walking preparation and gait training

1. Trunk Balance
During the period when the basic limb synergies dominate
motor behavior, the problem of ambulation is solved by
individual patients in different ways.

The individuals choice of compensation, as well as the

severity of the involvement, determines the ambulation
pattern.

Once a specific pattern has evolved it is likely to become

firmly established, hence difficult to change.

 During the early period following the onset of hemiplegia, it

would therefore seem advisable to concentrate on
preparation for walking while postponing actual walking for
some time, in order to avoid the establishment of a poor
gait pattern.

This doesnt mean that all weight bearing should be

avoided; a number of weight bearing exercises & activities
may & should be practiced as soon as feasible.

Preparation for walking should include:

1.Training in trunk balance, both sitting & standing.

2.Modification of motor responses of the limbs to
obtain muscular associations resembling those
required for normal walking.

3.Training of alternate responses of antagonistic

muscles, to promote a rapid release of tension of
muscle groups following their activation.

The upright posture (sitting, standing or

walking) requires the proper functioning of:
Afferent
impulses of
widespread
origins

A number of
central
balancing
mechanisms

Efferent
pathways

Damage to any one of the central mechanisms or

interruption anywhere along the sensory or motor
pathways sub serving the central mechanisms might
result in deficient balance.
Also, imbalance of trunk musculature, either in strength
or available ROM, may lead to deficient balance in
hemiplegic patients.

Trunk listing in sitting.

Success in maintaining standing balance cant be expected unless

the patient can balance the trunk in sitting position without relying
on back or side support.

Some patients have good sitting balance at an early date, while

others have a tendency to list toward the side when they sit
unsupported.

Studies by BRUELL & associates (1956, 1957) & by BIRCH &

associates (1960, 1961) suggest that listing phenomenon of
patients with hemiplegia may be related to a deficiency in the
perception of spatial relationships.

If the perception of verticality is imperfect, attempts should be

made to help the patient gain a better appreciation of spatial
relations.

 In spite of possible permanent damage, the patient may improve

his judgment by utilizing, to the best possible extent, those
mechanisms that remain functional.

For this purpose, reinforcement of afferent impulses from receptors

for position sense, kinesthesis, pressure, light touch, & so on, as
well as emphasis on specific clues, have been found useful.

A light touch by the normal hand on a horizontal or vertical

stationary object, a temporary raise under the buttock on one side
or the other, & repetitive head & trunk movements are examples of
treatment methods.

Trunk movements, whether passive or active, assisted or resisted,

are considered useful in several respects:

Afferent impulses thus evoked contribute not only to coordination

of trunk movements, but also produce reflex effects on the limbs.

Rhythmic rotatory movements of the trunk are required in walking

& are essential for proper coordination of arm & leg movements in
walking.

Sitting trunk balance.

Evoking balancing responses(figure 107 &108):

For the purpose of eliciting balancing responses, the sitting

trunk posture is deliberately disturbed in forward-backward
& side-to-side directions.

The patient is pushed off balance, 1st gently, then more

vigorously.

Note how the patient supports the affected arm to protect

the shoulder joint.

This arm posture also prevents the patient from grasping the
side of the chair with the normal hand.

Disturbing the balance in the direction toward the patient

tends to list is considered particularly important.

Trunk bending forward & obliquely forward (figure 109 through 112):

The patient sits in a straight-back chair & supports the affected arm
as before.

For the 1st trials, & as long as needed, the Physical therapist guides
the trunk & arm movements by holding under the patients elbows.

If the patients trunk balance is poor, the Physical therapist may use
her own knees to stabilize the patients knees, because the knee on
affected side has a tendency to fall into abduction.

As the trunk inclines forward, the Physical therapist guides the

patients arms in order to attain glenohumeral & scapular motions.

Because the serratus ant. Muscle May not functioning on the

affected side & the antagonistic muscles may be tight, the
instructor gently assists the forward movement of the scapula by
passively upwardly rotating its medial border; traction on the arm
should be avoided.

Trunk flexion with rotation promotes weight bearing

through the hip toward which the trunk is inclined, as
well as balancing responses.

Figure 107

Figure 108

Figure 109

Figure 110

Figure 111

Figure 112

Trunk rotation (figure 113 through 115):

In the neutral position, before trunk rotation begins, the

patients arms are close to the body & relatively relaxed,
except for the upward pressure on the elbow on the affected
side.

As the trunk rotates, the patient maintain a firm grip around

the affected elbow, & the arms swing rhythmically from side
to side; the principal movements are shoulder abduction on
one side & shoulder adduction on the other side.

Each time the movement is reversed the arms are lowered to

the starting position before the trunk rotates toward the
other side.

A total trunk-neck-arm pattern evolved. The shoulder

components of the flexor & extensor synergies are evolved
alternately & are initiated, or reinforced by tonic lumbar &
tonic neck reflexes.

 The patient supports the affected arm as before, & the

therapist initially guides the movement.

Trunk rotation is 1st performed gently & within small

range, then the range is gradually increased.

Throughout the movement, the patient looks straight

ahead, which results also in rotation of the trunk with
respect to the head & neck.

A certain amount of neck mobilization is thus obtained

without the patient noticing it.

Additional head rotation (figure 116) takes place if the

head rotates maximally to the left while the trunk rotates
toward the right, & vice versa.

Figure 113

Figure 114

Figure 115

Figure 116

2. Modification of Motor
Responses of the Lower Limb

Modification of
the motor
responses for:
Contraction of
hip flexors

Activation of
dorsiflexors of
the ankle

Hip abductors

Bilateral
contraction

Reflex response

reflexely

Unilateral
contraction

Introducing
voluntary effort

Superimpose
voluntary
response

Reinforcement of
voluntary effort

reinforcement

Combination
with hip & knee
extension

Reciprocal
movement

Dorsiflexion with
eversion

Side-lying
position
Bilateral action
of hip abd in
standing
Unilateral action
of hip abd in
standing

 Indications for special training procedures:

Modification of motor responses is indicated when basic
limb synergies dominate motor acts & thus prevent the
return of normal gait patterns.

The largest number of patients falls between the two

extremes of severely involved & mildly involved, when
involvement is mild, modification of motor responses may
not be necessary because the synergies soon lose their
dominance, & spontaneous return of normal or near
normal gait patterns may then be expected, but in severely
involvement modification of synergy responses is
indicated.

Bilateral contraction of hip flexor ms (figure 117through 120).

If the patient sits on the front portion of a chair & inclines the trunk
backward until arrested by the back of the chair, a brief bilateral
activation of the hip flexor muscles may be obtained. (As in fig: 117 &
118).

The hip flexor muscles respond with a lengthening contraction when

the trunk inclines backward & with a shortening contraction during
the return movement.

The hip flexor muscles may also be activated in the sitting position
when the patient attempts to maintain erect sitting against resistance
or move into trunk flexion with or without resistance. (as in fig: 119 &
120).

The flexor muscles of the hip may be employed either for balancing
the trunk in an anteroposterior direction or flexing the thigh with
respect to trunk.

Their bilateral trunk-balancing function is essentially an equilibrium

reaction, evoked automatically to prevent a fall.

Trunk balance may thus be utilized as preparation for hip flexion.

Figure 117

Figure 118

Figure 119

Figure 120

Unilateral contraction of hip flexor ms (figure 121 through 123).

Immediately following a backward trunk inclination or

while such inclination is still in progress, the patient makes
an effort to flex the hip with respect to the trunk.

The timing of this attempt is critical, for it must be made

before the tension in the hip flexor muscles developed
during trunk inclination, has subsided. Because muscles
can produce more tension during isometric or lengthening
contractions than during shortening contractions, the
Physical therapist assists in hip flexion just enough to lift
the foot off the ground, then gives the command hold or
dont let your foot down on the floor (as in fig: 121 &
122).

The patient then superimposes his voluntary effort taking

advantage of the background tension previously
established. (As in fig:123)

Figure 121

Figure 122

Figure 123

Activating the dorsiflexors muscles of the ankle

Requirements for early stance phase:

During the early stance phase of normal level walking, the following ms groups
show electrical activity:

The dorsiflexors of the ankle, the extensors of the knee, the extensors of the hip,
& the abductors of the hip.

In contradistinction, the extensor synergy which is activated on weight

bearing in patients with hemiplegia combines hip & knee extension with
plantar flexion of the ankle & adduction of the hip.

If somewhat more normal muscle associations are to be established, the

dorsiflexors of the ankle & the abductors of the hip must be activated
&induced to associate themselves with the extensors of the hip & knee, &
this association must materialize in the early stance phase.

Some patients however, may be incapable under any circumstances,

regardless of movement combinations, of activating the dorsiflexors
voluntarily. In this cases, the approach is

1. To elicit a reflex response in this muscle group as a

component part of the total flexor synergy.

2. To superimpose voluntary effort on the reflex

stimulation

3. To reinforce the voluntary effort as the reflex

stimulation is withdrawn.

4.Then training will be directed toward activating the

dorsiflexors in combination with hip & knee extension,
as required for the early stance phase of gait.

Reflex response (figure 124 &125)

When the patient has no control of hip flexion, passive plantar

flexion of the toes is administered, & this manipulation usually
elicits a mass flexor response, which includes a dorsiflexion of
the ankle. (MARIE-FOIX reflex).

The reflex is elicited with the patient in supine position, knee &
hip flexed slightly.

Figure 124

Figure 125

Introducing voluntary effort

When reflex contractions of the dorsiflexor muscles have

been evoked a number of times, the patients voluntary
effort is superimposed on the reflex contraction.

The proper timing of the voluntary effort with the reflex

contraction is of utmost importance because the reflex
tension may fade out rather rapidly.

When a good reflex response is obtained, the physical

therapist resists the total flexor movement by pressing
against the dorsum of the patients foot, while
simultaneously giving the command dont let me pull your
foot down.

Reinforcement of voluntary effort.

The next step in training the dorsiflexor muscles of the

ankle is to have the patient actively attempt to initiate
the movement without the use of reflex elicitation.

The supine or sitting position may be utilized.

The Physical therapist places one hand on the patients
thigh on the involved side just above the knee, pressing
down slightly; should the hip flexor muscles contract
together with the pretibial group, the pressure is
increased. Even though the hip flexor muscles may
become active, Movement at the hip joint must not be
permitted at this time because the objective is to obtain
a more isolated response at the ankle.

 Local facilitatory measures, such as quick stretch,

vigorous rubbing of the skin over the bellies of the
pretibial muscles, or percussion of their tendons as
they pass the ankle joint often prove effective.

A lengthening or isometric contraction is 1st required

dont let me pull your foot down, then a shortening
contraction (now pull your foot up again). Fig: 126

Figure 126

Combination with hip & knee extension, as required for the

early stance phase of gait (figure 126 through 132).

It must be kept in mind that these procedures are directed

toward increasing the patients ability to activate & control
ankle dorsiflexion with knee & hip extension. Thus if the
patient is supine, the procedure is repeated in positions
incorporating less & less flexion of the hip & the knee, so the
extended position is gradually approached (fig: 126 , 127 &
128).

If the patient is sitting, ankle dorsiflexion is attempted with

increasing amounts of knee extension (fig: 129 & 130).

When a patient can voluntarily dorsiflex the ankle while

sitting on an ordinary chair, he changes to a higher chair,
sitting on its edge only; then he stands leaning his buttocks
against a table of proper height, then stands with his back to
a wall, & finally stands without support with the affected foot
forward in a position of a short step (fig: 131 &132).

Figure 126

Figure 127

Figure 128

Figure 129

Figure 130

Figure 131

Figure 132

Dorsiflexion with eversion

Throughout the training of the pretibial muscles, attention

is paid to proper positioning of the ankle & to the
placement of the resisting hand for the purpose of causing
the long toe extensor ms, & eventually, the peroneal
muscles to participate.

The Physical therapists resisting hand gradually moves

laterally (figure 133) across the dorsum of the foot.

Figure 133

 When these procedures are 1st applied, it is of no avail to ask

the patient to evert the foot because this would only detract
from his effort to pull the foot up, an effort that must be
sustained.

Commands may be used such as HOLD YOUR FOOT STEADY;

DONT LET ME TURN YOUR FOOT IN & later, NOW TURN
YOUR FOOT OUT AGAIN.

These techniques may be applied in all the positions described

previously with respect to dorsiflexion of the ankle.

1. The above procedure follows the general principles of:

2. Having the patient attempt only those motions that are, at
least in part, under voluntary control, or that may be expected
to succeed in the near future.

3. Modifying the movements that have been obtained to include

other components.

4.Requiring isometric or lengthening contractions before

shortening contractions.

Hip Abduction

The approach to associating hip abduction with hip & knee

extension is similar to the one outlined for association of
ankle dorsiflexion with the extensors.

A contraction is elicited reflexely.

The patient superimposes voluntary effort on the reflex
contraction.

Local facilitatory measures are introduced to reinforce the

patients voluntary effort.

Attempts are made to cause the muscle groups that have

been activated to respond in the desired situation- in this
case, in early stance phase, continuing into midstance.

Hip abduction: reflexely

Raimistes phenomenon(figure 134):

It is evoked by strong isometric contractions of abductors

or adductors on the normal side. Resisted shortening
contractions are also effective.

Figure 134

Hip abduction: superimpose voluntary effort.

As soon as a reflex response in the involved abductors is

achieved, the command spread your feet apart is given. This
enables the patient to superimpose voluntary effort on the
reflex contraction.

Should this effort cause activation of other components of

flexor synergy, the resistance is decreased accordingly.

The reflex assistance is then gradually withdrawn as the

patients volition capability in performing the desired
movement of unilateral hip abduction with hip & knee
extension increases.

The supine position is maintained for these activities not only

for ease of eliciting the raimsites phenomenon, but also for the
patients sense of well-being.

If the upright position is used in early training, the patients

attention is focused exclusively on his fear of falling, which
leads to excessive contraction of the knee extensors &
consequent activation of the hip adductors.

Hip abduction: reinforcement.

Success in directing voluntary impulses to the abductors on the

affected side in the supine position, however, is only the beginning.

The abductors must then be strengthened to enable them,

mechanically, to perform their weight bearing function.
Hip abduction: reciprocal movements

The rapid rise & fall in tension required of the muscles active in normal
gait, enable a smooth transition between the stance & swing phases of
gait.

The comparatively slow rise & fall in tension of the component muscles
of the hemiplegic limb synergies, suggest that, active reciprocal
motions be introduced as soon as feasible.

Alternate hip abduction & adduction are achieved by changing the

angle of the hips & knees in the supine position.

That is, abduction is achieved with the hips & knees extended &
adduction with the hips & knees flexed.

When these movements can be performed freely, reciprocation is

introduced, the patient is asked to flex the hip & knee as he adducts the
hip, then to extend the hip & knee as he abducts the hip.

Hip abduction: side-lying position (figure 135)

The patient lies on unaffected side with the hip & knee on
that side partially flexed.

The Physical therapist stands behind the patient lifts the

affected limb into partial abduction, and then proceeds to
stimulate the gluteal muscles by means of vigorous
percussion with fist closed (beating).

Immediately following stimulation, the command hold,

dont let your leg fall down is given; simultaneously the
Physical therapist momentarily allows the limb to fall a
very short distance , if the patient is unable to comply with
the command; then the procedure is repeated.

This method aims at building up a reflex tension in the

abductor muscles which if augmented by a voluntary effort
may result in a muscular contraction strong enough to hold
the limb in the desired position or at least to slow its
download movement.

Figure 135

Bilateral action of the hip abductor muscles in standing

(figure 136)

This is an advanced training procedure that consists of

abducting 1st the affected & then the unaffected limb, &
which involves momentary weight bearing on one leg at a
time.

The patient stands at the parallel bar, using his hands for
support. Assuming that the LT side is the affected one, the
patient 1st shifts his weight over the RT limb & abducts the
LT one (fig: 136). This can be done within small range by a
pelvic movement, even if the abductor ms dont respond.

The body weight is next shifted toward the LT. if the pt

now demonstrates a Trendelenburg sign; the Physical
therapist may apply pressure downward on the LT iliac
crest & upward on the RT side of the pelvis.

 If given with sufficient force, this will prevent a sagging of the

pelvis on the RT side. Simultaneously, the patient is encouraged
to raise the RT limb into abduction.

Local stimulation (beating) of the hip abductors on the LT side

before & during the weight shift is also indicated if it can be
managed without disturbing the balance.

A more advanced variation of this activity requires that the

patient relinquish the support offered by the parallel bar &
perform the same activities with only the support of the Physical
therapist.

The Physical therapists attention during this activity, as during

all activities in the standing position, must be directed not only
to the primary purpose of the activity in this case, bilateral
activation of the hip abductors but also to equal distribution of
weight through the extremities when both feet are on the
ground & to assuring that the time spent on unilateral weight
bearing through the involved extremity (when the uninvolved
foot is off the ground) is equal to the time spent on unilateral
weight bearing through the uninvolved extremity (figure137).

Figure 130

Figure 131

Unilateral action of the hip abductors in standing.

This is the last & most demanding activity in the sequence

of procedures designed to activate & strengthen the hip
abductors on the affected side.

It is employed to emphasize & strengthen a muscle

combination already feasible.

In the standing position the patient is instructed to elevate

(hike) the pelvis on the unaffected side enough to lift the
foot off the ground.

It would serve no useful purpose & would only confuse the

issue to point out to the patient which muscle group is
expected to contract. The patients attention should be
focused on hip hiking on the unaffected side.

At the beginning, the patient uses his normal hand for

support & the Physical therapist assists to emphasize the
pelvic movement & to steady the patient.

 The hip hiking movement performed on alternate sides

represents a transition to the actual walking situation &
may later be repeated during walking.

The use of a cane during this type of training isnt

recommended because it interferes with the walking
rhythm. Furthermore, leaning heavily on a cane relieves
the abductors on the opposite side of their weight bearing
function; hence nothing is gained in terms of
strengthening the abductor muscles.

Elimination of Trendelenburg limp cant be expected to

succeed in every patient with hemiplegia, however, & good
judgment must be exercised to determine how long this
particular aspect of training should continue.

If the Trendelenburg limp persists, the patient should be

encouraged to use a cane, at least when walking outdoors,
to minimize the limp & guard the abductors on the affected
side from being overstretched.

3. Alternate Responses of
Antagonistic Muscles
Knee flexors & knee extensors:

Introduction:
The failure of quadriceps muscles to cease contracting at the
proper time is one of the major causes of disturbance of
walking pattern in patient with hemiplegia.

The training methods to be chosen depend to a great extent

on the flaccidity-spasticity status of the patient.

During the flaccid state, the quadriceps muscles must be

stimulated; during spasticity, inhibited.in both instances,
alternating action of knee flexor & knee extensor muscles is
stressed in order to decrease the duration of contraction of
opposing sets of muscles.

Supine position:

With the knee joint no longer locked in extension but held in

slight flexion, the patient may be able to initiate the flexor
synergy.

A modification of the flexor synergy is then attempted for the

purpose of limiting hip flexion & increasing ROM at the knee.

While the patient pulls his knee up toward the chest, the
Physicaltherapist holds the foot down so that the sole slides on
the horizontal surface. This movement is repeated several
times. The sensation thus evoked is emphasized (Do you feel
the sole of the foot sliding on the table?) (Feel it again.) & after
a few trials (Now keep touching the table & slide your foot
backs yourself (figure 138))

 Alternate knee flexion & extension movements in small

range are then attempted without permitting the sole of
the foot to leave the table.

Although the flexor movement is reinforced by manual

resistance, the extensor movement isnt.

In this manner, reciprocal movement is achieved, but

emphasis isnt placed on the already dominant extensors.

The total range of knee flexor-knee extensor motion & the

speed of reciprocation are increased in accordance with the
patients capabilities.

It should be kept in mind that initiating the flexor

movement becomes increasingly difficult as the knee
approaches full extension (figure 139 &140).

Figure 138

Figure 139

Figure 140

Side lying position:

If the extensor tone in the supine position is prohibitive of

voluntary knee flexion, the side-lying position may be
used.

Side-lying may be advantageous for 2 reasons:

The gravitational influence on the lower extremity has
been reduced, creating a lighter (load) for the patient to
lift.

Knee flexion may be facilitated by the influence of the

asymmetrical tonic labyrinthine reflex, which favors
flexion of the uppermost limbs in the side-lying position.

Sitting position (figure 141 through 144) :

The patient sits on a firm chair & places his foot forward on
the floor, the heel touching & the knee short of full
extension.

He then slides the foot backward, touching the floor with

the heel & then with the ball of the foot, as the foot slides
underneath the chair & the knee flexes to an acute angle.
Fig: 141,142 &143.

At the onset the Physical therapist may have to assist the

backward sliding movement of the foot directly or aid by
lifting the lower portion of the patients thigh just enough
to reduce friction of the patients foot on the floor.

 The lifting is accomplished by a grip just above the knee;

this grip also permits palpation & manipulation of the
tendons of the knee flexors.

The sitting position offers several advantages for the

activation of the hamstring ms:

Knee flexion is facilitated because the hip & knee are

flexed, & the 2 joint knee flexor muscles are relatively
elongated.

The hip angle changes very little during the motion so that
the patient experiences the sensation of more or less
isolated knee flexor motion.

The sliding of the foot on the floor serves as a guide for the
motion.

The position lends itself well to an additional type of

facilitation which is next described.

 When knee cant be flexed beyond 90 degrees, the patient

learns to synchronize a forward inclination of the trunk
with an effort to slide the foot backward, & additional knee
flexion may result. Fig:144

After completion of knee flexion the patient leans against

the back of the chair & extend the knee to the starting
position.

When control has improved, alternation between knee

flexion & extension in increasingly rapid succession & in
varying joint ranges begins, initially with & then without
accompanying trunk movements.

Figure 141

Figure 142

Figure 143

Figure 144

Semi standing position (figure 145).

Sitting on surfaces of graduated heights increases the

amount of the hip extension & enables further
development of reciprocal knee flexion & extension
independent of synergy influence at the hip.

Figure 145

Half prone position (figure 146 & 147).

The half prone position is also used as an intermediate step between

sitting & standing to reinforce alternate knee flexion & extension
with increasing amounts of the hip extension, preparatory to
standing with the hip in full extension.

Further any fear of falling that the patient may experience in the full
upright position is diminished in the half prone position because he
is able to bear some of his weight through the upper extremities.

The Patient stabilizes himself, & the Physical therapist furnishes

additional stabilization when needed.

In this position, isolated knee flexion is attempted by the patient, &

resistance is given as soon as a response is obtained.

Stimulation by percussion or vigorous stroking over portions of the

muscles of the posterior thigh may also be required to initiate the
movement.

For alternate responses, knee extension is incorporated & may be

resisted if such resistance doesnt cause hip adduction.

 When the patient is able to alternately to flex & extend the

knee in half prone position, the position is altered to
accommodate increasing amounts of hip extension by
having him bear weight on his hands with elbow extended,
rather than on his forearms.

It should be noted that both of these positions have the

added benefit of promoting stability of the shoulder joint
complex via weight bearing through the U.L.

Figure 146

Figure 147

Pawing (figure 148through 150):

The half-prone position can be used very effectively to incorporate

the desired ankle movement with the knee movement.

The term pawing has been coined for this exercise because it
resembles the movements of a horses pawing as the animal scrapes
the ground with his forefoot.

As the patient flexes the knee, he is instructed to plantar flex the

ankle so that the toes scrape the floor.

Then as knee flexion continues & the foot is lifted entirely off the
floor, he is instructed to dorsiflex the foot as he initiates knee
extension & to maintain that dorsiflexion as the knee comes into full
extension so that the heel of the foot strikes the floor 1st, followed
by the entire sole.

By so incorporating the ankle movements with the knee

movements, each of which was learned independently of the other,
the muscular associations required for various phases of gait
materialize in a satisfactory manner & the patients confidence in his
abilities increases.

Standing position.

The half-prone is gradually modified to a standing position

with the patient facing & leaning against a higher object,
such as a chest of drawers or even a wall. Eventually the
patient stands fully erect, using hand support only.

When in this position flexion of the affected knee can be

performed while the hip on the affected side is kept
extended, it is a sign that the hemiplegic limb synergies no
longer influence the patients movements.

Since the rectus femoris portion of the quadriceps ms

group crosses both the hip joint & the knee joint , flexion of
the knee beyond 90 degrees in the fully erect position with
the hip extended shouldnt be expected & isnt, in any
event, required for ambulation.

Predominance of flexion in the lower limb.

In somewhat unusual cases, the flexor synergy dominates

the motor behavior of the lower limb, sometimes to the
extent that the patient is unable to lower the limb to the
table in the supine position or to the floor in standing.

In such situations, attention must be given to inhibition of

the dominant flexor muscles & excitation of the extensor
muscles.

The treatment principles & objectives remain the same,

however; that is, muscle associations, particularly those
that will allow more normal swing & stance phases of gait,
must be established.

4. Standing and Walking

Knee stability in standing

In general, weight bearing on the affected limb is likely to evoke a

response of the quadriceps muscles, but satisfactory knee stability
doesnt always materialize. The knee may give way & cause a fall, or
the knee may snap into hyperextension. In either case, training
approaches are similar, in as much as the pt must learn to support wt
momentarily on a slightly flexed knee.

1- Standing knee bends:

As a safety measure, the Physical therapist stands behind the
patient, supporting his trunk on both sides of the chest.

The patient is guided in shifting weight toward the affected side with
both knees slightly flexed (figure 151). Thereafter, the knees are
flexed an additional 10 to 20 degrees, then extended, but not hyper
extended. A satisfactory response of the knee extensor ms will
probably be evoked on the affected side.

 When standing knee bends are 1st attempted, many patients

will automatically incline the trunk forward & bend the head &
neck forward, perhaps to incorporate visual cues. These
movements should be discouraged because they tend to
displace the C.O.G anteriorly. Additionally, if the patient
experiences knee buckling on the affected side, the Physical
therapist may place her leg in front of the patients knee to
minimize knee flexion. Similarly, the Physical therapist may
control hyperextension by placing her leg behind the patients
knee & gently encouraging weight bearing on a slightly flexed
knee.

Figure 151

2- Lateral weight shift.

Lateral weight shifting in the upright position with the knees

flexed slightly is used to prepare the patient for unilateral
weight bearing. Fig: 151

Using the skaters waltz position, described below, the patient

is instructed to slowly & rhythmically shift all his weight 1st to
the unaffected & then to the affected foot.
3- Marking time, knees slightly flexed.

The patient is instructed to flex both knees slightly, shift all

weight to the uninvolved side, & lift the involved foot off the
ground momentarily.

When this foot is returned to the ground, weight is shifted

entirely to the involved side, & the uninvolved foot is lifted off
the ground. The activity then continues with alternate,
rhythmic weight shifting & weight bearing. As has been noted
earlier, establishing proper rhythm in pregait activities helps
instill an even cadence during actual ambulation.

Preparation for swing-through in walking.

The purpose of this activity is to obtain a rapid release of

tension in the quadriceps muscles & sufficient knee flexion
to allow the affected limb to swing through freely in
walking.

The patient uses hand support to minimize balancing

difficulties & performs with the normal & then with the
affected limb.

At 1st, the Physical therapist may have to assist in keeping

the ball of the foot in contact with the ground on the
affected side during the backward scraping movement.

The affected limb performs 4 to 6 times before a change is

made to the other side. Eventually, a walking rhythm-once
R.T., once L.T.-is attempted.

The described movement requires simultaneous use of

knee flexor & hip extensor muscles & is therefore difficult
as long as the basic limb synergies are influential.

 If this is the case, the patient may 1st practice a slow

movement of hip-knee flexion with emphasis on knee
flexion in the following manner. The contact of the foot
with the ground is maintained during the backward
movement, & when the foot is taken off the ground, the
foot is made to follow the inner side of the normal leg,
sliding up toward the knee.

This requires a considerable amount of activity of the knee

flexors & a reciprocal decrease in tension of the knee
extensors.

Assisted walking (figure 152).

The use of parallel bars for walking is kept to a minimum. Because:

It is found to hamper the development of trunk rotation & reciprocal arm
swing.

Also it hampers weight bearing through the involved lower extremity.

In severely involved patient or in very early training in the upright position,
the patient may stand between the parallel bars for security purposes, but
should be instructed to hold the bar only when necessary to prevent loss of
balance.

The skaters waltz position has been used to describe the manner in which
walking is accomplished outside the parallel bars. Figure: 152

The Physical therapist walks beside the patient while grasping the patients
hands. This kind of support is helpful for controlling the patients weight
transfer from one limb to other, for practicing variations in walking cadence &
equalization of steps, & so on.

The Physical therapist may prefer to be either at the patients affected or

unaffected side, whichever seems more appropriate for the particular patient.

In addition, the hand hold may vary depending on the support requirements
of the Patient.

Figure 152

Walking instructions.

When the patient begins to walk, the Physical therapist

assists & encourages, but keeps instructions at a minimum.
Too many corrections may annoy the patient. if suggestions
are given, only one should be given at a time. For example,
attention may be focused on proper weight shift toward the
affected side, on preventing hyperextension of the knee, or
on touching the ground with the heel 1st, but not on several
of these factors simultaneously.

Approaches to 2 particular difficulties (supporting wt on a

slightly flexed knee, necessary to preclude the tendency
toward hyperextension of the knee, & incorporating ankle
dorsiflexion at the appropriate phases of gait) are presented
here as examples of how specific problems may be dealt
with while walking proceeds.

The shuffle gait, used to promote knee stability in walking,

follows from standing knee bends & marking time,

 The Physical therapist. walks with the patient in skaters

waltz position, keeping her own knees slightly flexed,
taking short steps, & encouraging the patient to do the
same. The walk is actually becomes a shuffling along, the
entire sole of the foot being placed on the floor, while the
hips & knees remain slightly flexed.

A moderate amount of forward inclination of the trunk is

permitted because it reduces the strain on the knee extensor
muscles.

At a later date, the inclination of the trunk may be increased

& decreased at regular intervals-for example, on every 4th
step-so that the knee extensor muscles adjust their activity
to changing requirements.

It has been observed that when walking with slightly flexed

knees with a therapist, patients with hemiplegia are capable
of a comparatively rapid succession of steps without
interference of spasticity in the quadriceps muscles.

 Some patients find it difficult to perform the shuffle gait

because of the inability of the ankle dorsiflexors to contract
effectively with the knee extensors, even though this
combination of muscles may contract effectively as a unit
in non weight bearing situations.

Again the Physical therapist walks with the patient in the

skaters waltz position, but this time both individuals
exaggerate hip flexion, as if to clear obstacles in their path.

Because of the synergistic relationship, exaggerated hip

flexion helps activate the ankle dorsiflexors. As walking
progresses, the amount of hip flexion is decreased until it
approaches normalcy.

As ambulation training continues over time, the shuffle &

high steppage(figure 153) gaits may be altered so that the
pt learns to respond quickly to the demands of normal
walking.

Figure 153