when ambulating as instructed.
G.J. Taylor, PhD, CAP, BCIAC. CBT.
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
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.
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.
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
the patient may be instructed to take a
larger step with the non-affected limb to