1. Gait: Cycle & Terminology
   1. Gait Cycle
   2. Gait Terminology
2. Task Analysis
3. Walking: Interventions, Outcomes & Mgmt Strats
   1. Prerequisite Requirements
      1. appropriate weight-bearing status
      2. musculoskeletal (postural) alignment
      3. ROM
      4. muscle performance (strength, power & endurance)
      5. motor function
      6. balance
      7. static & dynamic standing control
      8. ability to safely stand while engaging in UE functional movements under varying environmental demands
   2. Activity: Walking Forward & Backward
      1. this is a progression from stepping in place (standing & stepping)
      2. focus:
         1. timing & sequencing
            1. beginning with weight shift diagonally forward/backward onto stance limb & pelvic rotation with advancement of swing limb
      3. Important:
         1. ensure knee ext (not hyperext) occurs with hip flx during fwd progression
         2. ensure knee flx occurs w/hip ext during backward progression
      4. Guided Mvmts/Facilitation
         1. For Forward Progression
            1. PT can facilitate fwd pelvic rot during swing by placing hands on anterior pelvis
            2. Great for managing retracted & elevated pelvis = problem for many pts. w/LE spasticity
         2. For Backward Progression
            1. PT can facilitate hip Ext & Wt acceptance on stance limb by place hands posteriorly over Gluteals
            2. This also helps prevent knee on stance limb from hyperextending
      5. Verbal Cues
         1. Forward Progression
            1. "Shift fwd, & step, step, step"
         2. Backward Progression
            1. "Shift backward & step, step, step"
         3. Progress Walking Fwd & Backward:
            1. Change Level of assistance
            2. walking next to // bars/wall-->unassisted walking
            3. Incr. Step length
            4. Change speed of walking
            5. Can incld. TM & overground walking
            6. Modify BOS
            7. Feet apart (wide BOS)-->feet close together (narrow BOS)-->tandem
            8. Vary acceleration/deceleration by having pt. practice stopping & starting or turning on cue
            9. Incld. dual task walking
            10. Walk & talk; walk & turn head; walk & bounch ball
            11. Alter Environment:
            12. Varying walking surface
            13. flat-->carpet-->irregular(outdoors)
            14. Incld Anticipatory timing Demands
            15. Time req'd to cross street @ stoplight
            16. Incld Goal-Directed leisure or occupational reqs.
            17. return to work skills
      6. Resisted Progression
         1. IDEAL TO FACILITATE LOWER TRUNK & PELVIC MOTION
            1. • PT standing in front of or behind Pt. or sitting on rolling stool • As pt. moves fwd, PT moves in reverse or mirror-image of Pt’s mvmts (*so, place hands on pelvis, give a quick stretch/push into pelvis to get that hip flex to come in) and have pt step forward into your resistance) • PT provides maintained resistance to the fwd/backward progression by placing both hands on pelvis; provide reciprocal resistance
            2. Approximation can be applied down thru top of pelvis (so push down on ASIS/pelvis) to promote stabilizing responses as wt is taken on stance limb
            3. Stretch to pelvic rotators can be added to facilitate initiation of pelvic motion
            4. Alt pos for manual contact=on pelvis & contralateral shoulder
         2. Facilitates walking-improving timing and sequencing of gait
         3. using Theraband:
      7. To promote arm swing & trunk counter rotation using 2 wooden poles
         1. • PT is behind as Pt. walks fwd or in front as pt. walks backward • Both patient & PT hold on the poles. Pt is then able to assist in sequencing the arm swings & guides trunk counterrotation during fwd & backward progression
      8. Outcomes
         1. Motor Control Goal
            1. Skill
         2. Functional Skill Achieved
            1. Pt. able to ambulate independently with appropriate timing & sequencing of movement components
         3. Indications:
            1. Impaired timing & sequencing of local motor movement components
   3. Activity: Walking, Side-Stepping
      1. Resisted Progression
         1. Abductors are active on both the dynamic limb (to move limb) & static limb (to keep the pelvis level)
   4. Activity: Walking, Side-Stepping & Crossed-Stepping:
      1. Strategies & Verbal Cues
      2. Verbal Cues for Walking, Side Stepping & Crossed STepping
      3. Outcomes
         1. Motor Control Goal:
            1. Skill
         2. Functional Skill Achieved
            1. Pt. is able to walk sideways independently with appropriate timing & sequence of movement components (req'd for mvmt in confined areas)
         3. Indications
            1. Hip ABD weakness
            2. Activity facilitates protective sidesteps (stepping strategy) needed to regain balance
   5. Activity: Walking, Braiding
      1. Strats & Verbal Cues
      2. Verbal Cues for Walking, Braiding
      3. Resisted Progression
      4. Outcomes:
         1. Motor Control Goal:
            1. Skill
         2. Functional Skill Achieved
            1. Pt. walks independently using complex the thing patterns
         3. Indications
            1. Resisted progression can be used to facilitate lower trunk rotation & LE patterns in combo w/upright postural control as well as to promote protective stepping strategies for balance
   6. Activity: Stair Climbing
      1. Prerequisite REquirements
         1. Important Lead-up Activities:
            1. Bridging
            2. Sit to stand
            3. kneeling to heel sitting tansition
            4. Partial squats
            5. stepping activities
      2. Strats & Verbal Cues
         1. Quads & Gastroc powers elevation of body
         2. Walking Down:
            1. involves weight transfer onto stance limb with accompanying eccentric contraction of hip & knee extensors to lower body to next step
            2. Pt. needs to shift wt diagonally forward over the stepping limb
            3. PT needs to watch for & prevent excessive trunk bending
         3. Progression: light touch-down railing support-->No UE support
         4. Progression: step up on low step-->higher step-->standard step-->stair climbing
      3. Verbal Cues for walking, stair climbing
      4. Outcomes
         1. Motor Control Goal:
            1. Skill
         2. Functional Skill Achieved
            1. Pt. walks independently up & down stairs & walks independently in community up & down curbs
         3. Indications
            1. Impaired ability to transfer weight onto stance limb & simultaneously lift the opp dynamic limb up & onto a step
   7. Strategies for Varying Locomotor Task Demands
      1. Box 8.2 p. 206
         1. Upright Postural Alignment
         2. Foot Placement/Toe Clearance
            1. practice high step marching in place & then high step walking accompanied by marching music
            2. practice walking with even steps using footprints attached the floor; increase step length &/or step width using footprints or a floor grid
            3. Practice step to (have 1 limb step to opp limb)-walking
            4. Pract. walking with altered BOS; wide BOS-->narrow BOS-->tandem
            5. Pract walking on 3in wide line taped to floor on a split half/foam roller or low bal beam
         3. Single and Double Limb Support
         4. Forward Progression & Push-Off
         5. Walking Against Resistance
         6. Trunk Counterrotation & Arm Swing
         7. Walking Sideward
         8. Walking Backward
         9. Step Ups/Step Downs
         10. Stopping, Starting, & Turning on Cue
         11. Visual Input
         12. Head Movements
         13. Timed Walking, Increased Speed & Locomotor Rhythm
             1. use marching music or metronome to external pace the speed
             2. verbal commands: "walk fast" "walk slow"
         14. Duration of Walking
         15. Dual-Task Walking
             1. walking &: talking; counting/cognitive task; holding ball, moving side to side w/outstretched arms; holding tray/grocery bag/laundry basket; catching & throwing ball; while stopping to pick up an object off floor
         16. Compensatory REsponse to Unexpected Perturbations
             1. change speed of TM or stop & start TM while patient is walking on it
             2. Pract. resisted fwd progression using theraband w/unexpected release of resistance
             3. walking while recovering from small external perturbations given manually
             4. Walking while practicing recovery strats, such as stops or starts on a TM
   8. Strategies for Varying Environmental Demands
      1. Box 8.3 p. 207
         1. Walking Surfaces
         2. Stair Climbing
            1. using rail vs not
            2. 1 step at a time-->step over step
         3. Obstacles
            1. to improve foot placement
            2. walking w/dynamic obstacles in path: revolving door; elevator; escalator
            3. walking w/2 individs navigating the same optical course (collision avoidance)
         4. Slopes or Ramps
            1. Requirements:
            2. Descent=assoc. w/increased Knee Flx (stance) & increased Ankle & Hip motions (swing); during descent, peak moments & powers are higher at the knees
         5. Open Environments
         6. Time Requirements
         7. Visual Conditions
            1. full lighting-->reduced/low lighting
            2. w/dark glasses to alter visual conditions
            3. walking from outside to inside=varied lighting conditions
   9. BWS & TM Training
      1. Benefits of BWS & TM to Improve Locomotor Skill box 8.2 p. 2104
      2. BWS & TM Training: Mgmt Strats
4. TIPS
   1. UE FLEXOR SPASTICITY
      1. Reduce Tone:
         1. Muscle Elongation & Sustained Stretch using an Inhibitory Pattern
            1. 1. PT slowly moves limb into lengthened range while gently rotating (rocking) limb back & forth (rhythmic rotation)
            2. 2. Once full range is gained, PT maintains lengthened pos using inhibitory pattern: Shoulder is Ext, Abd, ER w/Elbow, Wrist & Fingers Ext
   2. Initiate Forward weight transfer
      1. Have pt clasp both hands together w/shoulder flx & elbow ext
         1. is also effective for inhibiting UE spasticity