Brunnstroms Movement Therapy in Hemiplegic Patient

Brunnstroms Movement Therapy in Hemiplegic Patientwalking preparation and gait training1. Trunk BalanceDuring 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:Training in trunk balance, both sitting & standing.Modification of motor responses of the limbs to obtain muscular associations resembling those required for normal walking.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: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 107Figure 108

Figure 109Figure 110

Figure 111Figure 112Trunk 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 113Figure 114Figure 115Figure 116 2. Modification of Motor Responses of the Lower LimbIndications 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 117Figure 118Figure 119Figure 120Unilateral 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 123

Figure 121Figure 122Activating the dorsiflexors muscles of the ankleRequirements 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

To elicit a reflex response in this muscle group as a component part of the total flexor synergy.To superimpose voluntary effort on the reflex stimulationTo reinforce the voluntary effort as the reflex stimulation is withdrawn.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 124Figure 125Introducing 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 126Combination 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 126Figure 127Figure 128Figure 129

Figure 132Figure 130Figure 131Dorsiflexion with eversionThroughout 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 133When 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.The above procedure follows the general principles of: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.Modifying the movements that have been obtained to include other components.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: reflexelyRaimistes 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 134Hip 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 movementsThe 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 135Bilateral 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 130Figure 131Unilateral 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 MusclesKnee 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 140Figure 138Figure 139Side 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:144After 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 141Figure 142Figure 143Figure 144Semi 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 145Half 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 146Figure 147Pawing (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 WalkingKnee stability in standingIn 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 1512- 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: 151Using 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: 152The 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 152Walking 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