A common goal after a stroke or a brain injury is to regain “normal walking”. However, this goal is not limited to just those who have suffered a stroke. I dare say it is the number one goal of almost everyone who has suffered an injury to their neurologic system. And I get it. Walking is freedom. Putting one foot in front of the other (successfully) allows you to do the things that bring life meaning and purpose. But what if you have already met this goal? Maybe your goal is to go further and walk without an assistive device? Or, maybe your goals is to get rid of…………that “thing”………
Do you feel your walking is abnormal?
If this is you, you know what I mean. YOU know what that “thing” is. That “thing” you call a “peg leg”, a “lead weight”, or your “frankenstein (gait)”. Now, I can’t forget about those of you who have done your research. You all have given your “thing” a much more “classy” name. You might refer to your “thing” as “foot drop”, “knee recurvatum”, “trendelenberg gait”, or “a weak glute max”…..etc. Whatever the case may be, it feels wrong and unnatural. And I know, you want nothing more than to fix it. The good news is I am here to help.
You all were actually the inspiration behind this next installment in an entire series on how to re-learn how to walk after a stroke or a brain injury. In this post we are going build on what I started in the post on “walking after stroke in the early stages”, and “walking after stroke in the intermediate stage“
As if the title didn’t give it away, we are now moving on to the “advanced” stage in the progression.
What does it take to learn to walking (properly)?
To “normalize” walking, it is important to continue to focus on three key areas of the body. The hip, knee, and ankle. At each of these areas it is critical that you have full motion, and adequate motor control (muscles can generate appropriate force and coordinate muscle activation with other muscles). I have covered these extensively in the prerequisite blogs, the early stage and intermediate stage of walking.
To build on the aforementioned early and intermediate progressions, we are going to start to incorporate developmental patterns, and higher lever stance control (the ability to stand on the involved leg).
Using Developmental Patterns For Normal Walking
Developmental patterns are “movement milestones” that we learn during normal development. For example, rolling, crawling, kneeling, and half kneeling (kneeling on one knee). After damage to the brain, it is beneficial to revisit some of these patterns during the recovery process. There are two benefits to developmental patterns.
FIrst, they can help to inhibit abnormal synergy patterns. For example a common (abnormal) synergy pattern is extension. In this abnormal pattern, the knee, and hip tend to straighten at the same time and the foot has a tendency to point. This pattern does not and should not occur during any phase of the walking cycle. So needless to say, we need to start addressing this to “normalize” your walking pattern. We can do this by starting to implement developmental patterns.
Second, you are closer to the ground so in many cases the body is more relaxed and you can focus on some of those key body areas mentioned above.
In this progression, we are going to add tall kneeling.
Tall Kneeling Exercise #1
The starting point is to learn how to get into this position and maintain this position holding on to something for support.
Tall Kneeling Exercise #2
Once you feel comfortable in this position, the next step would be to work straightening the hip (hip extension). This is probably one of the most important “motor control components” of walking. The goal of this exercise is to relearn how to straighten the hip without also straightening the knee. To perform this exercise, start with your hips flexed (see image), and try and come up to the tall kneeling position without pulling up with your arms. make sure that when you perform this movement, you do not shift your body weight over your stronger leg. A mirror is helpful to make sure your body weight stays centered over you knees.
Tall Kneeling Exercise #3
Once you can perform tall kneeling with hip extension, you can add an arm raise straigth up toward the ceiling or an arm movement on a diagonal pattern. Adding the arms helps to start to “simulate” normal walking since we naturally move our arms when we walk. The diagonal patterns (shown in the intermediate progression in sitting) also helps to simulate a more natural “walking body motion”.
Improve Hip and Knee Control To Regain Normal Walking
Hip and knee control are essential to standing and walking. Sit to stand is a great way to develop this control. In this stage of the progression we are advancing this activity by moving down to a lower surface. Therefore it might be better to call this next exercise more of a a “squat” to stand. By going down to a much lower surface the hip and knee has to generate a TON more power to get up. At this height, the hip, knee, and ankle also need to work together (another critical component of walking).
Squat to Stand
Squatting to standing is the next progression in the sit to stand component of this series. In the intermediate progression we started from a standard height chair. The benefit of dropping down to a lower surface helps to eliminate compensating with your strong leg. Because let’s face it, most of us do not have the leg strength to get that rump up with just one leg. ? ?
Sit to Stand with Single Leg Bias
The next progression would be to return to the single leg bias exercise we started in intermediate phase. This time, again, you are gong to drop down to a lower surface. The thing I like about the stairs is that you have to keep the strong leg so far out in front (see image below) it is near impossible to use it to assist with this movement. ? Yes, I call that a little “therapist trickery” ?
Standing and Stepping Exercise to Regain Normal Walking after a Stroke
The previous progression included some activities to start learning how to unload the uninvolved leg. Thus increasing demand on the involved leg. This progression is intended to build on that by fulling unloading the involved leg. With that being said, this exercise is NOT the best exercise for anyone who does not have the strength in the involved leg to support their body weight. It is also not ideal for anyone with a severely supinated foot.
However, if you have adequate control in the leg, this is a great set of exercises.
Standing with Weight Shift
Standing with a Forward Step
Other Articles You May Be Interested In:
Do you ever have any "well-meaning" therapist tell you to stand up taller? 😬🤷🏻♀️ Well, you would not be alone. This is a pretty common problem that has a few different root causes. What causes a forward flexed posture? Weakness Weak hip muscles can potentially lead...
Can't lift a stiff leg? This is a pretty common problem that has a few different root causes. Knowing the root cause is the best way to identify the best exercises. What can make it difficult to lift a stiff leg? Weakness Weakness in the muscles that flex the hip...
One of many problems when the neurologic system is damaged are ankle contractures. A contracture is where the soft tissue structures surrounding a joint shorten causing loss of movement. What Causes a Contracture? There are several factors that can lead to an ankle...
Clonus is an involuntary, rhythmic muscle contraction followed by a relaxation. It is a sign that there is damage to the brain and/or the spinal cord (upper motor neuron). More specifically, the part of the nervous system that controls movement (descending motor...
Abnormal muscle synergies are one of the most common "movement problems" after a stroke or brain injury. What is an abnormal muscle synergy? A flexor synergy is when the hip, knee, and ankle all flex at the same time (visualize drawing your knee into your chest). An...
Spasticity is an involuntary muscle contraction due to damage to the brain or spinal cord. This can cause muscle stiffness and pain. Additionally, involuntary muscle contractions cause the body to move in ways that feel out of one’s control. This is turn can create...
Are you super eager to relearn to walk? Walking is a HUGE goal for anyone who has lost that ability. Walking means different things to different people. And quite honestly, has far less meaning until you have lost this fundamental skill. All that being said, it is...
Vaulting is a walking abnormality where someone will rise up on their toe to ensure their “swinging” leg clears the ground. Under normal conditions, the swinging leg must “shorten” as it passes by the ground. To “shorten” the leg the knee must bend and the foot must...
One big problem after a stroke or brain injury is the inability to dissociate body movement. Movement dissociation is the ability for segments of the body to move independent of other segments. In other words, body parts (and their movement) want to "couple together"...
How do you regain the ability to walk without fear of falling? Fear of falling is a MAJOR concern for a lot of people. In the early stages of rehabilitation, the goal is to regain movement control at the hip, knee, and ankle. This is necessary to ensure that someone...