This document discusses hemiplegic gait following a stroke. It describes common gait deviations seen during different phases of gait including increased knee flexion, equinus foot, circumduction, and decreased weight shifting to the affected side. Physical therapy interventions aim to improve balance, coordination, weight shifting, and muscle strength through techniques like neurophysiological approaches, functional electrical stimulation, robotic devices, motor imagery, and mirror therapy. Outcome measures used to assess improvement include the Functional Ambulation Profile, Dynamic Gait Index, Stroke Impact Scale, and various walking tests.

1. Hemiplegic gait
Moderator : Mr. Sydney Rebello
Presentar : Ashik Dhakal

2. Normal gait

3. Terminologies used in gait
• Step length
• Stride length
• Step width
• Cadence
• Foot angle

4. • Step time
• Stride time
• Swing time
• Double support time

6. Hemiplegia
• Paralysis of one side of the body.

7. Hemiplegic gait

8. Gait deviations commonly seen following stroke
Stance Phase
Trunk/pelvis Unawareness of affected side: poor
proprioception
Forward trunk: Weak hip extension, Flexion
contracture
Hip Poor hip position
Trendelenburg limp: weak abductors
Scissoring: spastic adductors

9. Stance Phase
Knee Increase knee flexion Flexion contracture,
Weak hip and knee extensors
Ankle dorsiflexion range past neutral
Weakness in extension pattern or in
selective motion of hip and knee
extensors and plantarflexors

10. Stance Phase
Knee Decreased knee flexion (or
hyper extension)
Insufficient active tension with knee flexors.
Impaired proprioception: Knee wobbles or
snaps back into recurvatum
Severe spasticity in quadriceps
Weak knee extensors: compensatory locking
of knee in hyperextension

11. Stance Phase
Ankle/foot Equinus gait (heel does not touch the ground: spasticity or
contractures of gastrocnemius soleus
Varus foot (patient bears weight on the lateral surface of the
foot)
Lack of dorsiflexion range on the affected side (approximately
10˙ is needed)

12. Swing Phase
Trunk/pelvis Insufficient forward pelvic rotation (pelvic retraction): weak abdominal
muscles
Inclination to sound side for foot clearance: weakness of flexor muscles
Hip Inadequate flexion: Weak hip flexors, Poor proprioception.

13. Swing Phase
Knee Inadequate knee flexion Inadequate hip flexion and
poor foot clearance
Exaggerated but delayed knee
flexion
Strong flexor synergy
Inadequate knee extension at
weight acceptance
Spastic hamstrings

14. Swing Phase
Ankle/foot Persistent equinus and/or equinovarus: Plantarflexor
contracture or spasticity, Weak dorsiflexors, Delayed
contraction of dorsiflexors, Toe drags during midswing
Exaggerated dorsiflexion: strong flexor synergy pattern

15. Video

17. Description of gait
• Hip hike
• Circumduction of the leg
• Reduced hip and knee flexion
• Poor dorsiflexion — foot drop — toe first or flat foot placement
• Decreased weight shift towards affected side

18. 11
• Broader base of support
• Increased double stance time
• Shorter steps and stride length
• Slower gait speed
• Decreased walking efficacy
• Poor endurance,

19. Weak or imbalanced muscles
• Kinematic deviation occurs as a result of the inability to appropriately
activate muscles, as well as, from adaptive muscle shortening.
• Other than weakness, the person may experience clonus, spasticity,
exaggerated deep tendon reflexes, and decreased endurance.
• Weakened muscles include hip abductors, flexors, knee flexors, and weak
ankle dorsiflexors.

20. Functional task affected
• Difficulty maintaining balance due to limb weakness.
• Inability to properly shift their body weight.
• Staggering and stumbling.
• Difficulty performing activities of daily living. (barthel)

21. Physical therapy intervention
• Patient aimed at improving balance and restoring coordination.
• Tx is focused on
• Symmetrical weight bearing
• Weight shifting
• Step training
• Heel strike
• Single leg stance
• Push off

22. Treatment approaches :
• Conventional physiotherapy
• Neuro physiological techniques
• Functional electrical stimulation
• Robot assisted
• Brain computer interface
• Motor imagery
• Mirror therapy

23. 1. Neurophysiological techniques
• Physiotherapist supports the patient's movement patterns, acting as an active
participant and decision maker, so the patient acts as relatively passive
recipient.
• Most commonly used :
• Bobath Method is the most widely accepted treatment.
• This method consists on trying to inhibit increased muscle tone (spasticity)
by passive mobilization associated with tactile and proprioceptive stimuli.
• During exercise, pathologic synergies or reflex activities are not stimulated.

24. • Brunnstrom method is also well known but practiced less commonly.
• It is different to the Bobath strategy and focus on raising pathologic
synergies in order to achieve a normal movement pattern and promotes
return of voluntary movement through reflex facilitation and sensory
stimulation.
• Rood technique uses peripheral input (sensory stimulation) to facilitate
movement and postural responses in the same automatic way as they
normally occur.
• Johnson method assumes that damaged reflex mechanisms responsible for
spasticity are the leading cause of posture and movement impairment. These
pathological reflexes are controlled through positioning and splinting.

25. 2. Functional Electrical Stimulation
• FES consists delivering an electric current through electrodes to the muscles.
• The current elicits action potentials in the peripheral nerves of axonal branches
and thus generates muscle contractions.
• This technique is found effective to improve gait performance in hemiplegic
subjects and thought to give better results if used along with BWS.

26. • Video

27. 3. Robotic devices
• These devices provide safe, intensive and task-oriented rehabilitation with a minimal
physical assistance required to walk — reduces health care costs.
• It also provides kinematic and kinetic data in order to control intensity of practice, assess
changes and measure motor impairments.
• Robotic systems for gait recovery have been projected as simple electromechanical
assistances for walking, such as the treadmill with body weight support (BWS) , as end-
effectors, such as the Gait Trainer (Reha-Technologies, Germany, GT), lokomat.

29. 4. Motor imagery
• Imagining of an action without its physical execution; using all of the
senses.
• It is an active process during which the representation of an action is
internally reproduced within working memory without any overt
(observable) output.

30. 5. Brain Computer Interfaces
• BCIs establish a direct link between a brain and a computer without any use
of peripheral nerves or muscles enabling communication and control without
any motor output by the user.
• The users brain activity extracts specific features from brain signals that
reflect the intent of subjects and transform them into action.

31. • Video

32. 6. Mirror therapy
• Type of motor imagery where the patient moves his/her unaffected limb
while watching the movement in a mirror.
• This in turn sends a visual stimulus to the brain to promote movement in
the affected limb.

33. Outcome measures
• Functional ambulation profile
• Dynamic gait index
• Stroke impact scale
• Gait abnormality rating scale
• Functional independence measures
• Functional gait assessment
• Timed up and go test
• 6 min walk test
• 2 min walk test
• 10 meter walk test

34. Functional ambulation profile

36. Dynamic gait index

38. Stroke Impact Scale

39. Gait abnormality rating scale

40. Functional Independence measure

42. Functional gait assessment

44. Thank you