Gait and Therapeutic Exercise

1. Gait and Therapeutic Exercise

2. Gait Cycle • The gait cycle can be described in the phase terms of initial contact, loading response, midstance, terminal stance, preswing, initial swing, midswing and terminal swing. • The stance period consists of the first five phases: initial contact, loading response, midstance, terminal stance and preswing. • The swing period primarily is divided into three phases: initial swing, midswing and terminal swing. • Preswing, however, prepares the limb for swing advancement and in that sense could be considered a component of swing phase.

3. Initial Contact • Initial contact is an instantaneous point in time only and occurs the instant the foot of the leading lower limb touches the ground. Most of the motor function that occurs during initial contact is in preparation for the loading response phase that will follow. • Initial contact represents the beginning of the stance phase. • Heel strike and heel contact serve as poor descriptors of this period since there are many circumstances when initial contact is not made with the heel alone. • The term "foot strike" sometimes is used as an alternative descriptor.

4. Loading Response • The loading response phase occupies about 10 percent of the gait cycle and constitutes the period of initial double-limb support. • During loading response, the foot comes in full contact with the floor, and body weight is fully transferred onto the stance limb. • The initial double-support stance period occasionally is referred to as initial stance. • The term foot flat is the point in time when the foot becomes plantar grade. • The loading response period probably is best described by the typical quantified values of the vertical force curve. • The ascending initial peak of the vertical force graph reveals the period of loading response.

5. Midstance • Midstance represents the first half of single support, which occurs from the 10- to 30-percent periods of the gait cycle. • It begins when the contralateral foot leaves the ground and continues as the body weight travels along the length of the foot until it is aligned over the forefoot. • The descending initial peak of the vertical force graph reveals the period of midstance.

6. Terminal Stance • Terminal stance constitutes the second half of single-limb support. It begins with heel rise and ends when the contralateral foot contacts the ground. • Terminal stance occurs from the 30- to 50- percent periods of the gait cycle. • During this phase, body weight moves ahead of the forefoot. • The term heel off is a descriptor useful in observational analysis and is the point during the stance phase when the heel leaves the ground. • The ascending second peak of the vertical force graph demonstrates the period of terminal stance. • Roll off describes the period of late stance (from the 40- to 50- percent periods of the gait cycle) when there is an ankle plantarflexor moment and simultaneous power generation of the triceps to initiate advancement of the tibia over the fulcrum of the metatarsal heads in preparation for the next phase.

7. Preswing • Preswing is the terminal double-limb support period and occupies the last 12 percent of stance phase, from 50 percent to 62 percent. • It begins when the contralateral foot contacts the ground and ends with ipsilateral toe off. • During this period, the stance limb is unloaded and body weight is transferred onto the contralateral limb. • The descending portion of the second peak of the vertical force graph demonstrates the period of preswing.

8. Terminal Contact • Terminal contact is a term rarely used, describes the instantaneous point in the gait cycle when the foot leaves the ground. • It thus represents either the end of the stance phase or the beginning of swing phase. • In pathologies where the foot never leaves the ground, the term foot drag is used. In foot drag, the termination of stance and the onset of swing may be somewhat arbitrary. • The termination of stance and the onset of swing is defined as the point where all portions of the foot have achieved motion relative to the floor. • Likewise, the termination of swing and the onset of stance may be defined as the point when the foot ends motion relative to the floor. Toe off occurs when terminal contact is made with the toe.

9. Initial Swing • The initial one-third of the swing period, from the 62- to 75-percent periods of the gait cycle, is spent in initial swing. • It begins the moment the foot leaves the ground and continues until maximum knee flexion occurs, when the swinging extremity is directly under the body and directly opposite the stance limb.

10. Midswing • Midswing occurs in the second third of the swing period, from the 75- to 85-percent periods of the gait cycle. • Critical events include continued limb advancement and foot clearance. • This phase begins following maximum knee flexion and ends when the tibia is in a vertical position. • In the final phase of terminal swing from the 85- to 100-percent periods of the gait cycle, the tibia passes beyond perpendicular, and the knee fully extends in preparation for heel contact.

11. Gait MM and ROM

12. Principles of Ambulating with Patients • Be prepared to “catch” any patient with gait and always use a gait belt for safety. • Be aware of all lines and tubing with gait. Moreover, if the patient has a feeding or PEG tube, place the gait belt above the stomach level to avoid disturbing the PEG site in case of balance correction with the gait belt as needed. This should also be done with surgical incisions as well. • Stand slightly behind and to the weak side of the patient with gait to increase safety. • Determine if the patient has any special weight bearing precautions prior to ambulation. An assistive device may be necessary if the MD has determined weight bearing status were off-loading an extremity is necessary.

13. Principles of Ambulating with Patients • Get assistance if the patient has multiple lines, IV pole, and other equipment attached to them. It is difficult to push an IV pole down the hall and safely guard a patient against falls. • Remember to use a gait belt, if you think the patient has a risk of falls. Falls in the elderly can be especially dangerous. Osteoporosis can limit bone integrity during falls. • If a patient falls on your shift, a x-ray may need to be performed to rule out fracture and injury and document incident report. • If the patient has a catheter, keep the catheter below the level of the bladder during gait. Never attach the catheter to your person with gait or transfers, because sudden movements may cause extreme pain for the patient. In addition, kinks in the catheter line may cause autonomic dysreflexia, which is a medial emergency. Never let catheter lines touch the ground. It is a violation of health standards.

14. Gait Patterns NWB TTWB PWB WBAT FWB

15. Gait Sequence Two point Three point Four point Swing to Swing through

16. Gait Deviations in Stance Phase Trunk and Hip Joint Knee Ankle and Foot Joint

17. Gait Deviations is Swing Phase Trunk and Hip Joint Knee Ankle and Foot Joint

18. Exercises principles • 1. Give verbal cues or directions during exercise. • 2. Recognize substitution with abnormal movement. • 3. Modify the parameters to fit the activity. • 4. Specify your goals from the exercise. • 5. Start at the level determined by the evaluation. • 6. Base your activities based on evaluation. • 7. Demonstrate the exercise you want to perform. • 8. Position the patient in a safe position. • 9. Determine the end feel of the joint.

19. Strength Training MM size increases with resistive training in 6-8 weeks If ROM and strength needs to be target do a combo of strength and PNF training (pain free) Heavy Loads=Low Reps Beware of DOMS Rest period: 24 hrs

20. Types of Strengthening Isometric Isotonic Isokenetic Eccentric Open vs. Closed chain

21. Endurance Training High Rep=Low Load Mechanic Practice Time Aerobic Training

22. Flexibility Training Manual vs. Ballistic Stretching Prolonged mechanical Stretching

23. Stability Training Static vs. Dynamic