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Gait and Gait Deviations

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Presentation on theme: "Gait and Gait Deviations"— Presentation transcript:

1 Gait and Gait Deviations
Learn the gait cycle at each point, by muscle, speed, and what needs to happen. Most important phase is initial contact.

2 Normal Human Locomotion
Initial Contact Loading Response Mid-Stance Terminal Stance Pre-Swing Initial Swing Mid-Swing Terminal Swing Classic model of human gait developed by Perry at Los Ranchos. But what is gait really? What is happening? It is the constant forward progression of our COG, and our legs keep up to prevent us from falling. But we have to preserve energy – and the body does a beautiful job of storing energy in the movements so it doesn’t fatigue us.

3 Normal Human Locomotion
INITIAL CONTACT Hip = Flexed Knee = Nearly Flexed Ankle = Neutral Goal = Begin Stance - GRF is Posterior to ankle, creating PF MOMENT Classic model of human gait developed by Perry at Los Ranchos. But what is gait really? What is happening? It is the constant forward progression of our COG, and our legs keep up to prevent us from falling. But we have to preserve energy – and the body does a beautiful job of storing energy in the movements so it doesn’t fatigue us.

4 Normal Human Locomotion
INITIAL CONTACT GRF is Anterior to Knee and Hip, creating EXTENTION at knee, FLEXION at hip Passive extension aided by Quads and Hamstrings Gluts, Hamstrings HIGHLY active to overcome vector Gluts and Hams are acting STRONGLY here to overcome the strong flexion moment that is occuring at the hip. Passive knee extension is occuring due to placement of the vector, but is still maintained somewhat by a small quad/ham contraction present at the knee.

5 Normal Human Locomotion
LOADING RESPONSE Hip = Flexed Knee = is Flexing Ankle = Plantarflexing Goals = Weight Acceptance, Shock Absorption, Advance body over heel rocker GRF is still Posterior to Ankle, now Posterior to Knee This is where maximum PELVIC OBLIQUITY and STANCE PHASE KNEE FLEXION ARE AT MAX – at the point of opposite toe-off.

6 Normal Human Locomotion
LOADING RESPONSE Eccentric Control of Pretibials helps create the 1st ROCKER 15-18º Knee flexion as Shock Absorber 30º Hip Flexion maintained, creating 2nd highest Torque, only to dorsiflexion 1st rocker is at the ANKLE, where a fixed TC joint allows for forward progression of the Tibia as loading response is occuring

7 Normal Human Locomotion
LOADING RESPONSE Hamstrings help during LR to stabilize hip, prevent trunk flexion This is taken over by Gluts as stance progresses Eccentric action of Gluts, Hams, Adductor Magnus 1st rocker is at the ANKLE, where a fixed TC joint allows for forward progression of the Tibia as loading response is occuring hamstrings are highly active early in loading response, but become less so as stance phase progresses and gluts take over. Gluts are initially an extender, but become an abductor as we progress to midstance.

8 Normal Human Locomotion
LOADING RESPONSE Point of PEAK PELVIC OBLIQUITY and maximum STANCE PHASE KNEE FLEXION occurs here Opposite toe-off occurs here – helps to decrease overall vertical displacement of the body The PEAK VERTICAL DISPLACEMENT OCCURS at MIDSTANCE

9 Normal Human Locomotion
MIDSTANCE Hip = Extending Knee = Extending Ankle = Dorsiflexing Goal = Advance body over stationary foot GRF moves anterior to ankle, goes from post to ant. at knee Progression of the 1st rocker occurs here. Moves from 10 degrees of PF to 5-7 of DF, using eccentric control of the soleus at first, moreso the Gastroc as midstance ends due to extension of the knee which is more mechanically efficient for the gastroc complex. Quads are extending knee EARLY in midstance as vector moves anteriorly, then decreasing activity due to passive movement of the knee into extension.

10 Normal Human Locomotion
MIDSTANCE Early need for knee extensors, but not during late midstance due to placement of the force vector Early need for soleus for eccentric control, more on gastroc as knee extends for mechanical efficiency. Progression of the 1st rocker occurs here. Moves from 10 degrees of PF to 5-7 of DF, using eccentric control of the soleus at first, moreso the Gastroc as midstance ends due to extension of the knee which is more mechanically efficient for the gastroc complex. Quads are extending knee EARLY in midstance as vector moves anteriorly, then decreasing activity due to passive movement of the knee into extension. Since Soleus doesn't cross the knee, it is more active during the knee flexion part of LR/MS, then Gastroc becomes more active as it assists in knee extension as well as eccentric control of DF as the rocker continues.

11 Normal Human Locomotion
MIDSTANCE Hip flexion decreases from 30º to 10º as midstance progresses Vertical GRF reduced by upswing of contralateral side – still produce 2 ½ times body weight at peak on same side femoral head Gluts active as extensor early, abd. late Strong trendelemburg action as vector is quite medial in the frontal plane. This is fought early by glut medius, aided later by glut max as hip extension need is reduced. important point as people often feel hip/back pain early in amputee gait training. Stronger abductor force away from prosthetic side as patients don't like to wt shift creats increased vertical forces on the contralateral femoral head and an opposite lumbar sidebending will occur to compensate. Many of these patients will need lumbar mobilizations to correct facet joint abnormalities that occur with prolonged lumbar sidebending. Help Prevent This!!!!

12 Normal Human Locomotion
MIDSTANCE In Amputees, the Vertical GRF is INCREASED on sound limb due to prosthetic foot - This is less with Flex foot than with SACH foot; reinforces need to know componentry Study by Snyder, et al. Showed lack of dorsiflexion moment on prosthesis increases vertical GRF on sound limb – therefore increasing forces on that side and putting stress on sound limb. the more advanced componentry replicates that DF moment better, thus reducing stress on the sound side, but it still isn't the same as our own foot. Why? Limited ROM in prothetic ankle. Once the A/P range of motion is taken up, the forces get transmitted UP the chain to the knee and hip. The more that can be absorbed by the prosthesis, the less stress there is on the residual limb and the patients sound side.

13 Normal Human Locomotion
MIDSTANCE Hip flexion decreases from 30º to 10º as midstance progresses Vertical GRF reduced by upswing of contralateral side – still produce 2 ½ times body weight at peak on same side femoral head Gluts active as extensor early, abd. late Strong trendelemburg action as vector is quite medial in the frontal plane. This is fought early by glut medius, aided later by glut max as hip extension need is reduced.

14 Normal Human Locomotion
TERMINAL STANCE Hip = Extending Knee = Extended, then flexing Ankle = Dorsiflexed Goal = Advance body over forefoot rocker - GRF creates STRONG DF moment It is at this point that the gastroc – soleus complex is the most active, controlling forward tibial progression AND beginning the heel off over the MET heads;

15 Normal Human Locomotion
TERMINAL STANCE Movement over the Forefoot Rocker occurs Highest demand on gastroc-soleus as body vector moves outside the boundaries of the foot Max dorsiflexion occurs at TOE-OFF forefoot rocker is now dependent on the prosthetic keel. Again, know the componentry. Is it a stiff keel? Is it a long toe lever? this has immediate ramifications on what goes on at the knee. If the toe lever is long, it will be less flexible than the human foot, thus creating a stronger extension moment at the knee and more force will have to be generated to create initial swing. if the toe lever is short, then knee flexion as terminal stance ends will come sooner in the cycle, creating a "drop off" effect and also affecting the sound hip as a quick but powerful abduction moment is created since stance phase is a fraction shorter.

16 Normal Human Locomotion
TERMINAL STANCE NO muscle action at knee – this extension is created by external torque and GRF passing far anterior to joint Joint motion and forward progression created by momentum and swing of contralateral limb

17 Normal Human Locomotion
TERMINAL STANCE Mild hip extension torque created Passive hip extension aided by position of vector posterior to hip TFL helps control extension torque Vertical Magnitude of vector is similar here to Loading SO where is there the most vertical forces on the body and joints? Loading response and terminal stance according to the vertical vector readings.

18 Normal Human Locomotion
PRESWING Hip = Flexing Knee = Flexing Ankle = Plantarflexing Goal = Prepare for swing - GRF creates passive knee flexion, DF torque

19 Normal Human Locomotion
PRESWING During unloading of limb, PF activity is DECREASED; NO active push off during normal gait DF torque decreases as MP joints reach 60° of extension Again, created by momentum, contralateral limb. All part of the bodies ability to conserve energy

20 Normal Human Locomotion
PRESWING Hip flexes using MOMENTUM, plus rectus femoris, sartorius and add. Longus Add. Longus helps counteract hip abd. Created by contralateral off-loading PELVIC ROTATION helps balance the limbs out Posterior rotation on the contralateral side effectively lengthens that leg and helps counterbalance the hip flextion created by the initiation of swing

21 Normal Human Locomotion
INITIAL SWING Hip = Flexing Knee = Flexing Ankle = Dorsiflexing Goal = Clear foot and advance limb - Pre-tibs are active, helping reduce PF angle from 20° to around 5° Help prepare to clear the floor for Midswing

22 Normal Human Locomotion
INITIAL SWING Knee continues to flex to 60°, assisted by MOMENTUM plus biceps femoris (short head), sartorius and gracilis Hip flexed to 20° with help if iliacus, gracilis, sartorius, which help to flex both hip AND knee

23 Normal Human Locomotion
MIDSWING Hip = Flexing Knee = Extending Ankle = Dorsiflexing Goal = Advance limb and clear foot - Rapid knee ext. from 60° to 30° is PASSIVE, assisted by MOMENTUM

24 Normal Human Locomotion
MIDSWING - EMG shows only MILD hip flexor activity, maintaining 30° angle Gracilis, sartorius, iliacus stop in early midswing, hamstrings begin to decelerate limb Rest of limb advancement is MOMENTUM Reinforce the point about momentum creating a lot of movement.

25 Normal Human Locomotion
TERMINAL SWING Hip = Flexed Knee = Extending Ankle = Neutral Goal = Advance limb - Pretibs now act to place foot properly on the ground Prepares the foot for the HEEL ROCKER, and we start all over again.

26 Normal Human Locomotion
TERMINAL SWING Quads active at end of TS, help fully extend knee along with PELVIC ROTATION Eccentric hamstrings, Gluts help control hip and knee to control stride length

27 Using Gait to Your Advantage

28 When are Muscles Active, When are they not?
Initial Contact and Loading Response - Focus often on strong contraction of knee ext. in BK patients – not necessary due to strong ext. moment - Use of Gluts/Hamstrings EARLY in stance phase to overcome strong FLEXION vector at hip - Focus on HIP/BACK extention, as hams/gluts used primarily to stabilize back and counteract hip flexion moment Remember, Gluts become a hip abductor by midstance, so when concentrating your exercise regimen, remember that a full range of motion of hip extension exercises may not be necessary. Focus on when the muscles are active to optimize your training program.

29 When are Muscles Active, When are they not?
Midstance and Terminal Stance - Remember, quads active EARLY in midstance, but vector again moves ANTERIOR, becoming passive - Vector moves ANTERIOR to ankle, now fully reliant on prosthetic foot Remember, Gluts become a hip abductor by midstance, so when concentrating your exercise regimen, remember that a full range of motion of hip extension exercises may not be necessary. Focus on when the muscles are active to optimize your training program.

30 Understand the Components!!!!
Exercises done on the toes of the prosthesis can let the patient feel what give there is to the prosthetic and how they can adjust with their musculature. Get patient to understand the give of the foot and knee they are on to assist with this stage of gait

31 Understand the Components!!!!
Exercises done on the toes of the prosthesis can let the patient feel what give there is to the prosthetic and how they can adjust with their musculature. Remember, the Alignment of the prosthesis is such that, no matter what the foot, patient should be able to maximize his or her roll over to closely match the sound side. Due to lack of MTP extension, forces are transmitted up the chain to knee/hip. Pt MUST allow MOMENTUM to transfer over the foot to allow for minimizing forces at higher joints

32 When are Muscles Active, when are they not?
Pre-Swing and Initial Swing - Knee flexion throughout this phase done by MOMENTUM, so use to your advantage - All action at the knee and below can be controlled with proper PELVIC motion and use of proper hip muscles to create vector

33 When are Muscles Active, when are they not?
Pre-Swing and Initial Swing - Ipsilateral Adductors help propel hip forward while counteracting strong abduction vector during off- loading - USE BOTH actions to your advantage during exercise prescription – adductors are BOTH stabilizers and protagonists

34 When are Muscles Active, when are they not?
Mid-Swing and Terminal Swing - Knee extension in Mid-Swing is PASSIVE. In AK’s, extension assist components help with this action - ipsilateral hip musculature stops here, now Hamstrings begin to fire to slow knee ext, prepare for stabilization of back

35 When are Muscles Active, when are they not?
Mid-Swing and Terminal Swing - Pre-tibs prepare foot in TS, but not appropriate for amputees. Foot position is essential to maximize properties of prosthetic foot – FOOT PLACEMENT ACTIVITIES - End range Pelvic Rotation, quads are essential here to prepare for IC

36 IMPORTANT EXERCISES Eccentric Hamstrings, Concentric Quads
Adductors as both STABILIZER and PRIME MOVER Creating MOMENTUM, using it to your advantage QUICK BURST exercises

37 IMPORTANT EXERCISES SPEED OF CONTRACTION
- too much time does not allow for release of normal energy and eliminates importance of MOMENTUM in helping propel body forward TRANSITION EXERCISES - moving between cycles of gait, when to transition to next mode of ms contraction

38 QUESTIONS?????


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