cva pt walking with stiff knee in swing fase

[physiogeak]

Hi guys (and girls)

I have a 2 months post stroke cva pt walking with a stiff knee in swing fase
the knee is mobile enough but he keeps it in about 10-15 degrees the whole swingfase. a lot of tension in the quadriceps, no push off.

what could be the causes?
which exercises could I do to try to improve the knee movement during the swing fase?

thanks a lot i am very curious

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[clarett]

what's the tension like in hamstrings and why is there no push off? Is it due to lack of gastroc activity? I'm assuming that he is hip hitching to achieve swing through...correct me if I'm wrong.
Does he achieve heel strike?
It would be helpful to know what's happening at the hip & pelvis too. Especially active hip flexion in standing.
It's difficult to know what might help/be causing it without more information....

What is he like kicking a ball - does he fully extend the knee doing this or does he hold it in the same position?

Sorry - more questions that answers at this stage!

[physiogeak]

thank you for reacting to my post Clarett!

what's the tension like in hamstrings?:
There is a lot of tension in the hamstring as well as in the quadriceps during the swingphase, the quadriceps is so tight it seems to prevent the knee flexion. He therefore has a light circumduction

and why is there no push off? Is it due to lack of gastroc activity?:
There is a little more push off when is steps are bigger (I tried that now). In standing he has enough gastroc activity to lift his heels from the floor, but still not enough selectivity to actively create the push off during walking.

I'm assuming that he is hip hitching to achieve swing through...correct me if I'm wrong:
Only a little bit

Does he achieve heel strike?:
no he does not achieve heel strike because of lack of sufficient active knee extension.

It would be helpful to know what's happening at the hip & pelvis too. Especially active hip flexion in standing. He has a good active hip flexion while standing and while walking

It's difficult to know what might help/be causing it without more information....

What is he like kicking a ball - does he fully extend the knee doing this or does he hold it in the same position?:
I tried this and he keeps the knee in the same position only moving from the hip (and partly the torso)

Sorry - more questions that answers at this stage!


I gave him an AFO to correct the mild spasticity in the gastroc and the varus in the ankle.
I practice selectivity of his leg lying down and standing but his gait pattern is only improving a little bit (a little more knee flexion). When he walks with bigger steps and a little bit of speed it looks a little better as well.

Overall he’s doing a good job in rehab and his stability during walking has improved tremendously (no aid and safe) but this is an obstacle to try to overcome, a challenge, but a hard one.

[physiogeak]

Does he achieve heel strike?:
no he does not achieve heel strike because of lack of sufficient active knee extension.

He CAN however extend his knee way further while sitting down. but during walking he's not able to do it to make a (decent) heelstrike

[clarett]

Ok - thanks for the extra details.

Try practising kicking a ball as this mimics swing phase and you can easily break it down. Start in a high sitting position (the higher the better but dependent on ability - he needs to achieve active knee extension) as this will fix the hip and he can concentrate on knee extension. As active extension gets easier - get the position higher and the support less i.e. gradually working up into full standing.
You could also try some PNF both for knee extension & flexion
Squats without UL support and actively using hip & knee flexors to pull DOWN into the squat may also help (you may need to provide resistance in lying to give the patient a sensation of this - normally we just let gravity take us down.)

Also practise marching- if he is circumducting when walking he's going to get a pattern of shortening in the trunk & daily practising of marching (as you need no push-off & little knee flexion) will give him time to left his pelvis drop on that side. It's also good to practise arm swing at the same time which helps with appropriate trunk movement (or lets you see if there isn't) and can challenge balance/co-ordination. If he can't let the hip drop then work on it as this may be adding to the effect of the quads & hamstrings in inhibiting knee activity.
Are you practising push-off in active stance and assisting gastroc contraction?

It seems that the patient has overactivity of quads & hams which could be to decreased trunk stability (?) or as compensation for inactivity further down the chain. You could try taping to inhibit the action of both while walking but this is unlikely to help if gluts & abs are not providing sufficient stability.

Good luck and keep us updated!

[physiogeak]

we're practicing push-off in active stance and assisting gastroc contraction, thats getting better.

I tried the ball kicking and i did not work so I tried to find out why. I found out he has significant speed related spasm and clonus as well which prevents him form being able to extend the knee.

and... he has indeed a strong cocontraction of the knee flexors and extensors during the swing phase. partly seems to be trunc related (as you mentioned), thank you. We are working on that.

I arranged a gait analysis for him, consisting of manual research, EMG, goniometrie, etc.

Lets see what comes out.

best regards and thank you

[physiogeak]

spasm in the hamstrings when ext the knee during swingphase

[clarett]

Let us know how it goes...

Good luck

[catherine]

Sounds like a pretty classic positive support reaction - check the foot, mob anything that's vaguely stiff, de-sensitise and handle the sole. Get the client to walk around the house with bare feet. Quite difficult to elicit change unless client can have a blast of therapy as positive support reactions tend to be adopted by the CNS quite easily. Good luck

[fire_ice]

hello ,
was going through ur conversation i would like to make some suggestions, just move the limb passively in knee flexion and extension , it seems that both r tight , start with stretching of about 30 min each muscle ,if u wanna lenghtening of muscles by lengthening of sarcomere.......as the results r slow so have some patience u will c the results,no heel strike suggests that the TA might be tight too, does the patient goes for hyperextension of knee in the midstance if he tries to extend the knee,also check the hip flexors may be thay r holding the leg stiff if they r tight ........ hope u will find ur answer.....
thx

[siva_ji]

After seeing the details regarding the patient’s gait, it may be due to excessive coactivation of both flexors and extensors of knee joint during swing phase. He lacks reciprocal relationship between both muscle groups. If the case is like that try my ideas and I hope it will work.
Train his hip and knee flexion gait pattern in all 3 stages of swing phase (acceleration, midswing and deceleration).
To train initiation of gait (preswing and acceleration)- position the patient in step standing with affected leg behind with a bolster in between the legs, therapist’s position- kneel behind the patient with one hand supporting the forward leg pelvis and other hand over the shin of tibia of affected leg. Ask him to clear the ground and give him tactile cues through shin of tibia by sliding ur hand downwards and little backward to bend the knee. This will facilitate knee bending during initial stage of swing phase and also push off .
Midswing- patient stands on single leg with affected leg over a small stool and ask him to touch an object kept at reachable distance in front. This will bring knee flexion and extension in mid ranges, which will reduce coactivation of both muscle groups. You could train ball kicking in this stage.
Deceleration- same position as I mentioned for midswing but the affected leg is over bolster or roller skates. Ask him to roll it forward and bring it back. This will facilitate ankle dorsiflexion too.(check Hams length)
Note:It is not mandatory to train all in one session. Repetition is necessary to learn. For additional effect give pressure to the muscle bulk to activate it in correct timings. Ensure the patient balance and give additional support during training if he needs (parallel bar, stick support or others support etc). Don’t give resistance this may stimulate unwanted activation of other muscle group.

[rose]

i am following your conversation and discussion and i am agree with siva ji about pt seems he had cocontraction of both knee flexors and extensors dyscoordination of the muscles actions..the patint is rigid and it looks like basal ganglia or thalamus injury would please tell me if he had it or not..??
mecconall have a taping approch for individuals waliking with hyperextension of the knees try it it may works to inhibit the quads in loading responce and helps the hamistring to have chance to initiat the movement..
let the patint stand on one leg and the affected leg on low step and start the tape from posterior superior femoral condylesand the tape will end in inferior to tibial tuberosity so it will cross anteriorly with each other.so the patint will walk with flexion pattern of affected leg.
try this exercise let the patient stand on 5 cm and the as progresion on 10cm hight step and let him step with the souned leg backward and down to the grauned and the affected leg will stay on the step and becarfull he will need you support.
good luck with your patient i hope he will improve.

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[sandy_sana]

[hai i did check with your conversation so have you ever tried with HYDROTHERAPY,just take the patient near the swimming pool or even inside the pool and try doing ADL ,patient may be more comfortable as well muscles would be relaxed in water ,just try it and let me also know the result

[spandanphysio]

hello every1 i use step exs. as sandy mention.try initially low stool with affected leg on stool than ask the pt to climb stool 1st unaffected leg backwards than sideways to.it includes coordination in bot close and open chain as it requires in normal gait.also do mat activitir like bridging,kneel snading,kneel walking ,kneeling,reachout in kneeling.also do resisted movt. in supine.resistance should not be maximum.as it may increaswd spasticitiy.