Task Oriented Gait Training

Safe and independent gait is one of the most important physical function of human. Gait training is essential to people with gait difficulty. Although there are many types of gait training strategy, there are no consensus on which one is the best. Gait training strategy can be divided into compensatory approaches and restorative approaches. Although people with severe impairment wish to restore normal walking, it is too difficult to use their involved body part normally in gait. Also, people use compensatory approaches in gait even in training session. Therefore forced use of involved body part is indispensable in gait training to people with severe impairment. This book introduces new gait training frame which uses forced use of affected body part. First, strengthening of weakened muscle, second, step up with affected lower limb, third, step down with weight support with affected lower limb, and fourth is step down touch. Actual gait training starts after people can support their body weight and maintain balance with affected lower limb, without using hand. With this approach, people can restore impaired body function, regain more normal gait, and can reach optimal outcome. Preface Acknowledgment Contents Part I: Introduction 1: Overview 1.1 Importance of Independent Gait 1.2 Requirements of Independent Gait 1.3 Prognosis of Gait Training 1.4 Goals of Gait Training 1.4.1 Long-Term Goals 1.4.2 Short-Term Goals 1.5 Need for Better Gait Training 1.6 Summary References 2: Anatomy and Physiology 2.1 Anatomy 2.1.1 Joints 2.1.1.1 Hip Joint 2.1.1.2 Knee Joint 2.1.1.3 Talocrural Joint (Tibiotalar Joint) 2.1.1.4 Subtalar Joint 2.1.1.5 Midtarsal Joints 2.1.1.6 Metatarsophalangeal Joints 2.1.2 Neuroanatomy 2.1.2.1 Cerebral Cortex Frontal Cortex Temporoparietal Cortex 2.1.2.2 Basal Ganglia 2.1.2.3 Brainstem 2.1.2.4 Cerebellum 2.1.2.5 Descending Motor Tract Corticospinal Tract Reticulospinal Tract 2.1.2.6 Central Pattern Generator 2.1.2.7 Motor Unit 2.1.3 Muscles 2.1.3.1 Paraspinal Muscles 2.1.3.2 Hip Flexor 2.1.3.3 Hip Abductors 2.1.3.4 Tibialis Anterior 2.1.3.5 Peroneal Muscles 2.1.3.6 Calf Muscles Soleus Gastrocnemius 2.2 Physiology 2.2.1 Mode of Muscle Contraction 2.2.1.1 Open Kinetic Chain Muscle Contraction 2.2.1.2 Closed Kinetic Chain Muscle Contraction 2.2.1.3 Concentric Muscle Contraction 2.2.1.4 Eccentric Contraction 2.2.1.5 Isometric Contraction 2.2.1.6 Co-contraction 2.2.2 Sensory System 2.2.2.1 Somatosensory System Skin Receptors Sensory Proprioception 2.2.2.2 Vision 2.2.2.3 Vestibular Sensory 2.2.2.4 Sensory Integration 2.2.2.5 Sensory Redundancy 2.2.3 Synergy 2.2.4 Cognition 2.2.5 Balance 2.2.5.1 Steady-State Balance 2.2.5.2 Proactive Balance 2.2.5.3 Reactive Balance 2.2.6 Dual-Task Interference 2.3 Pathophysiology 2.3.1 Motor Learning 2.3.2 Neuroplasticity 2.3.3 Weakness 2.3.4 Paresis 2.3.5 Detraining 2.3.6 Regaining Function 2.3.6.1 Recovery 2.3.6.2 Compensation 2.3.7 Learned Nonuse 2.3.8 Increased Muscle Tone 2.4 Summary References 3: Normal Gait 3.1 Definition of Gait 3.2 Requirements of Normal Gait 3.3 Energy Conservation 3.3.1 Conversion of Energy 3.3.2 Minimizing Movement of the Center of Mass 3.3.3 Optimization of Muscle Contraction 3.3.4 Energy Storage and Release 3.4 Adaptation to Need 3.5 Velocity of Gait 3.6 Toe Out 3.7 Stride Width 3.8 Gait Cycle 3.8.1 Division of the Gait Cycle 3.8.2 Initial Contact Phase 3.8.3 Loading Response Phase 3.8.4 Mid-Stance Phase 3.8.5 Terminal Stance Phase 3.8.6 Pre-Swing Phase 3.8.7 Initial Swing Phase 3.8.8 Mid-Swing Phase 3.8.9 Terminal Swing Phase 3.9 Summary References 4: Abnormal Gait 4.1 Effects of Abnormal Gait 4.2 Evaluation of Abnormal Gait 4.3 Causes of Abnormal Gait 4.3.1 Weakness 4.3.1.1 Hip Flexor Weakness 4.3.1.2 Hip Extensor Weakness 4.3.1.3 Hip Abductor Weakness 4.3.1.4 Hip Internal Rotator Weakness 4.3.1.5 Knee Extensor Weakness and Paresis 4.3.1.6 Ankle Dorsiflexor Weakness 4.3.1.7 Ankle Evertor Weakness 4.3.1.8 Ankle Plantar Flexor Weakness/Paresis 4.3.2 Loss of Flexibility 4.3.2.1 Causes of Loss of Flexibility 4.3.2.2 Effects of Loss of Flexibility 4.3.2.3 Hip Flexion Contracture 4.3.2.4 Hip Adductor Spasticity 4.3.2.5 Quadriceps Spasticity 4.3.2.6 Knee Flexion Contracture/Hamstring Spasticity 4.3.2.7 Ankle Plantar Flexor Contracture/Spasticity 4.3.3 Pain 4.3.4 Sensory Disorders 4.3.4.1 Impaired Somatosensory 4.3.4.2 Impaired Vision 4.3.4.3 Impaired Vestibular Sensory 4.3.5 Balance Problems 4.3.5.1 Cerebellar Ataxia 4.3.5.2 Cautious Gait 4.4 Classification of Abnormal Gait by Gait Pattern (Kinematics) 4.4.1 Causes of Abnormal Gait Patterns 4.4.2 Abnormal Movement of the Trunk 4.4.2.1 Importance of Vertical Trunk 4.4.2.2 Side Lean 4.4.2.3 Forward Lean 4.4.2.4 Backward Lean 4.4.3 Abnormal Movement of the Pelvis 4.4.3.1 Anterior Pelvic Tilt 4.4.3.2 Posterior Pelvic Tilt 4.4.3.3 Contralateral Pelvic Drop 4.4.3.4 Ipsilateral Pelvic Drop 4.4.3.5 Pelvic Hike 4.4.4 Abnormal Movement of the Hip 4.4.4.1 Hip Circumduction 4.4.4.2 Excessive Hip Abduction 4.4.4.3 Excessive Hip Adduction 4.4.4.4 Excessive Hip Flexion 4.4.4.5 Limited Hip Flexion 4.4.4.6 Past Retract 4.4.4.7 Excessive Hip External Rotation 4.4.4.8 Excessive Hip Internal Rotation 4.4.5 Abnormal Movement of the Knee 4.4.5.1 Genu Recurvatum (Knee Hyperextension) 4.4.5.2 Limited Knee Flexion 4.4.5.3 Excessive Knee Flexion 4.4.5.4 Wobble 4.4.5.5 Excessive Valgus of the Knee Joint 4.4.5.6 Excessive Varus of the Knee Joint 4.4.6 Abnormal Movement of the Ankle 4.4.6.1 Excessive Plantar Flexion 4.4.6.2 Premature Heel Off 4.4.6.3 Delayed Heel Off 4.4.6.4 Lack of Heel Off 4.4.6.5 Excess Ankle Dorsiflexion 4.4.6.6 Prolonged Heel Only 4.4.7 Abnormal Movement of the Subtalar Joint 4.4.7.1 Excess Eversion 4.4.7.2 Excess Inversion 4.4.8 Abnormal Movement of the Toes 4.4.8.1 Clawed Toe 4.4.8.2 Excess Toe Extension 4.4.8.3 Limited Toe Extension 4.5 Summary References Part II: Evaluation 5: Assessment of Gait 5.1 Assessment of Participation 5.1.1 Self-Reported Measures 5.1.2 Ambulatory Monitoring 5.2 Qualitative Tests Using Single Items 5.3 Classification of Gait Function 5.4 Quantitative Assessment Using Single Items 5.4.1 Gait Velocity 5.4.2 Timed Up and Go Test 5.4.3 Step Length 5.4.4 Stride Length 5.4.5 Step Frequency/Cadence 5.4.6 Step Width 5.4.7 Endurance 5.5 Assessment Using Gait Pattern (Kinematics) 5.5.1 Observational Gait Analysis 5.5.2 Optoelectric Analysis System 5.5.3 Systems Using Motion Sensors 5.5.4 Smartphone Apps 5.6 Assessment Using Kinetics 5.7 Summary References 6: Assessment of Muscle Strength 6.1 Overview of Muscle Strength Test 6.1.1 Importance of Muscle Strength 6.1.2 Purpose of Muscle Strength Test 6.1.3 Proper Test of Muscle Strength 6.1.4 Field Tests 6.2 Manual Muscle Test 6.2.1 Overview of the Manual Muscle Test 6.2.1.1 Types of Muscle Contractions 6.2.1.2 Use of Qualitative Terms 6.2.1.3 Modes of Test 6.2.2 Grading of Muscle Strength 6.2.2.1 Muscle Strength Grade 1 6.2.2.2 Muscle Strength Grade 2 6.2.2.3 Muscle Strength Grade 3 6.2.2.4 Muscle Strength Grade 4 6.2.2.5 Muscle Strength Grade 5 6.2.3 Limitations of the Manual Muscle Test 6.3 Tests Using Closed Kinetic Chain Muscle Contraction 6.3.1 Heel Lift 6.3.2 Sit-to-Stand Test 6.3.3 Bridging 6.3.4 Squat Using Both Lower Limbs 6.3.5 Squat Test Using One Lower Limb 6.4 Dynamometer 6.4.1 Overview 6.4.2 Handheld Dynamometer 6.4.3 Isokinetic Dynamometer 6.4.4 Traction Dynamometer 6.5 Force Plate 6.6 Sliding Tilt Table 6.7 Test of Individual Muscles 6.7.1 Spinal (Back) Extensor 6.7.2 Hip Internal Rotator 6.7.3 Hip Flexor 6.7.3.1 Grade 2 6.7.3.2 Grade 3 6.7.4 Hip Abductor 6.7.5 Knee Extensor 6.8 Assessment of Power 6.9 Summary References 7: Assessment of Balance 7.1 Importance of Balance 7.2 Role of Balance Tests 7.3 Principle of Balance Tests 7.4 Safety 7.5 Subjective Perception of Balance 7.6 Assessment of Steady-State Balance 7.6.1 Sitting Balance 7.6.2 Standing Balance 7.6.2.1 Two-Legged Stance 7.6.2.2 Clinical Tests for Sensory Interaction in Balance 7.6.2.3 Single-Leg Stance Test 7.7 Assessment of Proactive Balance 7.7.1 Sitting Balance 7.7.2 Standing Balance 7.7.2.1 Functional Reach Test 7.7.2.2 Step Test 7.7.2.3 Timed Up and Go Test 7.7.2.4 Single-Leg Squat 7.8 Reactive Balance 7.8.1 Reactive Sitting Balance 7.8.2 Reactive Standing Balance 7.9 Balance Test Batteries 7.9.1 Berg Balance Scale 7.9.2 Balance Evaluation System Test 7.9.3 Community Balance and Mobility Scale 7.9.4 Fullerton Advanced Balance Scale 7.9.5 Performance-Oriented Mobility Assessment 7.10 Tests Using Force Plates 7.11 Summary References Part III: Training 8: Principle of Gait Training 8.1 Safety 8.2 Active Role of the Patient 8.3 Forced Use 8.4 Progressive Training 8.5 Feedback 8.6 Declarative Learning 8.7 Specificity of Training 8.8 Intensity 8.8.1 Amount of Training 8.8.2 Difficulty of Tasks 8.9 Motivation 8.10 Variable Training 8.11 Detraining 8.12 Gait Training Cycles 8.13 Facilitate Engagement with the Exercise Program 8.14 Summary References 9: Muscle Strengthening 9.1 Relationship Between Strength and Gait 9.2 Mechanisms of Muscle Strengthening 9.2.1 Lower Motor Neuron Lesions 9.2.2 Upper Motor Neuron Lesions 9.3 Principles of Muscle Strengthening 9.3.1 Appropriate Amount of Resistance 9.3.1.1 Lower Motor Neuron Lesions 9.3.1.2 Upper Motor Neuron Lesions 9.3.2 Postural Stability 9.3.3 Training Specificity 9.3.4 Control of the Effect of Gravity 9.3.5 Mode of Strength Training 9.4 Facilitation of Muscle Contraction 9.4.1 Functional Electrical Stimulation 9.4.2 Weight-Bearing 9.4.3 Change of Joint Alignment 9.5 Strengthening with a Closed Kinetic Chain Exercise 9.5.1 Bridging 9.5.1.1 Bridging with Two Legs 9.5.1.2 Bridging with One Leg 9.5.2 Sit-to-Stand 9.5.3 Squat with Two Legs 9.5.4 Single-Leg (Mini) Squat 9.5.5 Heel Lift 9.6 Exercise with Elastic Band 9.7 Exercise with a Sliding Tilt Table 9.7.1 Components of the Sliding Tilt Table 9.7.2 Characteristics of a Sliding Tilt Table 9.7.3 Advantages of a Sliding Tilt Table 9.7.4 Setup of a Sliding Tilt Table Before Exercise 9.7.5 Training with One Lower Leg 9.7.5.1 Training with Correct Motion 9.7.5.2 Amount of Resistance 9.7.5.3 Correcting Hip External Rotation when Training with a Sliding Tilt Table 9.7.5.4 Facilitate Lower Extremity Extension 9.7.5.5 Facilitate Lower Extremity Flexion 9.7.5.6 Correcting Uncontrolled Flexion of the Lower Limb 9.7.5.7 Correcting Knee Hyperextension 9.7.5.8 Ensuring Full Range of Motion 9.7.5.9 Maintaining Heel Contact 9.7.5.10 Training People with Wounds or Localized Pain 9.7.6 Training with Both Lower Limbs 9.7.6.1 Individuals with Lower Motor Neuron Lesion 9.7.6.2 Individuals with Upper Motor Neuron Lesion 9.7.7 Heel Lift Using a Sliding Tilt Table 9.7.7.1 Heel Lift Using a Single Lower Limb on a Sliding Tilt Table 9.7.7.2 Heel Lift Using Both Lower Limbs on a Sliding Tilt Table 9.8 Strengthening of Individual Muscles 9.8.1 Back Extensors 9.8.2 Hip Flexors 9.8.3 Hip Extensors 9.8.4 Hip Abductors 9.8.5 Hip Internal Rotators 9.8.6 Knee Extensor Strengthening 9.8.7 Ankle Dorsiflexor Strengthening 9.8.8 Ankle Plantar Flexor Strengthening 9.9 Power Training 9.10 Summary References 10: Balance Training 10.1 Effectiveness of Balance Training 10.2 Principles of Balance Training 10.2.1 Safety 10.2.2 Anxiety of Falling 10.2.3 Reduce the Base of Support 10.2.4 Movement of the Center of Mass 10.2.5 Progressive Training 10.3 Sitting Balance Training 10.3.1 Head Control Training 10.3.2 Steady-State Balance Training 10.3.3 Proactive Balance Training 10.3.4 Reactive Balance Training 10.4 Standing Balance Training 10.4.1 Steady-State Balance Training 10.4.1.1 Steady-State Balance Training with Both Lower Limbs 10.4.1.2 Steady-State Balance Training with a Step 10.4.1.3 Single-Leg Standing 10.4.2 Proactive Balance Training 10.4.2.1 Weight Shift at Level Ground 10.4.2.2 Weight Shift with a Step 10.4.2.3 Step-Up 10.4.2.4 Step-Down Movement 10.4.2.5 Step-Down-Touch (-the-Floor) 10.4.2.6 Single-Leg (Mini) Squat 10.4.2.7 Foot Reach 10.4.2.8 Step Touch 10.5 Balance Training with Equipment 10.6 Reactive Balance Training 10.7 Summary References 11: Flexibility 11.1 Importance of Flexibility 11.2 Maintaining Flexibility 11.3 Principles of Stretching 11.3.1 Focused Stretching 11.3.2 Minimize Resistance to Stretching 11.3.3 Appropriate Amount of Stretching 11.3.4 Sustained Stretch 11.4 Methods of Stretching 11.4.1 Manual Stretching 11.4.2 Stretching with Orthosis 11.4.3 Serial Casting 11.4.4 Stretching in a Standing Posture 11.4.5 Stretching with a Machine 11.4.5.1 Continuous Passive Motion Machine 11.4.5.2 Tilt Table 11.4.5.3 Sliding Tilt Table 11.5 Summary References 12: Task-Specific Gait Training 12.1 Definition of Task-Specific Gait Training 12.2 Level Ground (Overground) Gait Training 12.3 Gait Training with a Cane 12.4 Gait Training with Parallel Bars 12.5 Gait Training with a Treadmill 12.6 Body Weight-Supported Training 12.6.1 Body Weight-Supported Overground Training 12.6.2 Body Weight-Supported Treadmill Training 12.7 Gait Training with Functional Electrical Stimulation 12.8 Gait Training with Robots 12.9 Summary References 13: Task-Oriented Gait Training 13.1 Definition of Task-Oriented Gait Training 13.2 Evidence of Effectiveness of Task-Oriented Gait Training 13.3 Principles of Task-Oriented Gait Training 13.3.1 Strengthening Before Balance Training 13.3.2 Maximize Function of the Affected Limb 13.3.3 Safety 13.3.4 Progressive Training 13.4 Sequence of Gait Training 13.4.1 Muscle Strengthening of Weight-Supporting Muscles 13.4.2 Training for Steady-State Standing Balance 13.4.3 Training for Proactive Standing Balance 13.4.4 The Reasons for Placing Overground Gait Training at the End 13.4.5 Training People with Severe Ankle Plantar Flexor Weakness 13.5 Advantages of Step-by-Step Task-Oriented Gait Training 13.6 Summary References 14: Gait Training for People with Specific Diseases 14.1 Stroke 14.2 Traumatic Brain Injury 14.3 Spinal Cord Injury 14.4 Parkinson’s Disease 14.5 Cerebral Palsy 14.6 Knee Osteoarthritis 14.6.1 Hip Surgery 14.7 Elderly People with Gait Disability 14.8 Summary References 15: Abnormal Gait 15.1 Cautious Gait 15.2 Genu Recurvatum (Knee Hyperextension) 15.3 Poor Foot Clearance 15.4 Gait with Foot Inversion 15.5 Circumduction Gait 15.6 Ataxic Gait 15.7 Frontal Lobe Gait 15.8 Summary References 16: Others 16.1 Other Gait Training 16.2 Training Using Dual Tasks 16.3 Reactive Balance Training 16.4 Training Going Up and Down Stairs 16.5 Dizziness 16.6 Sensory/Perception Test 16.6.1 Hemispatial Neglect 16.6.2 Proprioception 16.7 Program to Maintain Function 16.8 Walking Aids (Assistive Devices) 16.8.1 Cane 16.8.2 Stick 16.8.3 Walker 16.9 Orthoses 16.9.1 Ankle-Foot Orthoses 16.9.2 Knee Orthoses 16.10 Summary References