GAIT TRAINING

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GAIT TRAINING
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• Definitions of normal gait
• "A method of locomotion involving the use of the
  two legs, alternately, to provide both support
  and propulsion. In order to exclude running, we
  must add 'at least one foot being in contact with
  the floor at all times'

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• In order that a person can walk, the locomotion
  system must be able to accomplish four things
• 1-Each leg must be able to support the body
  weight without collapsing.
• 2-Balance must be maintained statically and
  dynamically during single leg stance.
• 3-The swinging leg must be able to advance to a
  position where it can take over the supporting
  role.
• 4- Sufficient power must be provided to make the
  necessary limb movements and to advance the
  trunk.

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• In normal walking each of these requirements
  achieved without any difficulty.
• However, in many pathological conditions these
  requirements can be achieved by means of abnormal
  gait or by the use of walking aids such as
  walker, crutches, cane or orthotic devices.
  Failure to achieve all four requirements means
  that the subject is unable to walk.
• The pattern of gait is the outcome of a complex
  interaction between the many neuromuscular and
  structural elements of the locomotion system.
  Abnormal gait may result from a disorder in any
  part of this system. It may also result from the
  presence of pain.

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• CUASES OF GAIT ABNORMALITY
• A-The movement being forced by weakness,
  spasticity or deformity.
• B-The movement is a compensation, which the
  subject is using to correct for some other
  problem.

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• SPECIFIC GAIT ABNORMALITY
• 1- Lateral trunk bending bending of the trunk
  toward the supporting limb during the stance
  phase Trendelenburg gait. During the double
  support phase the trunk is usually upright but as
  soon as the swing leg leaves the ground, the
  trunk leans across towards the side of the stance
  phase leg, returning to the upright attitude
  again at the beginning of the next double support
  phase.
• In case of bilateral hip problem, the trunk
  swaying from side to side, to produce a gait
  pattern called waddling.

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• Standing on one-leg leads to increase the load on
  the stance hip because of three components
• 1-The whole of the weight of the trunk is now
  supported by the stance hip joint, instead of
  being shared between the two hips.
• 2-The stance hip now takes the weight of the
  swing leg, instead of by the ground.
• 3-The gluteus medius of the stance leg contract
  to keep the pelvis from dipping on the
  unsupported side, the reaction force of this
  contraction passes through the stance hip joint.

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• Causes of trendelenburg gait
• Painful hip (osteoarthritis, rheumatoid
  arthritis)
• Hip abductor weakness
• Abnormal hip joint congenital dislocation of the
  hip, coxa vara and Slipped femoral epiphysis
• Wide walking base
• Unequal leg length

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• 2-Anterior trunk bending the subject fiexes his
  trunk forward at the time of heel contact. The
  purpose of this gait pattern is to compensate for
  an inadequacy of the knee extensors .
• 3- Posterior trunk bending around the hell
  contact the subject moves the whole trunk
  backward in the sagittal plane. The purpose of
  this gait pattern is tocompensate for
  ineffective hip extensor early in the stance
  phase.
• A different type of posterior trunk bending may
  occur early in the swing phase, where the subject
  may throw the trunk backward in order to propel
  the swinging leg forward. This is most often to
  compensate for weakness of the hip flexors or
  spasticity of the hip extensors. Posterior trunk
  bending may also occur when the hip is ankylosed.

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• 4-Increased lumbar lordosis The most common
  cause of increased lumbar Lordosis is a flexion
  contracture of the hip. This deformity cause the
  stride length to be very short by preventing the
  femur from moving backward from its flexed
  position
• 5-Functional leg length discrepancy means that
  the legs are not necessarily different lengths
  when measured on the examination table, but that
  one or both are unable to adjust to the
  appropriate length for a particular phase of the
  gait cycle. Four gait abnormalities
  circumduction, hip hiking, steppage and
  vaulting are closely related, in that they are
  designed to overcome the same problem. This gait
  abnormality is frequently the result of a
  neurological problem

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• Circumduction by which the ground contact by the
  swinging leg can be avoided if it is swing
  outward.
• Hip hiking the pelvis is lifted on the side of
  the swinging leg by contraction of the spinal
  muscles and the lateral abdominal wall
• Steppage it consisting of exaggerated knee and
  hip flexion to lift the foot higher than usual
  for increased ground clearance. It is usually
  used to compensate for foot drop.
• Vaulting the ground clearance for the swinging
  leg will be increased if the subject goes up on
  the toes of the stance phase leg .

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• 6-Abnormal hip rotation the gait pattern may
  involve both stance and swing phase, and it may
  result from
• A problem with the muscles producing hip rotation
• A fault in the way the foot makes contact with
  the ground
• As a compensatory movement to overcome some other
  problem as foot inversion or eversion, quadriceps
  weakness and/or hip flexor weakness.

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• 7-Excessive knee extension the normal stance
  phase flexion of the knee is lost, to be replaced
  by full extension or even hyperextension, in
  which the knee is angulated backwards. The cause
  of this gait pattern is quadriceps weakness
• 8-Excessive knee flexion the knee is normally
  fully extended twice during the gait cycle, one
  or both of these movements into extension fails
  to occur. This gait pattern can be caused by
•  
• A flexion contracture of the knee flexors
• Spasticity of knee flexors
• Functional leg length discrepancy
• Stiffness of the ankle joint

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• 9-Inadequate dorsiflexion control It gives rise
  to two distinct gait abnormalities
• Between heel contact and foot flat, the
  dorsiflexors resist the external planterflexion
  moment, thus permitting the foot to be lowered
  gently. If they are weak, the foot is lowered
  abruptly in a foot slap.
• Failure to raise the foot sufficiently during
  early swing phase may cause toe drag. If it is
  bilateral subject may avoid toe drag by high
  steppage gait

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• 10-Abnormal foot contact the foot may be
  abnormally loaded in that the weightis primarily
  borne on only one of its four quadrants.
• Talipes calcaneus pes calcaneus loading of the
  heel occur in this deformity.
• Talipes equinus pes equinus in this deformity
  the forefoot is fixed in plantarflexion, usually
  through spasticity of the plantarflexors. In mild
  cases the foot may placed flat on the floor. But
  more commonly the foot' never touch the floor
  (Primary toe strike gait) ,talipas equinuverus .
• Excessive medial contact occur in weakness of
  invertors or spasticity of evertors.
• Excessive lateral contact occur in Talipes
  equinuvarus in which the medial border of the
  foot is elevated or the lateral border depressed
  by spasticity or by weakness.
• Stamping gait occur in loss of the sensation in
  the foot.

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• 11-Insufficient pushes off the weight is taken
  primarily on the heel, and there is no push off
  phase, the whole foot being lifted off the ground
  at once. The main cause of this pattern is a
  problem with the triceps surae, Achilles tendon
  or intrinsic muscles of the foot. It may also
  result from any foot deformity or pain under the
  forefoot.
• 12-Abnormal walking base either increase or
  decrease in the walking base beyond the normal
  range.
•  An increased walking base may be due to
  deformity (abducted hip, valgus knee),
  instability or fear of falling
• A decreased walking base may result from
  adduction hip or varus knee deformities.

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GAIT ANALYSIS

• 1-Visual gait analysis
• The subject needs to walk minimum of 8 m with
  different speed for the visual gait analysis. It
  is the most simplest gait analysis, but it
  suffers from four serious limitations.
• It is transitory, gives no permanent record
• The eye cannot observe high-speed events
• It is only possible to observe movements, not
  forces
• It depends entirely on the skill of the
  individual observer.

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• Common gait abnormalities and best viewpoint
  for observation
• Side view From the side view you can see the
  following abnormalities,lateral trunk bending,
  anterior trunk bending, posterior trunk bending,
  increased lumbar lordosis, steppage, excessive
  knee flexion, excessive knee extension,
  inadequate dorsiflexion control, insufficient
  push off, rhythmic disturbances and vaulting.
• Front and behind view From the Front and behind
  views you can seethe following abnormalities,
  circumduction, hip hiking, vaulting, abnormal hip
  rotation, abnormal foot contact and abnormal
  walking base.

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• 2-Videotape examination It helps to overcome two
  of the limitation of visual gait analysis- the
  lack of a permanent record and the difficulty of
  observing highspeed events. In addition, it
  confers the following advantage
• It reduce the number of walk the subject needs to
  do
• It makes it possible to show subjects exactly how
  they are walking
• It makes it easier to teach visual gait analysis
  to someone else

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• General gait parameters
• Cadence
• Cadence may be measured with the aid of a
  stopwatch, by counting the number of individual
  steps taken during a known period of time. It is
  seldom practical to count for a full minute, so a
  period of 10 or 15 seconds is usually chosen.
• Stride length
• Stride length can be determined in two-ways- by
  direct measurement, or indirectly from the
  velocity and cadence. The simplest direct method
  of measurement is to count the stride taken while
  the subject covers a known distance. A more
  useful method is where the subject steps with
  both feet in a shallow tray of talcum powder, and
  then walks across a polished floor, leaving a
  trial of foot prints.

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• . As an alternative to using talcum powder,
  felt adhesive pads, soaked in different colored
  dyes my be fixed to the feet. The subject walks
  along a stripe of paper and leaves a pattern of
  dots which gives accurate indication of the
  location of both feet.

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• These may be measured, to derive left and right
  step lengths, stride length, walking base,
  toe-out angle, and some idea of foot contact
  pattern. This investigation is able to provide a
  grate deal of useful information for the sake of
  a few minutes of mopping up the floor after ward
• Velocity
• The velocity my be measured by the subject
  while he or she walks a known distance, for
  example between two marks on the floor, or
  between two pillars in a corridor. The distance
  walked is a mater of convenience, but somewhere
  in the region of 6x10 m is probably adequate.
  Again the subject should be to walk at their
  natural speed, and they should be allowed to get
  into their stride before the measurement starts.

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• 3-Footswitches
• Footswitches are used to record the timing of
  gait.
• 4-Instrumented walkway
• 5-Electrogoniometer
• 6-Electromyography

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WALKING AIDS

• Walking aids can modify the gait pattern
  considerably. While some people using the walking
  aids to reduce the pain in a painful joint, some
  others are totally unable to walk without some
  form of aid. It is very important to put in our
  consideration under water gait training and gait
  training in the parallel bars.
• 1-Canes by means of which force can be
  transmitted to the ground through the wrist and
  hand. Canes can be used for three purposes

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• A-To improve stability, this is achieved by
  increasing the size of the area of support. If
  more stability is required two canes my be used.
• B-To generate a moment, if the cane used on the
  opposed side of the affected leg, a vertical
  force is applied through the cane, which generate
  a counterclokwise moment applied to the shoulder
  girdle and hence to the pelvis. This reduces the
  size of the moment, which the hip abductor
  muscles generated to keep the pelvis level.
• C-To take part of the load away from the legs, If
  the cane used in the same side of the affected
  leg, and placed closed to the foot. In this way,
  load-sharing can be achieved between the leg and
  the cane.

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• Types of canes
• Straight cane
• Tripod cane
• Tetrapod cane
• (L) shaped handle
• (U) shaped handle
• Angular shaped handle Adjustable in high

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• 2-Crutches
• The main different between cane and crutches is
  that a crutch is able to transmit significant
  forces in the horizontal plane.
• Types of crutch
• Axillary crutches they fit under the axilia,
  it can be used with some modification or addition
  like a platform which help to transfer the point
  of pressure.
• Forearm crutches (elbow crutches)

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• 4-Walking frames and rollators (walkers)
• The most stable walking aid, which enable the
  subject to walk within the area of support
  provided by its base.
• Types of walkers
• Regular walker
• Rolling walker

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• GAIT PATTERN WITH WALKING AIDS
• 1-Gait with a single aid if only a single cane
  or crutch is used. The aids moved forwards
  together with the worse of the two legs during
  the stance phase of the better one.
• 2-Three-point swing-through gait it is used when
  it is impossible to support the body weight on
  one leg. Three-point gait involves support of the
  body weight by the two crutches while the leg or
  legs are moving forwards, and by the legs while
  the crutches are moved.

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• 3-Three-point swing-to gait this gait pattern is
  similar to three-point swing-through gait, except
  that feet are advanced by a much shorter
  distance, being placed on the ground behind the
  level of the crutches.
• 4- Four-point gait It is only appropriate when
  both legs are able to support partof the body
  weight. Subject who have only minor stability
  problems my use two canes, each of which is moved
  forwards during the swing phase of the opposite
  leg, during which time the body has only two
  points of contact with the ground.

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• Planing of gait training
• 1- Safety measures
• A-Gait belt B- Dry surface
  C-Slippers or shoes
• D-Therapist to be on the affected side in cane
  walking and behind the
• subject with walker training.
• E-Turning around always towards the good leg
• 2- Point to start with It depends on the level
  of static and dynamic balance,according to the
  therapist's evaluation, gait training starts from
  the easier to the hardest way of walking as the
  following graduation
• A-Under water gait training b- Walking in
  the parallel bars
• C-Walker
  d- Crutches
• E-Cane
  f- Independent

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• 3- Weight bearing status
• None weight bearing (NWB)
• Toe touch weight bearing (TTWB, TDWB)
• Partial weight bearing (percentage of the body
  weight) (PWB) we need to use weight scale
• Weight bearing as tolerated (WBAT)
• Full weight bearing (FWB)

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•  
• 4-Mental status level of awareness or
  orientation of the subject to understand the
  instruction
• 5-Preparing of the treatment area
• Usage of the mirror in the treatment area
• Draw a line on the floor as a guidance in case of
  dynamic balance or coordination ex
• Decide the distance of walking according to the
  patient's tolerance
• The surface of the training area (level or ramp)

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Amputee gait

• The mechanical coupling between the stump and
  the prosthetic limb cannot be as good as in the
  normal, for these reasons
• The lever arm between the hip joint and the
  socket is relatively small.
• Relative motion between the stump and the socket.
• Uncomfortable socket makes the patient reluctant
  to apply large forces to the prosthetic limb.

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• Walking up and down stairs training
• Go up stairs with good leg first and down stairs
  with the affected leg first.
• Patients using canes, go up stairs with good leg
  first followed by cane then the affected leg and
  vise-versa going down stairs.
• Patients with crutches go up stairs with the
  legs first followed by the crutches, or crutches
  first followed by good leg then the affected leg
  and vise-versa going down stairs.