Gait Retraining in stroke patients in PMR department of BSMMU.pptx

Physical medicine and Rehabilitation

1. Welcome to ISDP 03.05.2023 Dr. Md. Saiful Islam Dr. Nilufar Yeasmin MD Resident (Phase-B) Department of Physical Medicine & Rehabilitation BSMMU

2. Mr Rahmat Ali ,62 years old, hypertensive, diabetic, smoker, from Gazipur admitted in PMR dept.of BSMMU with the complaints of sudden onset of weakness of left side of body for 21 days. Weakness initially involving the left upper Limb then left lower Limb, followed by fall to the ground while attempt to stand for going to the toilet. For this weakness he is unable to move his left side of the body and difficulty in walk. Patient is also unable to speak but can follows command. There is also urinary incontinence for the same duration .There is no history of fever, loss of consciousness, convulsion, trauma to head neck, Nausea, vomiting and double vision. Functional history : He is dependent, needs assistance in transfer, dressing, eating, personal hygiene and communication.

3. On general examination : Pulse- 88 bpm, BP- 140/90 mm Hg. On nervous systemic examination : Higher psychic function : Patient is conscious, but unable to speak. Cranial nerve examination: Intact Motor system examination : Muscle bulk is normal, Muscle tone increased in left side, muscle power reduced Left upper limb 3/5 and Left lower limb 3/5.Ankle plantar flexor and dorsiflexor 3/5. all DTR is exaggerated in Lt Upper and lower limb and Plantar- Extensor. Clonus -Absent, Co-ordination -Impaired in Lt side, Gait - Hemiplegic gait. Sensory system -Intact Other system examination: Normal.

4. Questions What is hemiplegic gait? What is Gait Retraining? Indication of gait retraining? What are the purposes of gait retraining? What are the steps of Gait retraining? What are newer techniques of gait retraining?

5. Hemiplegic gait In hemiplegia, shoulder is adducted,the elbow is flexed,the forearm is pronated and the wrist,fingers are flexed. Knee is held in extension and the ankle is plantar flexed. Hemiplegic gait usually have: Increased stance phase and prolonged swing phase of the paretic side.Decreased walking speed and shorter step and stride length. Here the spastic muscles do not allow the hip and knee to be flexed enough for the foot to clear the ground.So the person rotates the hip sideways during the swing phase and places the foot in flattened manner or places the toes first before heel strike.

6. Gait Retraining Gait retraining  or  gait rehabilitation  is the act of learning how to walk, after sustaining an injury or disability.

7. Indication of Gait retraining Brain and Spinal cord injuries Fractures Joint injuries or replacements Lower limb amputations Strokes Parkinsons disease Muscular dystrophy or other musculoskeletal disorders Cerebral palsy Multiple sclerosis

8. Purpose of Gait retraining Increasing static and dynamic balance Eliciting voluntary activation in key muscle groups in lower limbs Increasing muscle strength and coordination Increasing walking velocity and endurance Maximizing skill and increasing flexibility Increasing cardiovascular fitness Education on proper use of assistive devices

9. Steps of Gait retraining First the patient learns balance by holding onto a bar or other stable support while standing.When balance is beginning to be reliable,the patient learns to shift full weight onto the more affected lower limb. Once this is feasible, the patient can begin performing gait drills by standing in place,shifting the weight from one lower limb to other. When this procedure appears to be going well ,actual walking at the bar can begin. Once a good reciprocal pattern at the bar has been achieved,the patient start using axillary crutch then elbow crutch then a four point cane. When the patient is doing well with a four point cane and appears to have confidence , an attempt can be made to use a single ended cane. Walking on foot prints for coordination. Walking in stairs,ramps curbs and uneven surface. Special consideration for persons with stroke during gait training is the potential need for orthotics to assist with abnormalities such as drop foot.

10. Newer techniques of Gait retraining Body weight supported treadmill training Biofeedback Functional electrical stimulation Robotic assisted gait retraining Constraint induced movement therapy

11. Body weight supported treadmill training

12. Biofeedback Runners receiving visual biofeedback during gait retraining

13. Functional electrical stimulation

14. Robotic assisted gait retraining

15. Virtual reality gait retraining

16. Thank You