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Gait Pattern in the Early Recovery Period after Stroke*

INÈS A. KRAMERS DE QUERVAIN, M.D., SHELDON R. SIMON, M.D., SUE LEURGANS, PH.D., WILLIAM S. PEASE, M.D. and DAVID McALLISTER, M.D.¶, COLUMBUS, OHIO

Investigation performed at the Gait Analysis Laboratory, Division of Orthopaedics, and the Departments of Physical Medicine and Rehabilitation, Surgery, and Statistics, Ohio State University, Columbus

	Abstract

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The gait patterns of eighteen patients who had had a single infarct due to obstruction of the middle cerebral artery were evaluated within one week after the patients had resumed independent walking and before a gait rehabilitation program had been initiated. Gait was analyzed with use of motion analysis, force-plate recordings, and dynamic surface electromyographic studies of the muscles of the lower extremities. The patterns of motion of the lower extremity on the hemiplegic side had a stronger association with the clinical severity of muscle weakness than with the degree of spasticity, balance control, or phasic muscle activity. There was a delay in the initiation of flexion of the hip during the pre-swing phase, and flexion of the hip and knee as well as dorsiflexion of the ankle progressed only slightly during the swing phase. During the stance phase, there was decreased extension of the hip that was related to decreased muscle effort and a coupling between flexion of the knee and dorsiflexion of the ankle. The abnormal patterns of motion altered the velocity, the length of the stride, the cadence, and all phases of the gait cycle. The duration of the pre-swing phase was prolonged for the patients who had the slowest gait velocities. There also were abnormal movements of the upper extremity, the trunk, the pelvis, and the lower extremity on the unaffected side in an effort to compensate for the decreased velocity on the hemiplegic side. As velocity improved, these abnormal movements decreased. Therefore, the goal of therapy should be to improve muscle strength and coordination on the hemiplegic side, especially during the pre-swing phase.

	Introduction

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Stroke is considered to be a leading cause of disability throughout the world¹². Broderick et al.⁴ studied a population of 60,000 in Rochester, Olmsted County, Minnesota, between 1980 and 1984, and estimated an age-adjusted annual incidence of stroke of 135 per 10,000. Those authors extrapolated the data and estimated that a stroke affects 34,000 individuals in the United States each year. In the western hemisphere, the annual incidence of stroke has varied from 0.8 to 4.0 per 1000 (in a population of 5209) and the prevalence has been determined to be 6.0 per 1000 (in a population of 23,666)¹¹.

The ability to walk is the prime factor that determines whether a patient will go home or to a nursing home and whether he or she will return to the previous level of productivity after a stroke^{10,25,26,33,34}. The goals of rehabilitation should be focused on retaining the ability to walk. It is difficult to assess the effectiveness of any rehabilitation program that is used to improve the walking ability of patients who are recovering from a stroke^5,17. This difficulty is related, in part, to the variability in the severity of the neuromotor deficit after a stroke, the partial recovery of muscle function without therapy in the first three to six months after a stroke, and the presence of concomitant medical disorders^1,27,31,32. The initial deficits must be delineated clearly in order to provide the optimum rehabilitation program.

In this study, we examined only patients who had had an infarct due to obstruction of the middle cerebral artery. Although only eighteen of 400 new patients who had had a stroke and had been admitted to our rehabilitation program met our criteria for inclusion, we believe that the results of the present study are representative and provide a baseline that can be used to determine the effectiveness of various rehabilitation protocols.

	Materials and Methods

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The study included only patients who had had an infarct due to obstruction of the middle cerebral artery and were about to begin a gait rehabilitation program at the Rehabilitation Center of the Ohio State University Hospitals or an outpatient program at Riverside Methodist Hospital, Columbus, Ohio. Patients were excluded if they had had an infarct in another area of the brain, a cerebral hemorrhage, cognitive sequelae, or any pre-existing disorder that affected their walking ability. Socioeconomic factors, family structure, and patterns of working and living before the stroke were not evaluated, as they did not affect the pattern of walking immediately after the stroke. To be enrolled in the study, the patient had to understand the nature of the study and had to provide informed consent.

Eighteen patients (six women and twelve men) met our criteria and participated in the study. The gait pattern was assessed within a week after the patient had resumed independent walking, which was defined as the ability to walk ten to fifteen meters without the assistance of another individual. The average age of the patients was fifty-nine years (range, thirty-four to seventy-six years). Twelve patients had hemiplegia on the right side and six, on the left. The mean time-interval (and standard deviation) between the onset of the stroke and the return to independent walking was 7.8 ± 6.0 weeks (range, 2.3 to 27.6 weeks).

A detailed history was obtained and the results of a clinical examination were recorded. The passive range of motion was measured for all joints in the lower extremities, and muscle strength was tested manually and was graded on a scale¹⁹ from 1 to 5. The motricity index, introduced by Demeurisse et al.⁸, was determined with use of the muscle-grading scale and was used to assess the progress of the patient. For this index, a weighted score is given to each grade: grade 1 is assigned a value of 28 points; grade 2, 42 points; grade 3, 56 points; grade 4, 74 points; and grade 5, 100 points (normal). The weighted values for muscle strength during flexion of the hip, extension of the knee, and dorsiflexion of the ankle are added, and the total is divided by three. The level of motor control was graded with use of the hemiplegic assessment designed by Fugl-Meyer and Jaasko^13,14. For this assessment, numerical values are assigned to the performance of defined activities consisting of movements within or outside a primitive mass synergy pattern. The original assessment form consists of six sections: motor control of the upper and lower extremities, joint motion, joint pain, balance, and sensation. We evaluated the motor control of the lower extremities while the patient was supine, sitting, and standing; the maximum total score for this section of the assessment is 22 points (a maximum of 14 points when the patient is supine, 4 points when the patient is sitting, and 4 points when the patient is standing).

Computerized gait analysis was performed for all patients with use of a motion analysis system (VICON; Oxford Metrics, Tampa, Florida), which includes six strategically positioned charge-coupled device (CCD) video cameras (VC491; Oxford Metrics), a minicomputer (PDP 11/73; Digital Equipment, Maynard, Massachusetts), and software for the collection and analysis of the data. Twenty-one spherical reflective markers, one inch (25.4 millimeters) in diameter, were placed over predetermined anatomical landmarks on the trunk and the upper and lower extremities. The patient walked on a fifteen-meter walkway, and the position coordinates for the markers on both sides of the body were recorded simultaneously at fifty frames per second with use of the phase-locked cameras. The recording technique and the software allowed three-dimensional reconstruction of the motion of all of the major joints of the upper and lower extremities.

All of the patients wore shoes, and each walked at a self-selected speed. A harness that was attached to the ceiling was available for patients who were unstable or who felt insecure walking without assistance nearby; the harness did not provide support during walking but was designed to prevent the patient from falling. Two patients wore the harness, and fourteen patients used a four-point or straight cane. Six patients had been fitted with a semirigid ankle-foot orthosis before enrollment in the study but could walk without the device. At least three walking trials were recorded for each patient; the six patients who had been fitted for an orthosis had an additional trial while wearing the device.

The electrical activity of the tibialis anterior, the medial head of the gastrocnemius, the quadriceps (rectus femoris), the medial hamstrings, the gluteus medius, and the gluteus maximus was recorded bilaterally with a twelve-channel dynamic electromyographic telemetry system (Transkinetics, Canton, Massachusetts), with surface electrodes and sampling at 500 hertz. Simultaneously, two force-plates (OR6; AMTI, Newton, Massachusetts) that were embedded in the walkway sampled ground-reaction forces at 500 hertz.

Statistical Methods
For each patient, we selected the one trial that represented the patient's gait most accurately. To determine whether this approach was valid, we calculated the correlation coefficient with use of a random effects model²⁹. The measurements from the same patient were found to be closer in value than those from different patients, which means that the intraclass correlation coefficient was near 1.00—that is, the between-subject variance was much greater than the within-subject variance. We found that it was valid to use a representative trial for the analysis of the time-distance data and their relationships to other characteristics of the patients.

The representative trial was selected on the basis of an examination of five gait parameters: cadence, velocity, the timing of toe-off on the hemiplegic and contralateral sides, and the timing of foot-strike on the contralateral side. The multivariate statistic that is used to measure the so-called closeness or distance from the characteristics of a particular walking trial to the mean characteristics of all of the trials for a given patient is referred to as the Mahalanobis distance. A Mahalanobis distance of zero corresponds with a trial that exactly matches the mean of the trials. A combined covariance matrix was approximated by pooling of the five parameters from each walk of each patient across all patients; this matrix then was used to calculate a Mahalanobis distance between the dimensional vector of the five time-distance parameters from each trial for each patient and the mean of the data vectors for that patient. The representative trial that was chosen for each patient was the trial with the smallest Mahalanobis distance. The second-smallest Mahalanobis distance was used for three patients because the joint angles could not be reconstructed as the position of the upper extremity occasionally obscured the pelvic marker on the hemiplegic side.

	Results

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Gait Velocity in Relation to Clinical Measures of Function
The gait velocities ranged from 0.08 to 1.05 meters per second. Twelve patients had a slow gait velocity (mean, 0.16 meter per second; range, 0.08 to 0.24 meter per second); this velocity was 6 to 17 per cent of the reported age-specific free-walking speed²¹. Five patients had an intermediate gait velocity (mean, 0.55 meter per second; range, 0.4 to 0.7 meter per second); this velocity was 29 to 48 per cent of the normal free-walking speed. Only one patient had a nearly normal gait velocity (1.04 meters per second); this velocity was 74 per cent of the normal free-walking speed. The longer the interval between the stroke and the return to independent walking, the slower the initial gait velocity. Linear regression analysis showed that the interval between the stroke and the return to independent walking was not related to the age of the patient (p = 0.26, r² = 0.078). A slow gait velocity was not related to age (p > 0.05) but was associated with weakness and poor motor control of the lower extremity.

The twelve patients who had a slow gait velocity had a mean motricity index of 61 (range, 37 to 100), which reflected a generalized degree of muscle weakness in the lower extremities. These patients could not perform isolated movements outside a primitive mass synergy pattern in the upright position, such as flexion of the knee with extension of the hip or dorsiflexion of the ankle with extension of the hip and knee. The mean total score for motor control¹⁴ was 13 points (range, 7 to 21 points), and the mean score for motor control while standing was less than 1 point (range, 0 to 3 points). All twelve patients had abnormal stretch reflexes, ankle clonus, and increased muscle tone, and all needed a four-point or straight cane for walking. Six of the twelve patients had been fitted with a semirigid plastic ankle-foot orthosis before enrollment in the study, but they could walk without the orthosis.

The five patients who had an intermediate gait velocity had a mean motricity index of 93 (range, 91 to 100), which reflected only mild muscle weakness. The patients were able to isolate joint movements; the mean total score for motor control was 21 points (range, 19 to 22 points) and the mean score for motor control while standing was 3.4 points (range, 2, 3, or 4 points). Three of the patients had signs of spasticity, two used a straight cane when walking, and none had been fitted with an orthosis before the study.

The one patient who walked at a nearly normal speed had no evidence of muscle weakness (motricity index, 91). He had not begun to walk independently until four weeks after the stroke because of apraxia, and the level of walking ability was functional despite a marked hemianopsia. No motor score is given for this patient because although he was able to walk, he could not comprehend instructions regarding muscle-testing because of aphasia.

Time-Distance Parameters
The reduction in walking speed was related to reductions in both the length of the stride and the cadence. The mean duration, in terms of absolute time, of the single-limb stance phase was similar for all patients (Fig. 1), was independent of walking speed, and was equal to the duration of the single-limb stance phase that has been reported for normal individuals walking at a normal cadence of 110 steps per minute²¹. However, the mean duration of the pre-swing phase was markedly prolonged for the patients who had a slow gait velocity; it lasted for 0.72 to 2.18 seconds, which represented 28 to 54 per cent of the gait cycle. This phase was not as prolonged (0.20 to 0.44 second; 14 to 23 per cent of the gait cycle) for the five patients who had an intermediate velocity, and it was normal (0.12 second; 12 per cent of the gait cycle) for the one patient who had a nearly normal gait velocity. When viewed as a percentage of the gait cycle, therefore, the duration of single-limb stance was reduced for all patients except for the one who had a nearly normal gait velocity. It was most reduced for the patients who had a slow gait velocity.

View larger version (33K): [in this window] [in a new window]   Mean duration (absolute time) of the phases of the gait cycle for each performance level. The percentage of the gait cycle that each phase represents is printed below each bar. The bars were arranged to allow comparison of the duration of the single-limb stance phase for the hemiplegic side. HFS = foot-strike on the hemiplegic side, OTO = toe-off on the contralateral (unaffected) side, OFS = foot-strike on the contralateral side, and HTO = toe-off on the hemiplegic side.

Joint Angles and Dynamic Electromyographic Studies during the Pre-Swing and Swing Phases
In the twelve patients who had a slow gait velocity, abnormal motions were present at the hip, the knee, and the ankle; they were most abnormal at the hip. Flexion of the hip did not begin until the last one-third of the pre-swing phase in five patients and did not begin until toe-off or shortly thereafter in seven patients. Additional flexion during the swing phase continued at a very slow rate. There was an associated decrease in flexion of the knee during the pre-swing phase and little or no progression of flexion of the knee after toe-off; this caused a reduction in the peak flexion of the knee during the swing phase to a mean of 36 degrees (range, 27 to 47 degrees), and extension of the knee often occurred at or before toe-off. These patterns of motion at the hip and knee were unrelated to electrical activity in the hip extensor or quadriceps muscles during the pre-swing or swing phase. Nine of the patients who had a slow gait velocity had either no or only slight plantar flexion during the pre-swing and swing phases, despite electrical activity in the tibialis anterior muscle and no activity in the gastrocnemius muscle. Only three patients kept the ankle in neutral during the pre-swing and swing phases. Although all twelve patients had a foot drop, only one patient made initial contact with the ground with the forefoot; three others made contact with a flat foot, and the remaining eight had a heel-strike, with the foot moving backward before it hit the ground.

In the five patients who had an intermediate gait velocity and the one patient who had a nearly normal velocity, flexion of the hip was initiated earlier, at the mid-point of the pre-swing phase. The rate of increase and the progression of hip flexion during the swing phase was better and was associated with progression of knee flexion during the pre-swing and swing phases. The mean peak flexion of the knee was 47 degrees (range, 29 to 64 degrees). These patients also had more plantar flexion during the pre-swing phase than did those who had a slow gait velocity, but the degree of plantar flexion on the hemiplegic side was less than that on the unaffected side. All six patients had a normal heel-strike at the end of the swing phase.

Weight Acceptance and Single-Limb Stance Phase
During the stance phase, motion of the hip on the hemiplegic side was abnormal in all patients. The mean range of extension of the hip was 20 degrees (range, 9 to 32 degrees) for the patients who had a slow gait velocity and 31 degrees (range, 21 to 43 degrees) for those who had an intermediate velocity; the range of extension was 38 degrees in the patient who had a nearly normal gait velocity.

The pattern of hip motion was similar in all patients, but there were four coupling patterns of knee and ankle motion during the stance phase on the hemiplegic side. The extension thrust pattern (noted for three patients who had a slow gait velocity) was characterized by an extension thrust of the knee immediately after foot-strike and increased plantar flexion of the ankle at foot-strike, followed by decreased dorsiflexion (Fig. 2). In the stiff-knee pattern (noted for four patients who had a slow gait velocity), the knee remained stiff in a position of 20 to 30 degrees of flexion and the ankle remained in neutral or in slight plantar flexion throughout the stance phase (Fig. 2). The buckling-knee pattern (noted for four patients who had a slow gait velocity and one patient who had an intermediate velocity) was characterized by an increased range of flexion of the knee during weight transfer, with the flexed position continued during the entire stance phase, and an increased range of dorsiflexion of the ankle (Fig. 2 and 3). The normal knee pattern (noted for the remaining six patients) involved a nearly normal pattern of flexion and extension of the knee, with the knee being only slightly more flexed than normal, and with excessive dorsiflexion of the ankle during some portion of the stance phase (Fig. 3).

View larger version (52K): [in this window] [in a new window]   Graphs and electromyographic data for motion of the knee in the sagittal plane for one gait cycle of three patients. Each patient represents one of the three motion patterns associated with a slow gait velocity. The solid black line indicates the motion pattern, and the gray line represents the normal. HFS = foot-strike on the hemiplegic side, OTO = toe-off on the contralateral (unaffected) side, OFS = foot-strike on the contralateral side, and HTO = toe-off on the hemiplegic side.

View larger version (53K): [in this window] [in a new window]   Graphs and electromyographic data of motion of the knee in the sagittal plane for one gait cycle of two patients, one representing the motion pattern associated with an intermediate gait velocity and the other, the motion pattern associated with a nearly normal (functional) gait velocity. HFS = foot-strike on the hemiplegic side, OTO = toe-off on the contralateral (unaffected) side, OFS = foot-strike on the contralateral side, and HTO = toe-off on the hemiplegic side.

Motion of the Pelvis and the Trunk
Abnormal pelvic motion was noted in all three planes (frontal, sagittal, and transverse). A slower gait corresponded with a more substantial abnormality. Pelvic tilt increased anteriorly on the hemiplegic side, and the tilt was maintained throughout the single-limb stance phase. A posterior tilt of the pelvis began during some portion of the pre-swing phase and continued through the swing phase. In the patients who had a slow gait velocity, posterior tilt began before the onset of hip flexion. In the frontal plane, the pelvis remained level in three patients who had a slow velocity, three patients who had an intermediate velocity, and the one patient who had a nearly normal velocity; it was higher on the hemiplegic side throughout the gait cycle in two patients who had a slow velocity and one patient who had an intermediate velocity; and it was initially elevated before hip flexion on the hemiplegic side (a so-called hip hike) and remained elevated during the pre-swing and swing phases in seven patients who had a slow velocity and one patient who had an intermediate velocity. In the transverse plane, the pelvis was retracted on the hemiplegic side throughout the gait cycle in eleven of the twelve patients who had a slow gait velocity. Sway of the trunk and translation of the pelvis over the unaffected limb during the stance phase was seen in all of the patients who had a slow gait velocity. These factors, combined with the variable tendency of the same hip to abduct and elevate the contralateral hemiplegic lower extremity (hip hike), led to a variable pattern in the adduction and abduction of each hip in the patients who walked with a cane.

Motion Pattern on the Unaffected Side
A different pattern of abnormal joint motion was noted on the unaffected side. For the patients who had a slow gait velocity, the mean range of motion of the hip in the sagittal plane was 31 degrees (range, 23 to 36 degrees) on the unaffected side (compared with 20 degrees [range, 9 to 32 degrees] on the hemiplegic side). For the patients who had an intermediate velocity, the mean range of motion of the hip was 38 degrees (range, 35 to 41 degrees) on the unaffected side (compared with 31 degrees [range, 21 to 43 degrees] on the hemiplegic side). The one patient who had a nearly normal velocity had 43 degrees of motion of the hip on the unaffected side (compared with 38 degrees on the hemiplegic side). In each patient, the range of motion was consistent with the decrease in the velocity and the short stride compared with the normal values for different walking speeds reported by Murray et al.²¹. Flexion of the hip during the pre-swing phase was initiated, even in patients who had a slow gait velocity, with appropriate timing and sufficient flexion for normal peak flexion of the knee to occur during the swing phase.

Patients who had a slow gait velocity kept the unaffected knee in 15 to 30 degrees of flexion during the stance phase, and there was gradual motion of the ankle toward dorsiflexion during the prolonged period of weight transfer and the single-limb stance phase. Before toe-off, nine of the twelve patients had no plantar flexion and three had a decreased range of plantar flexion. The patients who had an intermediate or a nearly normal gait velocity had a more normal pattern of motion of the knee during the stance phase but had a calcaneus position of the foot late in the stance phase. Plantar flexion gradually or rapidly increased during the pre-swing phase and resulted in a normal range of plantar flexion before toe-off. All of the patients, except for the one who had a nearly normal gait velocity, had prolonged activity in the quadriceps, the hamstrings, and the gastrocnemius throughout the single-limb stance phase.

Use of the Ancillary Devices
Neither the time-distance parameters nor the clearance of the floor by the foot was altered by the use of an orthosis. The benefit of preventing a foot drop was lost, as the peak flexion of the knee during the swing phase was lower when the patient wore the orthosis. Two patients who had an extension thrust pattern during the stance phase had a stiff-knee pattern when the orthosis was worn. Two other patients had less dorsiflexion of the ankle during weight transfer when the orthosis was worn. For the fourteen patients who used a cane, the mean percentage of body weight supported by the cane was 19 ± 4 per cent (range, 7 to 30 per cent). The vertical ground-reaction forces were equivalent to the body weight during the stance phase of two of the four patients who did not use a cane and exceeded the body weight only for the two patients who had the fastest gait velocities.

	Discussion

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Rehabilitation therapy after a stroke is costly and can be justified only if the therapy program is appropriate and if recovery would not occur naturally. Although several studies have suggested that survivors of a stroke who are managed with rehabilitation therapy achieve a greater level of independence and have fewer complications than those who are not, the value of such therapy is still doubted by many^15,24,28,30. The absence of well recognized measures to evaluate functional recovery after a stroke and the large variety of rehabilitation techniques and protocols add credence to the questioning of the value of rehabilitation in terms of costs and psychosocial benefits^5,17,30.

Quantitative gait analysis has been used to evaluate the functional abilities of patients who have had a stroke. The gait velocity, the length of the stride, and the abnormal cadence of our patients were similar to those previously reported for patients at various times after a stroke^{3,6,7,9,10,16,20,25,26,32-34}. The gait velocity of our patients varied from exceedingly slow to nearly normal (functional) and the slower the gait, the more abnormal the physical findings and the more the patient depended on assistive devices. These results were found in the early stage of recovery, after the patient had resumed independent walking and before a rehabilitation program had been initiated. Our findings suggest that the determination of gait velocity can help to predict walking function even at this early stage; therefore, gait velocity should be measured during this stage for proper assessment of whether recovery subsequently will occur.

Abnormalities in standing balance and asymmetry during single-limb stance are assumed to be related to a decreased ability to bear weight on the hemiplegic side^2,3,9,20,34. However, the duration of the single-limb stance phase, in terms of absolute time, was not reduced independent of walking and corresponded with a normal cadence. The use of a cane reduced the load on the hemiplegic side by only as much as 30 per cent in a few patients; therefore, it may not be necessary to assess the standing balance and its relationship to weight-bearing. This may explain why Winstein et al.³⁶ found no association between gait function and standing balance.

The most striking finding in our study was the markedly prolonged duration, in terms of absolute time, of the pre-swing phase on the hemiplegic side. This prolonged duration was associated with a delay in the initiation and a decrease in the speed of flexion of the hip during the swing phase. These characteristics of the pre-swing phase led to a decrease in momentum and were major contributors to the asymmetry during the single-limb stance and swing phases. These features also differentiated the patients who had a slow gait velocity from those who had an intermediate velocity. Therefore, insufficient power and inappropriate initiation of flexion of the hip must be assumed to be the cause, as no activity was noted in the extensor muscles.

The results of the motion, electromyographic, and force-plate studies and the findings on the physical examination showed that muscle weakness was not isolated to the hip flexors^10,18,25,26. In patients who had a slow gait velocity, inadequate flexion of the knee during the swing phase was related to the weakness of muscles about the hip. Function of the quadriceps that could have prevented flexion of the knee was not present; therefore, any quadriceps function was a spastic response to a passive knee-flexion stretch of the quadriceps and did not change the pattern of motion of the knee. Plantar flexion of the ankle was secondary to gravity and weak dorsiflexion. Although many patients who had a slow gait velocity had ankle clonus during the stance phase, none had a fixed equinus deformity. In our study, increased dorsiflexion of the ankle and abnormal motion of the calcaneus were influenced by body weight and postural alignment, regardless of the pattern of muscle activity or the presence of spasticity. We did not see an equinus deformity at this stage of recovery. (An equinus deformity has been reported by others^22,23,35 to be a major cause of gait impairment during the later stages of recovery.)

Subtle abnormalities on the unaffected side, found in the later stages of the recovery process, are said to be due to dysfunction of the central nervous system^25,26. This may be associated with a decreased walking speed. The range of motion of the hip in the sagittal plane on the unaffected side in our patients who had an intermediate or a nearly normal gait velocity was consistent with that reported by Murray et al.²¹ for comparable walking speeds. For the patients who had a slow gait velocity, the walking speed and the range of motion of the hip in the sagittal plane were less than the normal values of 0.8 meter per second and 36 degrees, respectively, reported by Murray et al.²¹. Shiavi et al.^25,26 also reported that some patients had prolonged electromyographic coactivation of the hamstrings and the quadriceps during the stance phase on the unaffected side; however, at such slow speeds, the stability of stance requires muscle activity. Elevation of the hip (so-called hip hike) and lateral sway of the trunk both improved the clearance of the floor by the foot. The patients who had a slow gait velocity initiated trunk and pelvic movements early during the pre-swing phase, before flexion of the hip started, and shifted the body weight to the unaffected side immediately after foot-strike on the contralateral side. In patients who had an intermediate gait velocity, there were fewer aberrations of motion of the trunk and pelvis and there was a more normal pattern of motion of the hip during the pre-swing phase. Abduction (circumduction) of the hip on the hemiplegic side was not as marked in any patient as has been reported by others in the later stages of recovery.

Muscle dysfunction resulted in a prolonged duration of the pre-swing phase, inadequate momentum, and poor progression of flexion of the hip during the swing phase of the patients who had a slow gait velocity, leading to compensatory mechanisms to correct these deficiencies. If natural recovery occurred, these deficits would resolve over time without additional therapy. If rehabilitation is to produce improvement, more attention should be paid to generalized coordination and strength of all of the muscles of the lower extremities, especially the muscles about the hip, so that the initiation of the motion of the hip during the pre-swing phase can be coordinated.

NOTE: The authors express their appreciation to Jeffrey Pisciotta, Jean Nippa, and Dwight Meglan for their assistance in the establishment of the database and the development of the processing routines by which the data could be analyzed.

	Footnotes

 
*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Funds were received in total or partial support of the research or clinical study presented in this article. The funding source was National Institute for Disability Rehabilitation Research Grant H133E80017 (S. R. S.), an Easter Seals Research Foundation Grant, and a stipend from the Swiss Association for Internal Medicine (I. A. K. de Q.).

Laboratory for Biomechanics, ETH Zürich (Swiss Federal Institute of Technology Zürich), Wagistrasse 4, CH-8952 Schlieren, Switzerland.

Division of Orthopaedics, Ohio State University, 410 West 10th Avenue, Columbus, Ohio 43210. Please address requests for reprints to Dr. Simon. E-mail address: ssimon@surgery.medctr.ohio-state.edu.

Section of Biostatistics, Department of Preventive Medicine, Rush-Presbyterian-St. Luke's Medical Center, 1725 West Harrison Street, Chicago, Illinois 60612-3824.

¶Department of Orthopaedic Surgery, University of California at Irvine Medical Center, 101 The City Drive South, Building 29-A, Second Floor, Orange, California 92868.

	References

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