Gait, Orthotics, transfers, wheelchairs

Gait terminology

• Stance 60% (RLA→ Traditional)

  • Initial contact - heel strike

  • Loading response - foot flat

  • Mid stance

  • Terminal stance - heel off

  • Pre-swing - toe off

• Swing 40% (RLA → Traditional)

  • Initial swing - acceleration

  • Mid swing

  • Terminal swing - Deceleration

Phase of Gait

• Initial contact → loading response → midstance → terminal stance → pre swing

• Initial swing → mid swing → terminal swing

Kinematic data and norms of joint angles

• Sagittal plane- flexion/ extension

• Frontal plane- abduction/ adduction

ROM at hip needed for normal gait

• Stance phase: 0-30 degrees flexion and 0-20 degrees hyperextension

• Swing phase: 20-30 flexion

ROM at knee needed for normal gait

• Stance phase: 0-40 flexion

• Swing phase: 0-60 flexion

ROM at ankle needed for normal gait

• Stance phase: 0-10 DF, 0-20 PF

• Swing phase: 0-20 DF

Muscle activity in the gait cycle- pretibial muscles

• anterior tib, EDL, EHL

• prior to and during heel strike

  • Eccentric contraction: lowers foot to the ground

• Prior to and during swing

  • Concentric contraction: dorsiflexion, clear toes off ground

Muscle activity in the gait cycle- Calf muscles

• Gastrocnemius, soleus (FDL, FHL, post. tib)

• Mid stance

  • Eccentric contraction: control of tibia over the foot

• Heel off

  • concentric contraction: ankle plantar flexion

Muscle activity in the gait cycle- quadriceps

• Vastus medialis/ lateralis/ intermedius, rectus femoris

• Heel strike

  • quads contract eccentrically: control rapid knee flexion and to prevent buckling

• Pre-swing

  • Eccentric contraction: slow down leg (tibia)

Muscle activity in the gait cycle- Hamstrings

• Biceps, semitendinosus, semimembranosus

• Before heel strike

  • Eccentric contraction: protects knee from hyperextension

• Swing phase

  • concentric contraction: knee flexion

Hip Abductors

• Gluteus medius, Gluteus minimus, TFL

• Stance phase

  • Eccentric contraction: stabilize pelvis

Hip adductors

• Adductor longus/ brevis, gracilis, adductor magnus (horizontal and vertical heads)

• Early and late stance

  • concentric contraction: stabilize pelvis

Tightness v. weakness

• Tightness

  • Contracture will decrease the range of motion in the opposite direction

  • Hip flexion contracture will lead to decreased hip extension on the same side and decrease in step on opposite side

    • FLOP: flexors tight, opposite side

• Weakness

  • will cause a decrease in the range of motion of the same motion

  • weakness of hip flexors will lead to a decreased hip flexion on the same side and decrease in step length on the same side

Magnet rule

• Weak muscles attract the trunk toward them in the same plane in STANCE

  • trunk follows muscle weakness, moves COM towards weak muscle to decrease work of the muscle

• Swing- opposite → Run away

Causes of backwards lean

• Weak hip extensors (stance)

• Hip flexion rigid contracture (stace)

• Glute max weakness

Excessive knee extension causes

• Quadriceps weakness

• excessive ankle plantarflexion (spasticity)

  • both lead to anterior pelvic tilt

Excessive Plantar Flexion

• Causes loss of progression: leads to shortened stride length and reduced velocity

• Low heel contact at initial contact and forefoot contact

  • 3 substitutions from this

    • premature heel off

    • knee hyperextension

    • forward trunk lean

Ankle/ foot deviations

• Excessive inversion (IPAD)

• Excessive Eversion (EDAB)

• Premature/ early heel off → tight PF

• Delayed heel contact → weak DF

• Toe Drag → weak DF/ tight PF

• Foot slap → weak DF

COM after amputation

• Lose LE, COM moves higher and to area with more mass

  • R LLE amp → COM moves up and to the left

• Lose UE, COM moves lower and to area with more mass

  • R UE amp → COM moves lower and to the left

• If amp. is unilateral- always on opp side of amp

• if bilateral w/ equal mass- COM is in the middle and higher up

AKA prosthesis- giat deviations

• Low wall

  • similar to weak muscles → lean towards low wall in stance

    • Low anterior thigh wall = weak quadriceps

    • Low lateral wall = weak abductors

• High walls

  • similar to tight muscles

    • high anterior thigh wall = tight hip flexors → pulls pelvis into anterior pelvic tilt

Gait deviations- AKA stance phase

• ALL IN STANCE

• Lateral bend- short prosthesis, inadequate lateral wall

• Abduction- long prothesis, hip joint fixed in abduction

• Lordosis- anterior socket wall discomfort (wall too high)

• Forward flexion- unstable knee, short walker

Gait deviations- AKA, mostly swing

• Early swing → High heel rise → slack extension aid

  • go into knee flexion too early

• Late swing → terminal impact → taught extension aid

  • go into knee extension too early

• Stance/ Heel off → Heel whip → knee bolt rotated; prothesis donned in malrotation

  • LIME Whip - Lat./ IR, Med./ER

• Heel contact → foot rotation → stiff heel cushion, malrotated foot

Hard and soft bumpers (Stops)

• If PF of the foot is restricted by stiff heel cushion or hard PF bumper (same thing as stop)

  • The amputee’s knee may have to flex through more than the normal range to allow the sole of the foot to reach the floor

  • Bumper will not absorb the impact of the heel striking the floor, thus tending to produce abrupt and excessive knee flexion

• Too soft heel cushion or soft PF bumper allows excessive compressibility of heel cushion

  • The ground reaction force passes anterior to the knee between heel strike and midstance

  • causes hyperextension of the knee joint

Orthotic gait cont’

• Anatomic cause

  • weak DF or spastic PF

• Orthotic cause

  • inadequate dorsiflexion assist/ inadequate plantarflexion stop

• Inadequate assist is similar to weak muscles

• Inadequate stop is similar to spastic muscles

• Gait deviations caused

  • Toe drag

  • circumduction

  • hip hiking

  • vaulting

Inspection of residual limb/ pressure sensitive/ tolerant areas

• Pressure-tolerant areas are expected to have redness following doffing of prosthesis

• Pressure- sensitive areas should have no redness after prosthesis use

• Pressure-sensitive areas

  • Anterior tibia

  • Anterior tibial crest

  • Fibular head and neck

  • Fibular nerve

• pressure-tolerant areas

  • Patellar tendon

  • medial tibial plateau

  • tibial and fibular shafts

  • distal end

Prosthetic-related- Vaulting, pelvic hike, circumduction in swing phase

• Prosthesis is too long

• locked knee unit

• Insufficient suspension

• Insufficient friction

• socket too small

• socket too loose

• Plantar flexed foot

Prosthetic-related- abducted prosthesis in stance phase

• High medial wall to prevent pinching

• inadequately adducted lateral wall

• prosthesis is too long

• hip joint abducted

Prosthetic-related- Lateral trunk bending in stance

• prothesis is too short

• Lateral wall is inadequate

• High medial wall

Prosthetic-related- Forward flexion during stance phase

• Unstable knee unit

• short walker or crutches

Prosthetic-related- excessive lordosis in stance

• inadequate socket flexion

Prosthetic-related- High heel rise during early swing phase (preswing)

• insufficient friction

• slack extension aid (excessive knee motion)

Prosthetic-related- Terminal swing impact

• Taught extension aid

• Insufficient friction

Prosthetic-related- Excessive foot rotation at heel contact

• stiff heel cushion

• malrotated foot

Prosthetic-related- medial/ lateral whips

• poorly fitting socket

• Medial: Knee bolt in ER

• Lateral: Knee bolt in IR

• Foot malrotated

• Prosthesis donned in malrotation

Prosthetic-related- Asymmetrical step lengths

• Decrease stance time

• Poor alignment of the prosthesis

• Uncomfortable socket

• Inadequately flexed socket

Bilateral ADs

• Four point: AD, opposite LE, AD, opposite LE (separate, then, then, then)

• Two point: AD and opposite LE, AD and opposite LE (twogether)

Single AD

• Modified four-point: AD, opposite LE, followed by other LE

• Modified two-point: AD and opposite LE, followed by other LE

Bilateral ADs or walker

• Three-point: NWB- AD (and NWBing LE swing), WBing LE

• Three-one point: PWBing, ADs, and PWBing LE, WBing LE

Crutches and canes

• Standard crutches (axillary crutches)

  • Axilla space of aprox. 2”

• Forarm crutches (loftstrand)

  • Top of forearm cuff is just distal to elbow, aprox 1-1.5” below olecranon process

• Cane

  • Always held on the unaffected side -advance w/ affected

  • Ascending = good foot goes up first followed by bad foot and cane

  • Descending = bad foot and cane fist followed by good foot

• Handpiece height

  • Measure with tip of AD on the ground 2 inches lateral and 4-6 inches anterior to the toe of the shoe

  • Always with 20-25 degrees elbow flexion, hand piece at level of wrist crease, ulnar styloid process or greater trochanter

Ascending stairs

• Therapist should be positioned posterolateral (to the patient’s weak side)

• Grasp the gait belt with one hand; be prepared to use your other hand to control the trunk

• Advance your feet up one step after the patient has advanced one step, but maintain your feet in an anteriorposterior position

Descending stairs

• Therapist should be positioned anterolateral (to the patients weak side)

• Grasp the gait belt with one hand

• Do not allow the patient to develop momentum when descending the stairs

Lift and Transfers

• Three-person lift/ carry: used to transfer a patient from a stretcher to a bed or treatment plinth

• Two-person lift: Used to transfer patients of different heights or surfaces of different heights or surfaces or transfering to the floor

• Dependent squat pivot transfer: used to transfer a patient who cannot stand independently but can bear some weight through the trunk and LE

• Hydraulic lift: used for dependent transfers when the patient is obese, there is only one therapist available to assist with the transfer or the patient is totally dependent

W/C seat height

• Heel to popliteal fold (fosa) + 2 in

• Average 19.5-20.5 in

W/C seat depth

• posterior buttock along lateral thigh to popliteal fold - 2 in

• Average: 16 in

W/C seat width

• widest aspect of buttocks or thighs +1.5-2 in

• Average: 18 in

W/C back height

• Chair seat to axilla - 4 in

• consider cushions that add thickness to final value

• Average: 16 in

W/C armrest

• Seat of chair to the olecranon + 1in

• Consider cushioning

• Average: 9 in

W/C axel positioning

• Normal axle positioning- in line with the shoulder or slightly posterior (around S2)

• Bariatric Patients- move the rear wheel axle forward → abdominal adiposity

  • moving the axle anteriorly makes it easier to push

• Bilateral TFA→ move the rear wheel axle behind the patient’s shoulders

W/C propulsion

• Propulsion phase: apply a smooth, continuous push on the rims, extending your arms forward

• Recovery phase: after the push, release the push rims and bring your hands back to the starting position, ready for the next push

W/C propulsion- turns/ wheelie

• Turn: pull one side wheel backward and other side forward

  • Side you are pulling back on is the side that you are turning towards

• Wheelie: patient places hands back on handrims, then push them forward abruptly and forcefully

  • 11-1 o’clock

  • balance on rear wheel

W/C Ascending/ descending curb

• Ascending the curb

  • Lift the front casters onto the curb by performing a small wheelie

  • Push forward on the push rims to lift the rear wheels onto the curb

• Descending curb (2-ways)

  • Performing a wheelie and descending with rear wheels of the curb followed by castor wheels

  • Descending backwards: allow the rear wheels to slowly roll off the curb, followed by the castor wheels

longitudinal arch (scaphoid pad)

• Pes Planus (pronated foot/ flat foot)

UCBL (university of california berkeley lab)

• Controls hindfoot valgus

• Reduces subtalar motion

• three-point counterforces- control calcaneal eversion, forefoot abduction

AFO- Dorsiflexion assist AFO

• DF weakness

• Posterior leaf spring- it recoils during swing phase to produce dorsiflexion

• Klenzak joint- DF spring assist incorporated into stirrup

AFO- Plantar Flexion stop / resistance AFO

• PF tightness

• Plastic hinged AFO with a posterior stop

  • Keeps foot in neutral, good for PF weakness/ spasticity

Posterior leaf spring AFO

• lightweight and streamlined, made from a plastic insert; can be prefabricated or custom-made

• Bends backwards during early stance

• Recoils in swing phase to lift the foot to assist with DF

• Material can be removed to weaken the spring but not added to increase rigidity

• Offers slight plantar flexion at heel contact to prevent knee flexion

• no medial/lateral stability

Dorsiflexion spring assist (Klenzak)

• Incorporates a steel spring in the ankle stirrup, adjustable tightness via a screw on the spring

• Spring compresses in stance and rebounds in swing phase

• Bulkier compared to the posterior leaf spring AFO

• Provides slight plantar flexion at heel contact, similar to the posterior leaf spring AFO

• Avoid with spasticity

Posterior stop AFO

• utilizes metal ankle hinge with a posterior stop

• limits plantar flexion

• prevents toe drag during swing phase and imposes a flexion force at the knee during early stance, preventing the knee from hyperextending

Anterior stop AFO

• utilizes metal ankle hinge with an anterior stop

• Limits dorsiflexion

• Helps the individual with paralysis of the triceps surae (posterior calf muscles) to achieve propulsion during late stance

Solid AFO

• Made of plastic with trimlines anterior to malleoli

• Limits all foot and ankle motion

• Occasionally, this AFO is divided transversely at the ankle with the two sections hinged, creating the hinged AFO. It permits slight sagittal motion facilitating progression to the foot flat position in early stance

Bichannel adjustable ankle locks (BICAALs)

• Has spring and pins

• pins limit movement and springs assist mvmt

• A pin/ peg in anterior channel limits DF and causes PF

• A pin in the posterior channel limits PF and causes DF

Spiral AFO

• Limits all movements

• Contraindicated to use in the presence of moderate to severe spasticity or edema