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Post-stroke Standing & Locomotor Training
Terms in this set (14)
Pelvic, Hip Control; Impairment level Interventions:
Sid...., upper or lower trunk rotation?
sitting performing what on dyna disc? (til..)
Hooklying ==> sup...
What can you do in supine? (kn.. to ch..)
While in bridging, unilateral to bilateral or bilateral to unilateral?
While in kneeling you can progress from holding to what? (wt.. sh..)
Can go from kneeling to what? (he... sit...)
Progress from modified plantigrade to what? (st..)
Sidelying, LTR (protraction)
sitting pelvic tilts (disc, ball)
Hooklying > supine: BS abd / add
Supine: knee to chest
Bridging: bilateral > unilateral
Kneeling: holding > wt shifting
Kneeling > heelsitting
Mod. Plantigrade > standing
Knee Control; Impairment level Interventions:
Doing what in hooklying? (f... sl..)
While in prone, flex what?
concentric or eccentric sitting is good?
reciprocal knee flex or extension?
Sit==> ? ,1/2 kneeling ==> ? transfers
Half-standing off plinth doing what with knee?
Partial wall squats ==> stepping up or down?
Hooklying: foot slides (with ball)
Prone: knee flex, hold after positioning
reciprocal knee flex/ext
Sit > stand, half-kneel > stand transfers
Half-standing off plinth, reciprocal knee flex/ext
Partial wall squats > stepping up
Ankle Control; Impairment Level Interventions:
Hooklying== > ? (bri..) In this position you can progress from holding to what? (wei...)
In sitting position, pt can perform PF or DF? This can progress to what? (half sit..., ==> sta...)
Progress to open or closed chain with foot on what?
Can use Estim for what movement? (PF or DF?)
Progress from half-kneeling to sta....
Hooklying > bridging: holding > weight shifting
Sitting, DF (toe tapping) > half sitting > standing
Progress to close chain with foot on dynamic surface
Half-kneeling > standing: weight shifting
Sit to stand Functional Task Training:
What should you vary the height of?
Vary foot position to increase or decrease loading on hemi LE?
Vary UE loading for what? (push off to ... no TD)
Sit-to-stand & stand-to-sit:
Varying chair heights
Varying foot position to increase loading on hemi LE
Leg positioned behind will do more work
Varying UE loading: push-off to no TD
What will the orientation be for the patient? (mid.. with equal or unequal weight through LE?)
Progress from solid to what surfaces?
Minimal or maximal UE support?
What training is implemented? (func... and du... task..)
Stand Adaptability Training:
With static control, what challenges can be given to the pt? (rea.. and proa..)
With dynamic control, what can patient do? (wei.. sh..., rea..., or kick....)
Midline orientation with equal weight through the LEs (COM over BOS)
Solid > compliant surfaces
Minimal UE support
Functional & dual tasking training
Stand Adaptability Training :
Standing: static control - reactive & proactive challenges
Standing: dynamic control during weight shifts, reaching, kicking a ball
Locomotor Goals: Stability:
Maintain stable foot during what parts of movement? (he... st..., during forw.. prog..)
Patient wants to demonstrate coordinated extension of what joints for wight support during stance phase? (h.. and kn..)
In order to maintain vertical trunk posture, good hip and trunk flexion or extension is needed? Is stability of hip ab or adductors needed?
Locomotor Goals: Progression:
Want patient to progress to transfer momentum more freely or restricted?
Plantarflexion strength improves allowing for more adequate braking or propulsion?
Dorsiflexor and evertor strength improves for what part of gait? (stance or swing phase? when you need what sort of clearance? )
Maintain stable foot at heel-strike and during forward progression
Demonstrate coordinated extension of hip & knee for weight support during stance
Maintain vertical posture of trunk: good hip & trunk extension, abductor stability
Transfer momentum freely (adequate range and freedom of motion)
Adequate propulsion (plantarflexor strength)
Adequate toe clearance during swing (dorsiflexor & evertor strength)
Locomotor Goals: Adaptation:
What adaptations are made? (pos.. cont... ,and loco. .strat..)
You see changes in what? (sp.. and dir..)
Utilize what cues to identify upcoming challenges? (vis..)
Maintain safety with no L__ and fa...
Adapt postural control
Adapt locomotor strategies
Change speed, direction
Utilize visual cues to identify upcoming challenges
Maintain safety: no LOB, falls
Post-stroke Gait Deficits:
↑ or↓ walking speed?
shorter or longer step/stride lengths? ↑or↓ step length on non-involved side? Involved side?
Increase single or double support time?
Post Stroke Gait Deviations: Heelstrike to Midstance:
Trunk/pelvis is forward or backward?
Hip: what may be seen pertaining to hip? (tren.. and sciss)
Knee instability signs? (flex.. or hyper.. ex.. which may require splinting)
With the ankle and foot, ↑or↓ ankle dorsiflexion at initial contact?
Inability to transfer weight forward or backward?
Potential STGs? ( DF..., knee ext..)
Post Stroke Gait Deviations: Midstance to Toe-off:
What happens to tibial advancement? (rest..)
↑or↓ time end of stance? This leads to equal or unequal steps?
↑or↓ hip extension at the end of stance?
During pre-swing, is there active or absent close chained PF/gastroc activation?
What may you observe? (lack knee flex or extension? Active or absent heel off? )
Post Stroke Gait Deviations: Swing
The trunk and pelvis has insufficient forward or backward rotation?
Is there ↑or↓ hip flexion at toe-off and mid swing?
IS there ↑or↓ knee flexion at toe-off?
WIth terminal swing, is there inadequate knee flex or extension leading to an absent heel strike?
Ankle/foot is limited in DF or PF? This leads to ↑or↓ gastroc stiffness? ↑or↓ anterior tibialis strength?
Will persistent equinus and /or equinovarus?
WIll they have exaggerated PF or DF with strong flexor or extensor synergy?
Is a loss in reciprocal arm swing?
↓ walking speed
short and/or uneven step and stride lengths
↑step length on non-involved side
↓step length on involved side
increased double support time
Heelstrike to Midstance:
Trunk/pelvis: forward trunk
Hip: poor hip position (add or flex) Trandelenberg, Scissoring
Knee instability: flexes or hyperextends
may require early splinting
Ankle/foot: dec. ankle dorsiflexion at initial contact:
foot flat or forefoot 1st with supinated (equinovarus) foot
Usually results in "back loading" to get weight on heel with post. weightshift
Inability to transfer weight forward/unequal steps
Pt will demonstrate ↑ DF by 5 °
Pt will maintain neutral knee ext during stance
Midstance to Toe-off:
Tibial advancement restricted;
↓ time end of stance > unequal steps
Dec. hip ext at end of stance
Pre-swing: Absent close-chain PF/gastroc activation. Observe:
lack of knee flex
Absent heel-off: no active push-off (Major contributor to ↓ gait velocity)
Trunk and hip flexion
Trunk/pelvis: insufficient forward pelvic rotation
Hip: ↓ hip flexion at toe-off & mid-swing
Knee: ↓ knee flexion at toe-off
Terminal swing: inadequate knee ext → absent heel strike
Ankle/ foot: limited DF
Increased gastroc stiffness
Decreased Ant. Tibialis strength
Persistent equinus and/or equinovarus
Exaggerated DF with strong flex synergy
Loss of reciprocal Arm Swing
Compensatory Swing Phase Strategies:
Do you see an exaggerated extensor or flexor synergy?
Is IR/Abd or ER/Add seen more?
Vaulting with ipsi or contralateral side?
Anterior or Posterior pelvic tilt seen with ↑abdominals?
Exaggerated flex synergy
Vaulting with contralateral side
Posterior pelvic tilt with ↑ abdominals
LE Impairment Level Interventions:
Prevent adaptive changes where? (LE/sof.. tiss stretch..) Where especially in what muscles?
↑ muscle strength and coordination by doing active or passive exercises?
Do you use weight bearing devices? For what activities?
Do you want to elicit voluntary contraction in key muscle groups for synergies needed for gait?
When going from early to mid stance, you see hip and knee flex or extension along with abduction?
During toe off, you see hip ext or flex with knee extension or flexion?
During midswing, ankle PF or DF with hip and knee ext or flex, along with ab or adduction?
Prevent adaptive changes in LE/soft tissue stretching, esp. calf ms, rectus femoris
Overstretching @ gastroc origin with tightness @ insertion
↑ muscle strength and coordination:
cycling, isokinetic dynamometer
Use of functional weight bearing exercises
Sit ↔ stand, step work
Elicit voluntary contraction in key muscle groups for normal synergies needed for gait
Early > mid stance:
hip & knee ext. with abduction
Toe-off: hip ext with knee flex
Mid swing: ankle dorsiflex with hip & knee flex, adduction
sitting crossing hemi leg
Practice Overground Walking:
Walk using what device? (BWS... to ...)
LRD to what type of walking? (po...)
Walk with what on the floor? (gri..)
What to the beat of what? (met..)
Walk with BWS to no BWS
LRD to pole walking
Walk with floor grid
Walk with metronome (RAS)
Should you increase or decrease distance?
Speed should progress from comfortable to what?
How can the task change? (fwd.., bck... ,sid.. ,cross..)
What can patient progress to when cueing them on command? (fas.. sl..., piv.., head...)
What changes are seen with BOS? (wide==? )
Patients want to work on manipulation of what? (obj..)
What are some dual tasking activities that can be progressed to? (carry... what? )
Patient should be able to walk while doign what? (open.../clos.. , and while performing cog... tas...)
Have patient navigate to familiar or unfamiliar locations?
Distance changes: increasing distances
Speed changes: comfortable > fast
Task changes: forwards, backwards, side steps, crossed steps
On command: walk fast or slow, stops/starts
On command: walk with pivot turns
On command: walk with head turns
BOS changes: wide > narrow, straight line or balance beam
Walk while dual tasking
carrying a tray
Walk while opening/closing doors
Walk while performing cognitive task: walk & talk, counting backwards, serial 7's
Navigate to familiar and unfamiliar locations
How should they avoid static objects?
How should they avoid moving objects?
Practice what with elevators?
Walk over, around, and under static objects
Walk over and around moving objects
Practice getting on/off elevator (co-incident timing)
Do they provide temporary or permanent assist?
Plastic Molded AFO?
Double RIght AFO?
What ° of DF leads to control for knee hyperextension?
What ° of PF leads to control for knee buckling?
Does the orthotc need to be changed during the recovery process?
What must you consider when prescribing a device? ( futur.... )
What is included during orthotic training? ( don..., doff..., ski.. insp..., edu...)
Plastic molded AFO:
Double upright AFO:
5 ° DF > controls knee hyperextension
5 ° PF > controls knee buckling
Reassess patient frequently: orthotic needs change with recovery
Limited reimbursement issues: consider future needs when prescribing devices
Orthotic training: donning, doffing, skin inspection, education in safe use
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