bony problems are medial femoral torsion, lateral tibial torsion, midfoot breaching, with foot valgus and abduction.
- 35. ROTATIONAL DEFORMITIES • Childwith rotational deformities present with either an in-toed or out-toed gait • This in-toeing and out-toeing must be evaluated properly • It is due to position and pressure in the uterus during pregnancy
- 36. • Internal tibialtorsion: causing toe in • External tibial torsion: causing toe out • Internal femoral torsion: causes toe in • External femoral torsion: causes toe out
- 37. CROUCH GAIT PATTERN •This shows the features of `lever arm disease'. There is an out-toed stance and gait pattern because of midfoot breaching and lateral tibial torsion. • The right image is a sagittal view demonstrating a crouch gait pattern.
- 38. CROUCH GAIT PATTERN •When the bony lever (the foot) is bent and is abnormally directed. • Weakness of gastro-soleus is unable to control the progression of the tibia over the planted foot and a crouch gait results.
- 39. CROUCH GAIT • Excessivedorsiflexion or calcaneus at the ankle in combination with excessive flexion at the knee and hip. • Seen in children with more severe diplegia and in the majority of children with spastic quadriplegia
- 40. CAUSES Any of thefollowing causes or combination of following causes: • Spastic hamstrings • Weak Gastro-soleus. • Malrotation of femur, tibia and foot. • Tight Iliopsoas • Weak Quadriceps • Poor Balance
- 41. CAUSES • Isolated lengtheningof the heel cord in the younger child. • Once the heel cord has been lengthened, if the spasticity/contracture of the hamstrings and iliopsoas has not been recognized and is not managed adequately, there will be a rapid increase in hip and knee flexion. • The result is an unattractive, energy-expensive gait pattern, followed by anterior knee pain and patellar pathology in adolescence
- 42. SURGICAL MANAGEMENT • Bythe time it is recognized, the musculoskeletal pathology is usually too advanced to respond to intramuscular BTX-A. • Surgical management: lengthening of the hamstrings and iliopsoas, and adequate correction of bony problems such as medial femoral torsion, lateral tibial torsion and stabilization of the foot.
- 43. ORTHOSIS • A groundreaction AFO • Orthotic management: long-term use of a ground reaction AFO until the integrity of the plantar flexion- knee extension couple is clearly re- established.
- 45. PHYSIOTHERAPY MANAGEMENT • Strengtheningof weak muscles : gluteus maximus mainly • Strengthening the lower extremity muscle extensors can improve the excessive hip flexion, hip internal rotation, and knee flexion for an overall improvement ambulation, function, and quality of life.
- 46. FUNCTIONAL GAIT TRAINING •Walking on different surfaces • Side walking • Backward walking With orthosis off course Robotic Gait Training
- 47. SCISSORING GAIT • Ascissoring gait is most common in individuals with spastic Diplegic cerebral palsy. • There are a variety of abnormal gait patterns that can result from spastic cerebral palsy, but a scissoring gait is the most prevalent.
- 48. SCISSORING GAIT • Itis an abnormal walking pattern characterized by the thighs and knees pressed together or crossing each other. • This is caused by overactive contractions of the hip adductors. • Along with hip adductions, the feet will be pointed inwards due to internal hip rotation, and knees will be bent.
- 49. • This cancause the upper body to move quite a bit while the individual is walking and make it difficult to stay balanced. • Individuals with cerebral palsy and scissoring gait typically walk slowly with limited mobility. SCISSORING GAIT
- 50. COMPLICATIONS IF LEFTUNTREATED: • develop deformities due to uneven muscle pull • experience frequent falling due to poor balance • have limited independence and mobility due to poor range of motion • eventually, be unable to walk
- 51. MANAGEMENT • Fixing ascissoring gait pattern is two-fold: 1. Spasticity Management. 2. Physiotherapy.
- 52. SPASTICITY MANAGEMENT • Musclerelaxants like Baclofen: Help reduce muscle hyperactivity for temporary spasticity relief. • Botox Injections: Blocks nerve signals that cause muscles to contract. • Orthotics: Wearing an orthosis can help counteract spastic muscles from tightening even more.
- 53. SPASTICITY MANAGEMENT • Surgery:For a scissoring gait, an adductor lengthening surgery may be recommended. This involves lengthening the inner thigh muscles and weakening obturator nerve activity. • Another surgery that is commonly performed to reduce spasticity is a selective dorsal rhizotomy. • This involves cutting overactive sensory nerve fibers.
- 54. PHYSIOTHERAPY • Stretching tightmuscles : Hip Adductors • Strengthening underused muscles: Hip Abductors • Activating neuroplasticity by continuously practicing walking with correct form : Gait & Balance Training
- 55. GAIT & BALANCETRAINING • Gait reeducation • Balance & coordination exercises • Hydrotherapy • Mobility Rehabilitation
- 56. JUMP GAIT • Thejump gait pattern is very commonly seen in children with diplegia. • The ankle is in equinus, the knee and hip are in flexion, there is an anterior pelvic tilt and an increased lumbar lordosis. Also hip adduction and internal rotation.
- 57. JUMP KNEE • Itis characterized by gastroc-soleus spasticity or contracture • Impaired ankle dorsiflexion in swing • Flexed stiff knee gait as a result of hamstring/quadriceps co contraction. • There is often a stiff knee because of rectus femoris activity in the swing phase of gait.
- 58. MANAGEMENT • Single eventmulti level surgery : • Mainly muscle tendon lengthening for gastroc-soleus contracture • Orthosis: Hinged Dynamic AFO • Physiotherapy
- 59. PHYSIOTHERAPY • Stretching tightmuscles : Mainly Gastroc-soleus • Strengthening underused muscles: Anterior tibial group of muscles • Activating neuroplasticity by continuously practicing walking with correct form : Gait & Balance Training
- 60. GAIT & BALANCETRAINING • Gait reeducation • Balance & coordination exercises • Hydrotherapy • Mobility Rehabilitation
- 61. PARKINSONIAN GAIT • Itis characterized by small shuffling steps and a general slowness of movement (hypokinesia), or even the total loss of movement (akinesia) in the extreme cases. • Freezing can occur.
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- 63. PARKINSONIAN GAIT • Theirsteps become shorter. It is more common in someone suffering with later stages of Parkinson’s disease. • They may have problems stopping, starting and turning around during walking. • They may appear to be falling forward or in a forward flexed posture.
- 64. FESTINATING GAIT • Itis one in which the patient involuntarily moves with short, accelerating steps, often on tiptoe, with the trunk flexed forward and the legs flexed stiffly at the hips and knees. It is seen in Parkinson's disease and other neurologic conditions that affect the basal ganglia. • Also called festination.
- 65. SHUFFLING V/S FESTINATING •Steps may also be shorter in stride in a shuffling gait. The shuffling gait is also seen with the reduced arm movement during walking. • Festinating gait or festination – A quickening and shortening of normal strides characterize festinating gait.
- 66. MANAGEMENT • Medication :Levodopa (L- dopa), Carbidopa • Deep brain stimulation (DBS) • Physiotherapy : exercises & walking strategies
- 67. PHYSIOTHERAPY • Improving flexibilityand range of motion: improves balance & gait, as well as reduces rigidity. • Sit in a chair twist to your right and left. • Get on all fours and turn your upper body to the right and left. Lift your arm on the side you’re turning to as you turn.
- 68. PHYSIOTHERAPY: STRENGTH TRAINING •Leg exercises: Q drills. • Mini Squats with support in front. • Stationary exercise bike. • Repeatedly sit in and rise out of a chair. • Kitchen sink exercises.
- 70. PHYSIOTHERAPY Metronome or musiccues • Walking to the beat of a metronome or music may reduce shuffling, improve walking speed, and reduce freezing of gait. Try it for half an hour at a time, a few times a week.
- 71. WALKING VISUALIZATION • Askpatient that before you start walking, visualize yourself taking long strides and “rehearse” walking in your head. This can help you focus your attention on walking. It also activates parts of your brain besides the basal ganglia, which some studies show can help you compensate for low levels of dopamine.
- 72. TAI CHI • Thisset of exercises helps align posture and increase stability and coordination.
- 73. MYOPATHIC GAIT • Myopathicgait (or waddling gait) is a type of gait abnormality in which the affected person walks like a duck. The "waddling" is due to the weakness of the proximal muscles of the bilateral pelvic girdle. • Also known as Trendelenburg Gait because of presence of Trendelenburg sign. • Weakness: Hip Abductors Bilateral weakness Waddling gait.
- 74. ROLE OF HIPABDUCTORS IN WADDLING GAIT • The gluteus medius originates on the ilium (between ant. and post. gluteal lines), eventually terminating on the lateral surface of the greater trochanter. • Its contraction pulls the two insertion sites toward one another, thus elevating the opposite side of the pelvis. • Its weakness causes contralateral sagging of the pelvis (Trendelenburg Sign)
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- 76. • During stancephase: weakness of proximal muscles of hip girdles, will interferes with the stability of the pelvis during walking. • During swing phase: failure to stabilize pelvis, it will produces exaggerated rotation of the pelvis with each steps. • Hip are slightly flexed as a result of weakness of hip extension and there is an exaggerated lumbar lordosis. GAIT CHANGES…
- 77. NOTE… • One importantthing to notice is lateral trunk shifting on affected stance leg to align COG and maintain balance when affected side is in weight bearing during gait. • This is a compensatory strategy to maintain balance during waddling gait Affected side in stance/ weight bearing. Trunk shifts on this side.
- 78. CAUSES • Muscular dystrophiese.g. Duchenne’s muscular dystrophy • GB syndrome • Spinal muscular atrophy • Superior gluteal nerve injury • L5 radiculopathy • OA of hip • Avulsion of gluteus medius tendon following hip surgery
- 79. MANAGEMENT • Strengthening programs •Functional balance exercise • Gait training
- 80. STRENGTHENING PROGRAMS • Primarilytarget the muscles that are responsible for gait, weakness of muscles can lead to variety of abnormality. • The muscle to be strength while walking is gluteus maximus and hamstring for hip extension, quadriceps for knee extension, soleus & gastrocnemius for ankle plantarflexion and dorsiflexion to step forward. • Progressive resisted exercise using weight cuff, Thera band, resistance tube
- 81. STRENGTHENING PROGRAMS • Sidelying – Hip abduction
- 82. STRENGTHENING PROGRAMS • Clamshell without& with Thera band
- 83. STRENGTHENING PROGRAMS • Isometricsingle leg wall lean
- 84. STRENGTHENING PROGRAMS • ResistedAbduction with Thera band
- 85. FUNCTIONAL BALANCE EXERCISE Static exercises: • Sit to stand • Tandem standing with or without support • Stand with eye open and close Dynamic exercises: • Straight walking • Tandem walking • Side walking
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- 87. GAIT TRAINING • Parallelbar walking by placing a mirror in front of the patient this will provide a feedback to the patient to correct the postures. • During walk promote heel strike at initial contact with the floor • Prevent hip dropping and stabilize the pelvis
- 88. ATAXIC GAIT • Ataxia: Ataxia is typically defined as the presence of abnormal, uncoordinated movements. • This describes signs & symptoms without reference to specific diseases.
- 89. ATAXIC GAIT • Itis described as clumsy gait with , staggering movements with wide base of support. • Patient is not able to walk from heel to toe or in single line • Uncoordinated gait appears to be not ordered. • Also known as drunken gait.
- 90. CAUSES •Head injury. •Cerebral palsy. •Autoimmunediseases. •Infections. •Vitamin E, vitamin B-12 or thiamine deficiency. •Thyroid problems. •Abnormalities in the brain: An infected area (abscess) •Toxic reaction: Potential side effect of certain medications, especially barbiturates, Alcohol and drug intoxication.
- 91. MANAGEMENT Intensive physical therapy: •Strength training • Balance training • Gait training
- 92. STRENGTH TRAINING • Wholebody functional strength training in form of treadmill training and stationary cycling.
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- 94. FUNCTIONAL BALANCE EXERCISES Reachouts: 1. Quadruped weight shifting 2. Siting on Physio ball & lateral weight shifts 3. Standing lateral weight shifts 4. Standing anterior posterior weight shifts Tandem standing with/without support Dynamic exercises:
- 95. BALANCE TRAINING Balance-Based TorsoWeighting (BBTW) : • Small weights were applied to the torso on a specially constructed vest like garment that allowed Velcro application of weights to the front, back, or sides of the torso between the shoulders and waist to maintain the balance of the upright posture.
- 96. GAIT TRAINING • Hurdlewalking • Walking on commands of start & stop • Straight walking • Tandem walking • Side walking