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The purpose of this study was to describe and compare the gait of 20 patients with Peggy R Trueblood
hemiplegia secondary to cerebrovascular accident (CVA) before and after a Joan M Walker
treatment regimen of resisted pelvic motions. Ten women and 10 men were Jacquelin Perry
studied, with a mean age of 48 years and a mean duration post-CVA of two JoAnne K Gronley
months. Nine subjects (45%) were right hemiplegic, and 11 subjects (55%) were
left hemiplegic. Treatment consisted of four sets of five repetitions each of
manually resisted pelvic anterior-elevation and posterior-depression movements
on the involved side. An insole footswitch system, knee electrogoniometer, and
force walking aid were used in gait analysis performed before treatment,
immediately after treatment (posttest 1), and 30 minutes after treatment (posttest
2). Results showed significant overall improvement in gait in posttest 1 (p < .005)
compared with the pretest. This improvement, however, was not maintained in
posttest 2. Ten patients improved overall in posttest 1; only 4 patients also showed
improvement in posttest 2. The major improvements seen immediately after
treatment were obseved in stance stability and limb advancement in the involved
limb. More research is needed to identify an optimum treatment with carry-over
using this technique. [Trueblood PR, WalkerJM,Perry J, et ah Pelvic exercise and
gait in hemiplegia. Phys Ther 69:18-26, 1989]
A variety of neurologically based approaches for specific conditions or explained first by Rabat,1,2 based on
techniques are used by physical problems. Sherrington's work in muscle and
therapists in the treatment of nerve physiology.3 Kabat suggested that
hemiplegic patients. Although these Proprioceptive neuromuscular patterns of movements performed in
techniques are used widely, few facilitation is a philosophy of treatment combination with other facilitory
studies have been reported in the based on principles of neuro- procedures result in enhanced
literature validating these diverse physiology. The principles of PNF were voluntary responses.2
Response to Treatment
Subjects' overall response to treatment
in posttest 1 demonstrated a significant
improvement as compared with the
pretest (p < .005). Fourteen subjects
showed improvement, with gains in 10
subjects greater than one standard
deviation. Only 4 subjects improved
GAIT CYCLE DURATION (sec) greater than one standard deviation in
posttest 2 compared with the pretest.
F i g . 2 . Durations of total gait cycles (in seconds) and the component phases Mean subject response to treatment in
(percentage of gait cycle) of stance (shaded area) and swing (unshaded area) in this posttest 2, however, did not show
study's sample ofhemiplegic subjects as compared with a sample of healthy subjects.16 The
hemiplegic subjects had a 2.5-second gait-cycle duration; in healthy subjects, it averages significant improvement. When the
1.03 seconds.16 (R = right side, L = left side, I = involved side, S = sound side.) variables were grouped into the three
categories described previously, two of
(n = 11). Nine subjects wearing an subjects with knee hyperextension in those categories showed significant
AFO commonly displayed knee stance increased their terminal improvements in posttest 1: force
hyperextension in stance. The double-limb support period by 13% of walking aid data (p < .01) and knee
durations of initial double-limb support the gait cycle (Fig. 3). Subjects from motion data ( p < .005). Eight
and single-limb support periods were both knee motion groups displayed individual variables within those two
relatively equal in both groups. Those prolonged duration of peak knee categories showed statistically
EXCESSIVE FLEXION
NORMAL
HYPEREXTENSION
Fig. 3 . Mean knee motion during pretest in hemiplegic subjects displaying excessive knee flexion in stance (n = 9) or knee
hyperextension in stance (n = 11) as compared with a sample of healthy subjects.16 Vertical lines indicate components of stance phase in
hemiplegic subjects. Initial double-limb support (IDLS) and single-limb support (SIS) periods were the same for both groups. Terminal
double-limb support (TDLS) period was longer for those subjects displaying knee hyperextension in stance as compared with the group with
excessive knee flexion.
Fig. 4 . Mean knee motion during pretest andposttest 1 in those subjects with improved gait as compared with sample of healthy
subjects17,18: (left) subjects displaying excessive knee flexion in stance (n = 3); (right) subjects displaying knee hyperextension in stance
(n = 7). Vertical lines indicate components of stance phase in pretest. Arrows indicate the end of single-limb support (SIS) and terminal
double-limb support (TDLS) in posttest 1 that were substantially different from the pretest. (IDLS = initial double-limb support.)
significant improvement. Given hyperextension in stance) are different between pretest and posttest 1
measurement error, however, these described separately. Only three of the (Fig. 4).
improvements were not clinically nine subjects with excessive knee
significant. No significant gains were flexion in stance during the pretest Subjects in the improved group with
seen in the three categories of variables displayed knee motion closer to a knee hyperextension in stance during
for posttest 2 when compared with the normal pattern in posttest 1. Peak knee pretest (n = 7) showed a similar
pretest. flexion during loading response was 5 amount of knee flexion during limb
degrees less. Peak knee extension in loading, but maintained more flexion
Improved Group stance increased 10 degrees, and (5°) at the end of the initial
extension at opposite heel contact double-limb support period and had
The two patterns of knee motion found increased 12 degrees. Knee flexion less peak knee hyperextension (3°) in
(excessive knee flexion and knee during the swing phase was not posttest 1. Stance time was increased
10% because of a 10% increase in
single-limb support time for the
posttest group. Peak knee flexion at
toe-off increased 7 degrees with a
4-degree increase during the swing
phase (Fig. 4).
Discussion
Spasticity—Therapist determines available range of motion by passively taking the joint through ROM slowly before testing spasticity (subject
positioned supine):
1. Hip—Therapist moves hip joint passively through a "fast 1—No resistance felt as joint is moved passively through a fast ROM.
ROM"a noting resistance to 1) abduction and 2) adduction. 2—Moderate resistance felt through fast ROM.
3—Excessive resistance felt through fast ROM.
2. Knee—Therapist moves knee joint through a fast ROM noting 1—No resistance felt as joint is moved passively through a fast ROM.
resistance to 1) flexion and 2) extension. 2—Moderate resistance felt through fast ROM.
3—Excessive resistance felt through fast ROM.
3. Ankle—Therapist moves ankle joint through a fast ROM noting 1—No resistance felt as joint is moved passively through a fast ROM.
resistance to 1) flexion and 2) extension. 2—Moderate resistance felt through fast ROM.
3—Excessive resistance felt through fast ROM.
Upright Controlb (subject is standing for all tests; two people required to administer the test):
Flexion
1. Hip—Therapist asks subject to bring knee toward chest; 1—Actively flexes >60°.
assistant gives hand support on opposite side. 2—Actively flexes 30°-60°.
3—No motion or actively flexes <30°.
2. Knee—Therapist asks subject to bring knee toward chest; 1—Actively flexes >60°.
assistant gives hand support on opposite side. 2—Actively flexes 30°-60°.
3—No motion or actively flexes <30°.
3. Ankle—Therapist asks subject to bring knee and foot toward 1—Actively dorsiflexes to a right angle or greater.
chest; assistant gives hand support on opposite side. 2—No motion or actively dorsiflexes <90°.
Extension
1. Hip—Therapist provides hand support on opposite side; 1—Maintains trunk erect on hip.
assistant provides ankle and knee support; therapist asks 2—Unable to maintain trunk erect but able to stop forward trunk motion;
subject to lift uninvolved leg. wobbles back and forth; hyperextends trunk on hip.
3—Uncontrolled trunk flexion on hip.
2. Knee—Therapist positions knees at 30°; assistant provides 1—Supports body weight on flexed knee and able to straighten knee on
hand support on opposite side; therapist asks subject to lift request.
uninvolved leg and to straighten knee. 2—Supports body weight on flexed knee without heel rise or increased
flexion.
3—Unable to maintain body weight on flexed knee.
4—Excessive tone; unable to position knee flexion.
3. Ankle—Therapist prevents knee hyperextension of involved leg; 1—Maintains knee at neutral and lifts heel off floor.
assistant provides hand support; therapist asks subject to lift 2—Maintains knee at neutral.
uninvolved leg and to go up on toes. 3—Unable to maintain knee at neutral.
A—Excessive equinus or varus; unable to maintain plantigrade platform.
Scoring System
a
"Fast ROM" is defined as the quickest motion the therapist can use passively in the subject's available ROM.
b
ROM measured objectively by primary investigator in all tests. (Upright control test adapted from Montgomery J, Gillis KM, Winstein C, Physical Therapy
Management of Patients with Hemiplegia Secondary to Cerebrovascular Accident, Downey, CA, Professional Staff Association of Rancho Los Amigos Medical
Center, Inc, 1979.)
45%24), and shorter duration post-CVA showed statistically significant gait cycle and limited hip flexion in the
(2 months vs 3 months20 to 13 years24). improvements in posttest 1, most swing phase and at initial contact,
Lehmann's sample of 7 hemiplegic motion differences were less than 5 which persisted throughout the
patients demonstrated excessive knee degrees and may not be clinically single-limb support period. Both hip
flexion during stance (range = 4°-17°; relevant. and pelvic position at initial contact
mean velocity = 27.8 m/min).24 Nine of showed a mean increase of 5 degrees
our subjects demonstrated excessive Studies have shown that many gait in the four subjects who were also in
knee flexion during stance; however, variables, including time-distance the improved group. At the hip, this
greater knee flexion values were variables and angular limb motion, are improvement remained throughout
observed in our study (range = 10°- velocity dependent.26,27 The treatment initial double-limb support. Subjects
22°; mean velocity = 19 m/min) than in had no effect on velocity; therefore, we increased pelvic motion (toward
Lehmann's study.24 were not surprised to see no change in posterior tilt) 5 degrees during
the subjects' stride characteristics. The single-limb support and during the
Basically, the major improvements seer improvements in knee motion and swing phase in posttest 1.
immediately posttreatment were in weight on force aid, therefore, cannot
stance stability and limb advancement be explained by changes in velocity. Improvements observed may be due to
in the involved limb. Further evidence spontaneous recovery; however, the
of the improved stance stability were The changes in knee motion may have time lapse from pretest to posttest was
decreased force on assistive device at occurred secondary to improvements a maximum of 45 to 60 minutes.
the end of initial double-limb support, in pelvic and hip motion. Ten subjects Second, a comparison of two gait trials
mid-stance, and beginning of terminal were also analyzed using automated on 17 hemiplegic patients (P. R.
stance; improved knee motion during motion analysis; however, only 4 of Trueblood, unpublished pilot study,
initial double-limb support; and those subjects were also in the November 1984) was analyzed to
improved peak and duration of knee improved group. The results of the determine the normal variation between
extension in stance. Evidence of study, therefore, were inconclusive. gait trials. No significant differences in
improved limb advancement was Major gait deviations of the pelvis and temporal characteristics or knee
demonstrated in a longer step length hip observed in the hemiplegic electrogoniometric data were found.
and more knee flexion in the swing subjects studied were excessive pelvic
phase. Although those gait variables anterior tilt occurring throughout the