Exercise Therapy

Observe during the initial part of the stance phase. Note any deviations from the normal repeat the process until completed assessment of all segments in the sagittal and frontal planes. Concentrate on one segment at a time in one part of the gait cycle. There are two GAIT are Determinants of GAIT and Pathological GAIT. The Determinants of GAIT are
i. Pelvic rotation: The pelvis rotates by 4 degree on either side and elevates the lower end of the center of gravity by 6/16″.
ii. Pelvic tilt: The pelvis drops on the side of swinging leg (action of abductors of opposite side). This saves vertical excursion by 3/16″.
iii. Knee flexion: During mid stance, this decreases leg length and height of center of gravity by 7/16″. Thus the total saving in the vertical excursion of Center of gravity 7/16″ + 3/16″ + 6/16″ = 1 inch. The other determinants function to smoothen out the movement of the Center of gravity.
iv. Knee and ankle: Movement smoothens out the vertical excursion to 2″ amplitude.
v. Pelvic sway: This is the sideways sway of pelvis, brings the center of gravity over 1 leg and produces a side to side sinusoidal curve.
vi. Limb rotation: The leg goes into a total of 25 degree internal rotation on stance and external rotation on swing, smoothening out the sideways curve. Stride Length: The distance between heel strike of one leg and heel strike of same teg. This is approximately 156 cm on an average.
vii. Step length: The distance between heels strike of one foot to heel strike of the other foot (1/2 of stride length).
viii. Stride Width: This is the distance between midline of one foot to mid line of the other. It works out to 8 cm + 4 cm.

GAIT or human locomotion may be described as a translator progression of the body as a whole produced by co-ordinated movements of body segments. It is the forward progression of the center of gravity of the body based on the reciprocal movements of the lower extremities. Normal GAIT is rhythmic and characterized by alternating propulsive and stabilizing motions of lower extremities. Each person has his own characteristic GAIT pattern. The GAIT cycle includes the activities that occur from the point of initial heel contact of one lower extremity to the point at which the heel of the same extremity contacts the ground again. GAIT is divided into 2 phases namely Stance and Swing. Stance forms 60 percent of the total duration of the GAIT Cycle, when the foot is in contact with the ground. Swing, when the foot is off the ground, forms 40 percent of the cycle. The Studying Normal Human Locomotion Factors are force of gravity and Forces exerted by muscular contraction. The Effects of Inertia are such as Angular Relationship between the Segments, Gait Analysis, and Qualitative Gait Analysis. The Four Different Reference Systems:
1. Absolute spatial system: The environment is used as a reference.
2. Relative system: The position of one body segment is described in relation to, another body segment.
3. Absolute reference system: The body segment is described in reference to 1 the vertical or horizontal position.
4. Relative reference system: The excursion of a body segment from one position 1 to another.

Posture is the attitude assumed by the body either with support during muscular in activity or by means of the co-coordinated action of many muscles working to maintain stability or to form an essential basis which is being adapted constantly to the movement which is super imposed upon it. The inactive Postures consists of attitudes adopted for resting or sleeping and they are most suitable for this purpose when all the essential muscular activity required to maintain life is reduced to a minimum. The Active Postures is integrated action of many muscles is required to maintain inactive postures which may be either static or dynamic. The Static Postures is a constant pattern of posture is maintained by the inter action of groups of muscles which work more or less statically to stabilize the joints and in opposition to gravity or other forces. The Dynamic Postures is a type of active posture is required to form an efficient basis for movement. The pattern of the posture is constantly modified and adjusted to meet the changing circumstances which arise as the result of movement. The Postural Mechanism Muscles intensity and distribution of the muscle work which is required for both static & dynamic postures varies considerably with the pattern of the posture and the physical characteristics of the individual.

The patient should be taken to a retraining area fitted with parallel bars and steps. The wheelchair is placed between the parallel bars, brakes applied & patient moved to the front of the chair, footrests raised and by pulling with his arms on the parallel bars he is encouraged to stand up bearing weight wherever he is permitted to do so. The therapist should stand at the side and block the standing shoe toe with her instep and the knee of that leg with her knee. The turning must be taught early unless the bars are of inordinate length and the wheelchair can be taken inside them. In taking the patient any distance inside or outside the bars it must be remembered that he must traverse a similar distance to return to his wheelchair. The various turning are In the Parallel Bars, With Walking Aids, Walking up Stairs and Walking down Stairs. In the Parallel Bars the foot is hopped through 45° or less and the now rear arm is moved to the bar the patient is turning to face. In Walking Aids the direction of turn is decided and agreed. The aid on that side is moved backwards and that on the opposite side is moved forwards with a small hop of the appropriate foot.

Walking together with its variants running, going up and down stairs. It is a skilled co-ordinated action which we acquire in infancy and improve with practice. It is an action which involves many joints and muscles but which is performed by each of us without conscious effort until one of the muscle or joint components involved is disordered. The propulsion muscles are the flexors of the toes, plantarflexors of the ankles & extensors of the knee and hip. All exercises should be resisted by the use of springs or weights when possible and some of those in the sequence may be practised during the course.
For the Arms
1.gripping
2.wrist extension
3.elbow extension
4.shoulder extension
5.shoulder medial rotation.
6.shoulder,depression
For the Trunk
1.Upper trunk - rotation
2.extension flexion
3.Lower trunk - rotation
4.extension
5.flexion pelvic side flexion or hip hitching.
For the Legs
1.toe and foot flexion and extension
2.knee flexion and extension
3.hip flexion and extension
4.hip abduction and adduction
5.hip medial and lateral rotation
Some of the exercises are very suitable for the patient to practice alone. The patients should be encouraged to reach down to the side & across the bed to use their locker. So work the arms and trunk and maintain some balance reactions.

Co-ordinated movement is natural to the body, which tends to remain still if only inco-ordinated movement is possible. It is of major importance to interest and encourage patients suffering from inco-ordination to persevere in making the effort to overcome it. The uses of alternative nervous pathways impulses essential for co-ordinated movement travel are blocked and the purpose of re-education is to encourage the use of those which remain or to develop alternative routes. The condition of the muscles is preliminary to reeducating the movement. The condition of the muscles requires attention as they are the effector organs concerned. They must be prepared to receive the co-ordinating impulses so that their reaction to them is as normal as possible by an attempt to relax those which are spastic or tense and to strengthen those which are weak. Treatment is designed to correct imbalances by emphasis on the activity of weak or ineffective muscles and to restore the normal integrated action of muscles in the performance of patterns of functional movement. The spasticity of the muscles modifies their reaction to the stimuli they receive as they cannot, or can only with difficulty, relax and so allow movement to occur. There is marked reluctance to attempt movement, while in those which are achieved. The essential rhythm which is characteristic of efficient movement is lost. The training in accuracy & the finer and highly co-ordinated movements such as those of the hand is deferred until basic movements and rhythm are established.

CO-ORDINATED movement which is smooth, accurate & purposeful is brought about by the integrated action of many muscles, superimposed upon a basis of efficient postural activity. The muscles concerned are grouped together as prime movers, antagonists, synergists and fixates according to the particular function they are called upon to perform. The Group Action of Muscles is a contraction of the prime movers results in the movement of a joint, while the reciprocal relaxation of the opposing group, the antagonists, controls their action without impeding it. The Nervous Control consists of four are Motor Pathways, Cerebral Cortex, Cerebellum, and Kinaesthetic Sensation. The Inco-ordination is with the function of any one of the factors which contribute to the production of a co-coordinated movement will result in jerky, arrhythmic or inaccurate movement which is said to be in co-ordinate, as the harmonious working together of the muscles is disturbed. There are four main types usually benefit from suitable exercise therapy are Inco-ordination associated with weakness or flaccidity of a particular muscle group, Inco-ordination associated with spasticity of the muscles, Inco-ordination resulting from cerebella lesions, and Inco-ordination resulting from loss kinesthetic sensation. Involuntary movements, sometimes associated with these conditions, or a state of abnormal general tension superimposed on an otherwise normal pattern of group action, may interfere with movement and reduce its efficiency.

Electromyostimulation (EMS) is a physical technique of reeducation which is used since a long time and is actually experiencing an important rise in some applications as muscle strengthening of athletes and also particularly in the medical field for the treatment of atrophies. The main actual medical indications of EMS are without any doubt the following:
The prevention and treatment of muscle atrophies due either to immobilization or denervation, the pain control by similar side effect to TENS and endorphinic stimulation, the improvement of muscle disbalance and the increase of local blood circulation and thereby obtaining of better muscle recovery. If the literature of the past years is particularly abundant concerning EMS, we have to admit that there is such methodological diversity which makes difficult to build substantial scientific foundation. The target of EMS in the medical field is to treat muscle contraction deficiency and therefore it is important that this stimulation replaces as precisely as possible the physiological mechanisms inducing this contraction. The advantage of EMS in association with classical reeducation exercise program is that the pain control effect is associated with muscle strengthening in order to correct muscle deficiencies. The use of EMS as muscle recovery is more recent and so far empirically its efficiency seems undeniable. Other reported studies have shown positive effect of EMS on prevention of deep venous thrombosis of lower limbs, on improvement of arterial blood flow in lower limbs and an increase of speed of muscle recovery by acceleration of lactate elimination.