when ambulating as instructed.


G.J. Taylor, PhD, CAP, BCIAC. CBT.

Gait Training

Below is an examination of the helicoped gait that is common in hemiplegia and a method of training I called the BOSS gait (Bend-Out-Short-Step), which survivors of brain injury can learn to use and protect themselves against an additional TBI through falling injury. Included is information about hyperextension injury.  

1. Toe points down and inwardly, due to lack

    of innervation (paresis) of tibialis anterior

    muscle, causing drop-foot and foot


2. Foot swings around and inwardly, while

   leaning on the contralateral side.

3. The affected limb rarely is fully extended,

     which weakens the limb in bearing the

     weight of the upper body. The pigeon-

     toed stance psychologically affects the

     individual with an ever narrowing path


4. With the foot inverted, the affected limb

    strains to support the weight of the upper

    body. The risk for falling is increased

    proportionally when the path is disinclined,

    such as when walking down a driveway,

    which predisposes the individual to

    accelerate and suffer fall injury.

    Hemiplegics often suffer additional head

    injuries as a result of the helicoped gait.

5. Typically, the hemiplegic will point the toes

   of the affected limb down and inwardly,

   placing the foot flat on the floor (absent

   heel strike).

6. Transferring the weight of the upper body

    onto the bent limb can cause the knee to

   violently snap backwards. Knee hyper-

   extension injury involves painful ligamental

   and cartilage damage that may takes many

   months to resolve. A torn anterior cruciate

   ligament (ACL) may require surgical repair

   and extensive physical therapy.

                                             HYPEREXTENSION INJURY

Injury to the ligaments and tendons of the knee can be prevented by training the patient to employ a heel strike, to “roll” trunk weight onto the affected limb. Below is an illustration of how hyper-extension injuries. Despite loss of sensation in the affected limb, nondescript pain is reported.

7. BEND. Upper body weight shifts only

   slightly to the unaffected side and the knee

   bends, rather than lifting the entire leg off

   the ground. If a cane is used, the patient is

   trained firstly not to lean on the cane but

    use it much as a snow skier uses a ski

    pole, solely for reference, which facilitates

   re-development of balance.

Passive stretching of a paralytic limb to lengthen shortened tendons is helpful. Almost all other prescribed exercises tend to be ineffective as without cognitive involvement, the controlling motor cortex will remain unprogrammed.

Note that tonic spasm is often released during sleep. A cognitive-behavioral approach and biofeedback-assisted neuromuscular re-education can permanently modify the resting state of flexor muscles, especially if initially aided by Botox injections.

                                                         BOSS GAIT

This writer developed a gait training method with an acronym to serve as a mnemonic for patients to gain control of  the complex process of walking. BOSS: Bend (knee)-(point toe) Out- (take a) Short-Step.

8. OUT. The toe points outward. The affected

    limb always takes a short step. If the patient

    is able to visualize, a metaphor may be an

    effective mnemonic to gain cooperation and


9. SHORT STEP. Termination of the short

    step focuses on the important heel strike.

    Since a heel strike requires full extension

    of the limb, injury secondary to hyper-

    extension is prevented (q.v. below).

10. Upper body weight is transferred to the

     affected limb, which is fully extended. The

     short step inhibits potential for uncontrolled

     acceleration. Utilizing patient vanity, use of

     mirrors to show the individual how much

     better they look

11. A normal step with the unaffected leg

      stretches the Achilles tendon, often

      shortened after time. During training only,

      condition the tendon. Calf stretching is

      always indicated.


                                                                        the patient may be instructed to take a

                                                                        larger step with the non-affected limb to