Gait Rehabilitation in Hemiplegia: Training Swing and Stance Phases

Understanding the Normal Gait Cycle First

FIG. 6.10A — Normal phases of the gait cycle. — Miller's Review of Orthopaedics, 9th Ed.

FIG. 6.10B — Time dimensions: stance phase = ~62% of gait cycle, swing phase = ~38%. — Miller's Review of Orthopaedics, 9th Ed.

Hemiplegic Gait: Key Impairments

• Prolongation of stance and double-limb support on the affected side
• Excessive plantar flexion (equinus foot) → prevents heel strike
• Weakness of ankle dorsiflexors, hip flexors, and knee flexors
• Spasticity of plantar flexors → foot drop / flat-foot landing during swing
• Limited knee flexion during swing → circumduction or hip hiking to clear the foot
• Increased hip flexion
• Balance impairment

Exercises to Correct the Swing Phase

1. Ankle Dorsiflexion Training (Anti-Foot Drop)

• Active assisted dorsiflexion: therapist assists the paretic foot into dorsiflexion repeatedly; patient attempts to hold the position.
• Resisted dorsiflexion (Theraband around forefoot): sitting, patient pulls foot upward against band resistance — trains tibialis anterior concentrically (the muscle that contracts concentrically during swing to clear the foot).
• Heel slides on mat: supine, slide heel toward buttocks while maintaining foot dorsiflexed.
• Functional electrical stimulation (FES) to the peroneal nerve can trigger dorsiflexion at swing initiation.

2. Hip and Knee Flexion for Limb Clearance

• Step-through with high knee lift: patient practices exaggerated hip and knee flexion on the affected side to clear the foot, progressing to normal step length.
• Seated knee curls: sitting on edge of bed/chair, patient actively flexes the knee to 90° or beyond — trains hamstrings for swing initiation.
• Treadmill gait training with partial body weight support (BWS): reduces fall risk while allowing repetitive swing phase practice at varied speeds.
• Step-up/step-over obstacles: placing a small obstacle (cone or roll) on the floor forces hip and knee flexion to step over it — directly challenges swing clearance.
• Hip flexor strengthening (supine): straight leg raises or marching in place to improve hip flexion initiation at swing.

3. Reducing Circumduction

• Side-stepping with mirror feedback: patient watches and corrects abnormal hip hiking or trunk lean.
• Treadmill with visual biofeedback or gait labs where applicable.
• Constraint on the sound side (shortened step length training) encourages proper swing mechanics on the affected side.

Exercises to Correct the Stance Phase

1. Weight-Bearing Stability and Knee Control

• Parallel bar standing: patient bears weight through the affected limb with therapist guarding; focus on avoiding knee hyperextension.
• Weight shifting side to side: standing, therapist guides pelvis to shift weight onto the paretic leg and back — trains single-limb stance loading.
• Mini-squats / sit-to-stand: trains quadriceps eccentrically (controls knee flexion at loading response) and concentrically (terminal stance extension).
• Step-up on affected leg: step up onto a low step with the paretic leg leading — strengthens quadriceps for stance-phase stability.

2. Heel Strike and Push-Off Training

• Rocking on a rocker board (heel to toe): trains the coordinated sequence of heel strike → foot flat → heel off → toe off.
• Calf raises (with support): standing at parallel bars, rise onto toes on the affected side — trains gastrocnemius-soleus for push-off (toe-off phase).
• Heel walks: patient walks on heels, training tibialis anterior eccentrically at heel strike and maintaining dorsiflexion through mid-stance.
• Treadmill incline walking: forward inclination encourages a more heel-dominant contact pattern.

3. Single-Limb Balance and Pelvic Stability

• Tandem standing on the affected leg (with support progressing to unsupported): improves single-limb stance duration.
• Gluteus medius strengthening (side-lying hip abduction): weakness of the gluteus medius causes Trendelenburg/pelvic drop in midstance — resisted hip abduction in side-lying trains this directly.
• Lateral step-overs: stepping sideways over a low obstacle while keeping trunk upright — challenges hip abductor stability in stance.
• Perturbation training: therapist applies gentle perturbations while patient stands on affected leg — improves reactive balance and ankle strategy.

Orthotic Support During Gait Training

• A solid AFO prevents foot drop during swing and provides a stable base at heel strike.
• A hinged AFO (with heel stop at ~5° dorsiflexion) allows some dorsiflexion for midstance and sit-to-stand while still supporting swing.
• In patients with combined knee instability + ankle drop, a KAFO (knee-ankle-foot orthosis) allows the knee to lock in stance while clearing the toes for swing.

"These fabricated ankle-foot orthoses are designed for ankle and knee control in a hemiparetic patient... A wider lateral flange with hook-and-loop straps across the front of the ankle provides greater ankle and knee control. The thermoplastic hinged ankle orthotic includes a heel stop to allow about 5 degrees of dorsiflexion for standing up and in the early stance phase of gait." — Bradley and Daroff's Neurology in Clinical Practice

Summary Table