PARTICULARITIES OF GAIT REHABILITATION IN ADULT

HEMIPLEGIC PATIENTS

Lucaci P. (Lucaci Paul)¹, Neculăeş M (Neculăeş Marius)¹

¹ “Alexandru Ioan Cuza” University, Iaşi, Romania, Faculty of Physical Education and Sport
E-mail: lucacipaul91@yahoo.com

Abstract
This study aims at underscoring the importance of gait rehabilitation process in adult hemiplegic patients
and the necessity of individualizing the treatment by the type of stroke, by its location and gravity. The study was
conducted on a sample of thirty-one patients diagnosed with hemiplegia, who benefitted from significant outcomes
concerning gait rehabilitation, after a particularized application of rehabilitation programs. Long-term rehabilitation
programs and the patient’s interest for regaining independence represent the motivational engine and the main pillar
for attaining the proposed and expected outcomes. Thanks to these programs, the patients managed to walk on their
own; as for locomotion under difficult circumstances, subjects have benefitted from increased degree of movement
autonomy.

Keywords: locomotion re-education, kinesiotherapy, movement autonomy, parameters.

Introduction
Rehabilitation assistance has always focused on the sequelae of neurological diseases;
among them, hemiplegia came first, in terms of both frequency and the great results achievable
through functional re-education. [4]
Clinical studies, anatomopathological data, and the development of modern
neuroimagistic technique allow the pinpointing of hemiplegia physiopathology, thus providing
the premises for understanding the normal and pathological biological process, in order to offer
more efficient therapies.
Gait implies a coordination action that requires a corresponding integration of the sensory
and motor functions. [1]
In order to walk, the hemiplegic uses to the maximum the remaining muscular functions,
which entails an alteration of step structure. The alteration of the stance and the swing phase is
due to the following phenomena: positive support response, negative support response, and
crossed extensor reflex. [3]
During gait, the plegic lower limb remains rigid and it describes a circular motion,
because it is projected forward through the pelvic swing. The kinesiotherapist must teach the
patient how to walk, first using parallel bars, then a cane, and eventually without any support.
Kinesiotherapy also plays the crucial role of providing stability to gait, by equalizing as much as
possible the frontal symmetrical motor skills and by establishing their accurate sequence in
sagittal plane, all of them in optimal relation with the floor. [5]
The coordination of a movement, wrote Bernstein, represents the process of controlling
the multiple possibilities of movement, characteristic to all organisms in motion; more precisely,
the conversion of these movements into a determinate structure. The multiple movement
possibilities can be reduced by connecting muscles to joints, so that they can act together as a
whole or as a synergy; the goal is to simplify movement coordination. Such a connexion is
greatly illustrated in the co-operation between the muscle force of the hip, the knee, and the
ankle, to produce a support force that provides complete safety to the leg. [2]
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 Gait involves a basic locomotion model adapted to the demands of the environment and
to the obstacles that it may entail: border stones, stairs, etc. Among the ways that a hemiplegic
may use for coping with the variable conditions of the environment and for improving his gait
performance, I mention the following: walking in a crowded hallway, crossing the street fast
enough to ensure safety, going up and down the stairs, walking through automatic doors, walking
on top of or under obstacles, climbing platforms, walking in various light conditions. The patient
must practice this type of exercises to identify the potential dangers and to build his own
strategies for solving more difficult situations. The ability to walk fast or to overcome obstacles
represents a very important factor for the security of the hemiplegic.
Gait is an important factor for reinserting the hemiplegic in the society; such reinsertion
is far from easy and it cannot be accomplished directly; it requires a family stage, in its turn
conditioned by the patient’s state. It may be attained if he is autonomous enough, if his mental
state does not make him prone to a catastrophe when left alone, if the family has a free caregiver
to take him over, to help him, and to improve the rehabilitation level achieved up to that moment.
Methods
The study was conducted on a sample of thirty-one adult hemiplegic patients, who were
advised to benefit from kinesiotherapy, accompanied by continuous training of locomotion.
Through the Tinetti mobility test, we analyzed several components of gait: gait initiation,
step length, step continuity, walking itinerary deviation, torso movement, and distance between
heels while walking.
For gait assessment, we tested the step pace, the step length, and the distance covered
within two minutes. Step pace and distance were tested with the help of the Omron Walking
Style Pro pedometer, which calculates mean velocity, distance, and number of steps per time
unit. In order to calculate step length, the subjects stepped on talc powder in order to have their
plantar print on the floor. After asking them to do ten steps, we measured the distance covered
and then we divided it by ten, thus determining a mean step length for each patient.
We began the gait re-education exercises between parallel bars. Therefore, first the
patients had to walk forward with support on the bars, to walk by stepping on obstacles, and to
walk on the sides. In order to re-educate motion autonomy, we determined various paths with the
patients, such as walking through pegs, walking by stepping on thresholds, walking on the sides,
going up and down the stairs. Furthermore, in order to improve the spatio-temporal variables
(step pace, step length, and distance covered per time unit), the patients walked on the treadmill.
Within rehabilitation programs, we insisted on maintaining muscle elasticity, as well as
on the muscles of triceps surae, and on the Achilles tendon.
Findings
We analyzed the results in SPSS, which provided us information regarding this study, by
comparing the initial data on the sample of patients with the final results. We were interested in
the step pace, the simple step length, the distance covered within two minutes, and the “Get up
and walk” test.

Table 1 – analysis of initial and final results of the “get up and walk” test, step pace,
simple step length, distance covered within 2 minutes, by arithmetic mean.

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 Following
this analysis, by
comparing the initial
and the final stage, we
highlight a positive
evolution of arithmetic mean of the four parameters of reference (“get up and walk” test, step
pace per minute, simple step length, distance covered within 2 minutes). Furthermore,
concerning standard deviation, it is worth highlighting higher variation of results obtained in step
pace per minute. Concerning the other areas of evaluation, standard deviations have close values.
Table 2 – differences between initial evaluation and final evaluation concerning the
parameters of the “get up and walk” test”, step pace, simple step length (cm), and distance
covered within 2 minutes (m).

The

statistical analysis allowed us to pinpoint significant differences between the initial and final
evaluation of the “get up and walk” test (mean: 0.77); between the initial testing of step pace per
minute and the final testing (mean: -13.29); between the initial testing of simple step length (cm)
and the final testing (mean: -6.41); between the initial evaluation of distance covered within 2
minutes (m) and between the final evaluation (mean: -8.80). This attests the efficiency and
importance of kinetic activities in the rehabilitation of patients who suffered a stroke. The t test
for independent samples in the Table above for p=0 argues this hypothesis statistically.
Table 3 – correlation between the variables of initial and final evaluation of the score for
the “get up and walk” test”.

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 By analyzing the correlation between the initial evaluation variables of the “get up and
walk” test score and the final evaluation of the “get up and walk” test score, we obtained the
correlation coefficient r=0.79, a significance level p=0.0, and the number of subjects N=31. The
significance level obtained shows a strong connection between the variables used, because it
exceeds 0.50 (r=0.79).
Graph 1 – correlation between the variables of initial and final evaluation of the score
for of the “get up and walk” test”.

The correlation graph is an ascending cloud of points (from lower-left to upper-right)

because the relation is positive or directly proportional.

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 Table 4 – correlation between the variables of initial and final evaluation for step pace.

By analyzing the correlation between the variables of initial testing evaluation for step
pace/minute and the final testing for step pace/minute, we obtained the correlation coefficient
r=0.90, a significance level p=0.0, and the number of subjects N=31. The significance level
obtained shows a strong connection between the variables used, because it exceeds 0.50 (r=0.90).
Graph 2 – correlation between the variables of initial and final evaluation for step pace.

The correlation graph is an ascending cloud of points (from lower-left to upper-right)

because the relation is positive or directly proportional.
Table5 – correlation between the variables of initial and final evaluation for simple step
length (cm).

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 By analyzing the correlation between the variables of initial testing for simple step length
(cm) and the final testing a simple step length (cm), we underscore the correlation coefficient
r=0.93, a significance level p=0.0, and the number of subjects N=31. The significance level
obtained shows a strong connection between the variables used, because it exceeds 0.50 (r=0.93).
Graph 3 – correlation between the variables of initial and final evaluation for simple step
length (cm).

The correlation graph is an ascending cloud of points (from lower-left to upper-right)

because the relation is positive or directly proportional.
Table 6 – correlation between the variables of initial and final evaluation of the distance
covered within 2 minutes (m).

By analyzing the correlation between the variables of the initial evaluation of the distance
covered within 2 minutes (m) and the final evaluation of the distance covered within 2 minutes
(m), we highlight the correlation coefficient r=0.85, a significance level p=0.0, and the number
of subjects N=31. The significance level obtained shows a strong connection between the
variables used, because it exceeds 0.50 (r=0.85).

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 Graph 4 – correlation between the variables of initial and final evaluation for the
distance covered within 2 minutes (m).

The correlation graph is an ascending cloud of points (from lower-left to upper-right)

because the relation is positive or directly proportional.
As illustrated in the Graphs below (5, 6, 7, 8), the results obtained within our research
demonstrate and validate the theory of the improvement of assessed parameters, from the initial
to the final evaluation. It is apparent that all parameters, without any exception, recorded
progress.

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 Conclusions
Gait rehabilitation in adult hemiplegic patients represents a necessity because the family
and socio-professional reintegration depends upon their degree of independence. Hemiplegia
involves a complex clinical picture, while the rehabilitation possibilities and limits are closely
connected to the gravity of the lesion, the patient’s age, his biological capacity, the moment of
treatment debut, as well as certain objective factors. In this sense, we mention the patient’s co-
operation and his participation and scrupulosity in the application of therapeutic programs. A
very important aspect is represented by kinesiotherapy at home, and mostly by the optimization
of gait training under various and difficult environmental circumstances, which will help patients
acquire more stability and safety during movement.
Within this study, through the initial and final evaluation, we have noticed an
improvement of the remaining functions of subjects. Through kinesiotherapy programs and daily
walking, they improved their gait parameters significantly.
The final conclusion of this study highlights that the application of a therapeutic plan
adapted to the particularities of adult hemiplegic patients and walking in different conditions lead
to a more effective rehabilitation of locomotion.

References
1. Geraint Fuller, Neurological Examination Made Easy, Callisto, third edition.
2. Janet H. Carr, Stroke rehabilitation, Butterworth Heinemann, 2004.
3. Mariana Cordun, Medical Kinesiology, Axa Publisher, 1999.
4. Sbenghe Tudor, Prophylactic, Therapeutic and Rehabilitation Physical Therapy,
Medical Publisher, Bucharest, 1987.
5. Tiberiu Vlad, Liviu Pendefunda, Recovery of hemiplegic adult patient, International
Contact Publisher, Iaşi, 1992.

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