This Case Study describes the gait of a patient who suffered from a cerebrovascular accident, commonly known as stroke.
Mrs. B is a 68-year old female who suffered a stroke due to a thrombotic blockade of the internal carotid artery, approximately 4 months ago. As a result of the stroke, Mrs. B had hemiparesis of the upper and lower extremities of her dominant right side.
RIGHT Upper extremity: Flexion synergy with the typical hemiplegic resting posture.
RIGHT Lower extremity: Active ROM was impaired; passive ROM was within normal limits. Muscle strength was a 1+/5 for ankle dorsiflexion and plantarflexion. For knee flexion and extension, muscle strength was 1+/5. The hip muscles had better voluntary control, with hip flexor strength of 3/5 and hip extensor strength of 2-/5
LEFT Upper extremity: Active ROM was within functional limits. Muscle strength was a 4+/5
LEFT Lower extremity: Active ROM was within functional limits. Muscle strength was a 4/5
Reflexes, skin sensation and myotomes/dermatomes were all normal. Balance was impaired and endurance was low.
Following the initial gait assessment, it was determined that the patient’s intervention should focus on improving: Balance/Stability; Symmetry between the two limbs and Progression. An AFO with double upright metal joints was prescribed for providing ankle stability and improving balance. The patient also underwent 6 weeks of physical therapy for improving muscle strength and range of motion. The following video shows the patient’s gait after these interventions.
The Gait Comparison Chart was used to document changes in the patient’s gait pattern due to the AFO. Patient has a significant improvement in forward progression with the AFO. Her walking speed has increased significantly, as she is able to take a longer step with the Right lower limb. A longer step with the Right limb also indicates improvement in balance. Her energy consumption is lower as she no longer demonstrates the deviation of Right Thigh Retraction and does not hesitate to lower the Right limb on the ground. Introduction of the AFO did not improve the movement symmetry between the limbs, nor did it change the shock absorption mechanism. Since the AFO restricted movement at the ankle and introduced new deviations, the total number of deviations were the same with the AFO.
From the available sagittal plane videos, it is difficult to determine the patient’s step width and hip adduction angle. Hence, these deviations were not marked. When walking without the AFO, she has a greater than normal toe-out angle. With the AFO, she moves her Right limb into external rotation following heel strike, which results in a similar toe-out angle. Her step length is more asymmetrical with the AFO, as she is taking longer steps with the Right limb. As a result, her step length with the AFO has declined. Her stance time on the Right limb has increased and that on the Left limb has decreased, which has resulted in a significant improvement in stance time symmetry.
Overall, the patient’s gait shows a moderate improvement with the AFO and the patient is recommended to continue with the AFO. Since the AFO is only able to address the function of forward progression, additional physical therapy to address balance and symmetry is also recommended.
The completed gait comparison chart for this patient is given below.
Test your knowledge on the topics of this chapter. Click on the arrow on the Right to see the answer
In Thigh Retraction, a flexed hip and a flexed knee are observed at the end of the Swing interval. The patient has strong hip flexors, but weak knee extensors. As a result, patient is unable to extend the knee for ground contact towards the end of the Swing interval. Therefore, with a flexed thigh and a flexed knee (i.e. a vertical tibia), the only way to achieve ground contact with the foot is to retract the thigh, i.e. reduce the flexion angle of the thigh.
Multiple functions have been affected in this patient. The intervention can focus on improving
1) BALANCE, since the patient has poor balance on the Right side
2) EQUALITY / SYMMETRY, because his Left step length is much shorter than the Right step length.
3) ENERGY CONSUMPTION, since he flexes his trunk with each step, which increases energy consumption
4) PROGRESSION as he is unable to swing the Left limb sufficiently forward.