Assessment and physiotherapy management of High step gait.pptx

high step gait

1. Assessment and physiotherapy management of High step gait Dr. M adhu (PT)

2. High step gait, also known as steppage gait, is characterized by exaggerated lifting of the legs, especially during the swing phase. It is most commonly associated with foot drop, a condition in which there is difficulty lifting the front part of the foot due to weakness or paralysis of the dorsiflexor muscles (e.g., tibialis anterior). This gait pattern is often seen in individuals with neurological conditions such as peroneal nerve palsy, lumbar radiculopathy , multiple sclerosis, or Charcot-Marie-Tooth disease. Introduction

3. Kinematics refers to the analysis of movement without regard to the forces involved: Exaggerated Hip and Knee Flexion: During the swing phase, individuals must excessively flex the hip and knee to clear the toes from the ground, compensating for the weakness in ankle dorsiflexion (foot drop). - The range of motion in the hip and knee joints during this phase is notably increased compared to normal gait. Kinematic Analysis

4. 2. Lack of Heel Strike: Patients tend to slap the foot down during the initial contact (heel strike) because the dorsiflexors are unable to control the descent of the foot. This may result in an abnormal *foot slap* upon contact with the ground. 3. Decreased Step Length: The overall stride length may be reduced as the person struggles to coordinate the exaggerated movements of the lower limbs during walking. - Step length asymmetry is often present if only one leg is affected by the dorsiflexion weakness. Kinematic Analysis

5. 4. Altered Trunk Movements: - There may be trunk leaning during the swing phase to compensate for the lack of foot clearance, further affecting gait balance and stability. 5. Abnormal Toe Clearance: - Toe clearance is achieved primarily by the exaggerated movements of the hip and knee, as the foot remains in a plantarflexed position due to foot drop. Kinematic Analysis

6. Kinetics refers to the forces that produce movement: Weakness in Ankle Dorsiflexors : The primary kinetic issue in high step gait is the insufficient force generation by the tibialis anterior and other dorsiflexors to lift the foot. - This results in compensatory activation of the hip flexors and knee flexors to elevate the leg during the swing phase. Kinetic Analysis

7. 2. Altered Ground Reaction Forces (GRF): GRF is higher at the moment of foot slap as the uncontrolled descent of the foot increases the impact on the ground during initial contact. Reduced push-off during the stance phase due to diminished control of the ankle plantarflexors . 3. Inefficient Propulsion: Lack of proper push-off from the toes during the terminal stance phase leads to inefficient forward propulsion, increasing the energy cost of walking. - Reduced ankle plantarflexor engagement means the gait lacks the usual forward momentum generated during push-off. Kinetic Analysis

8. 4. Increased Energy Expenditure: - Exaggerated movements in the hip and knee joints result in a gait pattern that requires more energy than a normal gait pattern, leading to early fatigue during walking. Kinetic Analysis

9. Foot drop, causing difficulty clearing the foot during the swing phase. 2. Abnormal hip and knee flexion, leading to inefficient and exaggerated movements. 3. Foot slapping during initial contact due to poor control of foot placement. 4. Decreased stride and step length, resulting in inefficient gait. 5. Balance and postural instability, as patients compensate for foot drop with excessive movements. 6. Early fatigue due to the increased energy required for gait. 7. Frequent tripping or falling due to poor foot clearance. 8. Psychosocial impact, including a loss of confidence in walking or avoidance of social interaction. List of Problems

10. Improve foot clearance during the swing phase to prevent tripping and falls. 2. Enhance muscle strength in the ankle dorsiflexors (if not permanently impaired). 3. Increase gait efficiency by reducing excessive hip and knee flexion during walking. 4. Improve balance and reduce compensatory trunk movements. 5. Enhance functional mobility in daily activities such as walking on uneven surfaces or climbing stairs. Short-Term Goals:

11. Maintain functional independence in walking and reduce the risk of falls. 2. Optimize gait mechanics to improve long-term mobility and energy efficiency. 3. Enhance overall strength and endurance, especially in lower extremities. 4. Prevent further musculoskeletal complications that may arise due to compensatory movements. 5. Improve quality of life by increasing mobility and reducing fatigue during walking. Long-Term Goals

12. Physiotherapy interventions are aimed at improving foot clearance, gait efficiency, and balance while addressing any underlying weakness or neurological impairment. Physiotherapy Management

13. 1. Strengthening Exercises - Dorsiflexor Strengthening: Focus on exercises that target the tibialis anterior, such as toe raises, resisted dorsiflexion using resistance bands, and functional exercises like stepping or toe tapping. - Hip and Knee Strengthening: Strengthening exercises targeting the hip flexors, quadriceps, and hamstrings can help improve leg control during gait. Exercises like marching, step-ups, and lunges are beneficial. Physiotherapy Management

14. 2. Stretching and Range of Motion (ROM) Exercises - Calf Stretching: Patients with foot drop often develop tightness in the calf muscles ( gastrocnemius and soleus ). Regular stretching can help prevent contractures. - Passive and Active ROM: Focus on improving range of motion at the ankle to facilitate normal gait mechanics and prevent stiffness. Physiotherapy Management

15. 3. Gait Training - Treadmill Training with Body Weight Support: This helps patients practice a normal gait pattern in a controlled environment, allowing for repetitive practice without the risk of falling. - Visual and Auditory Cues: Use visual floor markers or auditory cues (e.g., metronome) to improve rhythm and step length during walking. - Obstacle Courses: Practicing foot clearance over small obstacles can improve dynamic balance and foot control during gait. Physiotherapy Management

16. 4. Functional Electrical Stimulation (FES) - FES can be used to stimulate the dorsiflexor muscles during the swing phase, improving foot clearance. Devices such as WalkAide and Bioness L300 are commonly used for patients with foot drop secondary to neurological conditions. 5. Balance and Postural Control Training - Balance exercises: Incorporate single-leg stance, tandem walking, and dynamic balance exercises* to improve postural control during walking. - Core stability trainin g : Strengthening the core muscles helps improve trunk control and reduce compensatory leaning during gait. Physiotherapy Management

17. 6. Orthotic Interventions - Ankle-Foot Orthoses (AFO): AFOs are commonly prescribed to support the foot in dorsiflexion during the swing phase, preventing foot drop and improving gait mechanics. - Custom foot orthotics: These can assist with proper foot placement during gait and improve alignment. Physiotherapy Management

18. 7. Functional Mobility and Endurance Training - Engage the patient in functional mobility tasks, such as walking on uneven surfaces, turning, and climbing stairs. Gradually increasing the difficulty of these tasks improves the patient’s ability to handle real-world challenges. - Aerobic exercises such as cycling or walking can be incorporated to improve overall endurance. Physiotherapy Management

19. 8. Education and Home Program - Educate the patient on fall prevention strategies, emphasizing the importance of environmental modifications (e.g., removing obstacles) and safe walking practices. - Provide a home exercise program focusing on strengthening, stretching, and balance training to maintain the progress achieved during therapy sessions. Physiotherapy Management

20. 1. Stolze , H., et al. (2001). Gait analysis in Huntington's disease. Movement Disorders. 2. Lewek , M. D., et al. (2009). Functional Electrical Stimulation of the lower limb. Physical Therapy. 3. Perry, J. (1992). Gait Analysis: Normal and Pathological Function. References