April 7, 2012

Arm and Leg Synergies are Different and the Same

Limb synergies seen after a stroke are different.  The hemiplegic (paralyzed) arm is dominated by the flexion synergy while the hemiplegic leg is dominated by the extension synergy.  Extensor muscles that straighten the knee and point the toes are strong while flexor muscles that bend the hip, knee, and ankle are weak.  Yet arm and leg synergies are the same because both make it difficult to move a single joint.  When clients who are synergy bound want to move a limb we have to move all the joints in the limb whether we want to or not.  

To point my toes I have to straighten my whole leg (photo on left).  To bend my ankle I have to bend my hip and knee (photo on right).  
 Problem #1: Two trips to the emergency room after bad falls were enough for me.  My weak hip and knee flexors do not lift my leg high enough to clear my toes as I take a step.  To make things worse my leg is mostly straight when I swing my leg to take a step so the extension synergy forces my toes to point       (top left photo).  Weakness and synergy produce foot drop which makes me stub my toes (photo on left).                              Solution #1: The brace holds my toes and ankle up as I walk.     I faithfully wear my leg brace because it prevents falls. 
 
Problem #2: I am not interested in learning how to survive rehab after a knee replacement.  The extension synergy can cause full knee extension when I take a step with my hemiplegic foot.  This abnormal movement can eventually damage my knee when I walk.  Unfortunately, the hamstring muscles on the back of my thigh (pink line) are too weak to keep my knee from snapping into that dangerous position.
Solution #2: My leg brace keeps my knee slightly bent (green line) when I take a step.  I faithfully wear my leg brace because it defers the need for knee surgery. 

19 comments:

  1. Thank you for the explanation. Even though my PTs have tried to explain some of my gait issues, your summary (and the photos) is very helpful.

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  2. Humm.. this all has me very curious. I'm wondering if I am creating problems for the future. I seem to walk pretty well, but I'm not sure if it's correct. I'm going to have to investigate my gait further. My shoe always falls off the affected side so I'm guessing there is weakness somewhere even though I get around very well. Thanks for pointing this out!

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  3. I love your technical descriptions - with photos - of what is occurring to stroke muscles. Which brings up the question, why do my toes curl if my foot is extending?
    Thanks,
    Dean

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    1. A muscle that curl you toes (flexor digitorum longus) originates in the calf and crosses the ankle joint along with muscles that straighten your ankle. Since these muscles lie side by side it is difficult to fire one muscle without firing the other. Synergies in stroke survivors are all about recruiting groups of muscles together whether we want to or not.

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  4. Thanks for the explanation. I'm getting a better understanding. Wish I could see your brace. I have a lot of hyperextension in my knee which causes me to walk stiff legged. Also have 'drop-foot', though I've been told it's not that bad. My walking is very exhausting and have considered a walk aid.

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    1. Some stroke survivors hate their leg brace. Because I live alone I walk a lot when I do ALL my shopping. My leg brace increases my endurance so I don't have to go home half way through an outing. What's most important varies from person to person.

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  5. Are you doing exercises without your brace on? The reason I ask is that I have found that to get full range of motion, the brace should be off.

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  6. All the exercises I do for my hemiplegic leg I do with my brace off.

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  7. Rebecca, thanks for the straightforward, helpful post. I had a hemorrhagic stroke about 3 and 1/2 years ago with right side hemiplegia and significant aphasia (initially including total inability to talk). For about 2 years I used a brace that allowed my right foot to rest an a custom, slender but strong platform. The platform was connected to a tailor-made piece which extended around the back of my calf from the platform up to the top of my calf. A mechanism allowed my foot to move up and down within a restricted range of motion (no "drop foot"), Three velcro straps held the brace on.

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  8. can anyone explain. to me why my foot turns outward. during a forward. stretch? any way to improve it?

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    1. When I have a problem I can't solve I ask my doctor to send me to out-patient therapy. I'm not shy about telling therapists about the specific problem I expect them to address during the current round of treatment.

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  9. Rebecca, thank you for opening up for followers. I'm post stroke x 30 days. It is extremely insightful. I wouldn't dream of standing without my AFO. One near fall was enough. Unlike you I've had a knee and hip replacement prior to my stroke which compounds the therapy issues. Ah such is life. Your blog helps.

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  10. I hada stroke 3 years ago due to a motor accident i have left side weekness im useing an afo and lately im finding it imposible to walk my toes and foot keep curling down in it can anyone help me

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    1. I've gone back to out-patient PT twice when I had a problem with walking.

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    2. Doctors and insurance companies take safety seriously. Your curling toes are a potential fall hazard. Ask your doctor for a presciption to "increase safety while walking."

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  11. I've recently started back to out-patient PT. My leg is really swinging out (In a circling motion) with each step I take. Do you think a brace will make me walk with a more normal gait? I was informed that my hip is weaker & the hyper extended knee is not getting better. I keep blaming all this on the spasticity. But could it be I need a brace for support?

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  12. These are great questions to ask your PT. When I go back to therapy I always have one goal I want to achieve - like being able to walk farther on the boardwalk in Point Pleasant Beach or increased safety when making turns in the kitchen while preparing lunch. Therapy should be more personal than "have a normal gait" or "reduce spasticity."

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  13. I had a stroke six months now, everything works ok except my right leg, it gets stiff especially when I get anxious when someone is watching me walk im so conscious of condition my husband says I need more therapy, but I can not afford health insurance so I can't see a doctor or therapist. What can I do to help myself, I walk everyday. My county broward 33068. Thanks

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