Preparing the foot for third rocker and initial contact Nicky Schmidt PT, C/NDT copyright 2012 References Laboratory Strategies developed and taught by Nicky Schmidt, P.T. in the NDTA Approved Advanced Gait Course. Photography by Kristen S. Wiss. Content not to be copied without permission of Nicky Schmidt, P.T. Achieving Adequate Toe Hyperextension Patients post brain lesion often lack the 60 of toe hyperextension required for third rocker in order to transition from terminal stance through pre-swing. This may be due to increased toe flexion occurring in early stance because the patient does not advance forward over the foot appropriately, or it can occur when the patient has excessive weakness or hypotonus of the plantarflexor and toe extensor muscles. Toe hyperextension with ankle plantarflexion and mid foot supination is also a major requirement for ascending and descending stairs, transitioning to half kneeling, or performing a squat lunge to reach for objects near the ground safely and with normal motor components. Nicky Schmidt PT, C/NDT 1
Achieving Adequate Toe Hyperextension Strategy One: Stretching in a lunge The patient can start in a bilateral stance position in front of a hi-lo mat (preferably with shoes off). Ask the patient to squat on the midline keeping both feet flat on the floor. While squatting raise the mat enough so that the patient can reach forward and place both hands on the mat with elbows, wrist and fingers extended. Therapist may need to assist the involved hand onto the mat and assist in preventing the hand from sliding and maintaining the elbow in neutral extension. The therapist should be seated on the mat or on a chair on the patient s more involved side. Achieving Adequate Toe Hyperextension Strategy One: Stretching in a lunge The therapist will use his/her own foot to assist the patient to slide the involved foot backward while keeping the toes in contact with the floor. The knee should move into extension. The patient will appear to be in a squat-lunge position with the stronger leg forward. If the patient requires manual assist to keep the foot on the floor and the knee extended then a second person can assist the UE while the primary therapist moves to the floor to facilitate over the quadriceps muscle and around the calcaneous of the foot. Achieving Adequate Toe Hyperextension Strategy One: Stretching in a lunge Place a pillow or foam mat on the floor under the patient s knee. Then, ask the patient to flex the knee as if transitioning to half-kneeling. The therapist must provide approximation down towards the foot with the hand over the quads and femur while allowing the knee to flex. Simultaneously, the therapist s hand that is holding around the medial and lateral sides of the calcaneous will give an approximation into the MTPs and assist the foot to plantarflex as the knee bends. The patient need only flex into the range the toes tolerate. Repeat knee flexion/extension 3-4 times before returning to squat and stand position. Nicky Schmidt PT, C/NDT 2
Strategy Two: Stretching into toe extension in standing with the knee extended This activity can be performed at the bottom of a flight of stairs or with the use of a 4-8 inch platform. Provide the patient with bilateral hand support. The patient should be barefoot. First, ask the patient to place the less involved foot on the first step or on the platform. Have the patient shift over that foot as if they were going to ascend the step, but do not allow them to fully ascend. The therapist will again place one hand over the quadriceps and hamstring muscles on the anterior/lateral thigh and the other hand around the calcaneous. The therapist assist the patient to activate hip and knee extension as they plantarflex the ankle, supinate the mid foot and hyperextend the MTP jts with weight bearing. Strategy Two: Stretching into toe extension in standing with the knee extended Part two of this activity is to have the patient stand with both feet on the first step (or platform) facing the ground as if descending. The patient must have bilateral hand support at first and can progress to unilateral support as able. The therapist will place one hand under the toes and the other on the calcaneous and guide the involved foot to the floor (ground) as the patient attempts to descend on that leg. The foot will again move into plantarflex, supination and MTPhyperextension. The therapist will assist the patient to lower and raise the heel off the floor as the patient loads and unloads the involved foot on the floor. Strategy Two: Stretching into toe extension in standing with the knee extended Part three of this strategy is to now have the patient step down to the ground from the bottom step (or platform) with the less involved foot while maintaining weight on the involved LE. Again, patient should be barefoot with bilateral hand support. Therapist will assist the patient to raise the heel off the step and shift weight forward onto extended MTPs as the hip and knee flex to lower the body down to the ground. This trains the patient to move from ankle rocker to toe rocker in weight bearing as the hip and knee flex similarly to pre swing in gait. Nicky Schmidt PT, C/NDT 3
This strategy can be worked on by using a larger bolster with the patient standing in stride with the less involved LE forward beside the bolster. Patient is wearing shoes The therapist is seated straddling the bolster and he/she assist the patient to place the more involved foot on top of the bolster. The therapist will use one hand to help the patient stabilize the femur in neutral hip rotation and neutral hip abduction/adduction. The therapist s other hand will be on the patient s foot guiding it s transition from toe to heel contact. As the patient shifts weight from mid to terminal stance on the other leg the therapist moves the bolster forward and assist the patient s foot to move with the bolster from heel rise (3 rd rocker to heel strike (1 st rocker) Nicky Schmidt PT, C/NDT 4
The patient should be standing barefoot in a stride position with the less involved LE forward. Provide the patient with arm support as needed. Use a 1.5 to 2 inch diameter cylindrical tool such as a dowel, PVC pipe, or a firm foam object. Therapist will be on the floor holding the tool and contacting the patient s foot to keep it in contact with the cylindrical object. Start the patient s foot in a pre swing alignment with toes hyperextended on the tool. Gradually roll the object forward on the floor as the patient flexes the hip and knee and guide the patient s foot from plantarflexion to dorsiflexion with contact progressing to the heel. As the patient repeats using hip and knee flexion to advance the rolling object with some momentum allow the foot to move off the object and onto the floor with heel strike. After practicing this maneuver 3-4 times progress the patient into gait encouraging the swing momentum after pre swing. Nicky Schmidt PT, C/NDT 5
Nicky Schmidt PT, C/NDT 6