Functional Re-education: Mobility, Gait & Limb Function + Practice MCQs

Functional Re-education: Principles & Practice

💡 Core Concept: Functional Re-education aims to restore the patient's ability to perform essential daily tasks (ADLs) by training voluntary muscle control, coordination, and balance. It follows the developmental sequence: Lying → Sitting → Standing → Walking.

1. Lying to Sitting (Bed Mobility)

This is the first step in independence. It involves changing the Base of Support (BOS) from the entire posterior body to just the buttocks and thighs.

Technique A: Roll and Push (Common for Stroke/Back Pain)

• Step 1 (Rolling): Patient flexes knees, reaches across the body with the arm, and rolls onto their side (Log Rolling).
• Step 2 (Legs Down): The feet are dropped over the edge of the bed (Leverage).
• Step 3 (Push Up): The patient pushes down into the mattress with the lower elbow and upper hand to lift the trunk.
• Muscles: Triceps, Obliques, Hip Abductors.

Technique B: Straight Sit-up (Long Sitting)

• Description: Sitting up directly from supine.
• Indication: Paraplegia (using arms), young patients.
• Muscles: Strong Abdominals (Rectus Abdominis), Hip Flexors (Iliopsoas).
• Note: Contraindicated in acute lumbar disc herniation due to high intradiscal pressure.

2. Sitting Activities

Once seated, the goal is to achieve Static Balance (holding posture) and Dynamic Balance (moving within posture).

Key Components

• Pelvic Tilt: Teaching Anterior (Lordosis) vs Posterior (Slump) tilt. Anterior tilt is essential for Sit-to-Stand.
• Weight Shifting: Shifting weight from one ischial tuberosity to the other. Essential for pressure relief and walking preparation.
• Reaching (Limits of Stability): Reaching out with arms without falling. Increases the "Cone of Stability."
• Protective Extension: Training the reflex to extend arms to break a fall.

Sit-to-Stand (STS) Biomechanics

1. Flexion Phase: Trunk leans forward (Forward translation of trunk).
2. Momentum Transfer: Buttocks lift off (Critical phase). Needs Anterior Tibial Translation (Dorsiflexion).
3. Extension Phase: Hips and Knees extend together against gravity.
4. Stabilization: Full upright posture.

3. Gait Re-education

Walking is a complex task requiring progression, stability, and adaptation.

Pre-Gait Activities (In Standing)

• Weight Acceptance: Shifting weight onto the weak leg.
• Single Leg Stance (SLS): The most critical prerequisite for walking.
• Stepping Strategy: Practicing step-ups or tapping the foot forward/backward.

Phases of Gait (Rancho Los Amigos)

Stance Phase (60%)	Swing Phase (40%)
Initial Contact (Heel Strike)	Initial Swing (Acceleration)
Loading Response (Foot Flat)	Mid Swing
Mid Stance	Terminal Swing (Deceleration)
Terminal Stance (Heel Off)
Pre-Swing (Toe Off)

Common Deviations & Corrections

• Trendelenburg Gait: Weak Gluteus Medius. Rx: Abductor strengthening, SLS.
• Circumduction: Weak Hip Flexors or Foot Drop. Rx: Flexor strengthening, AFO.
• Genu Recurvatum: Weak Quads or Spasticity. Rx: Hamstring strengthening, terminal knee extension control.

4. Limb Function (Upper & Lower Extremity)

Upper Limb Function

• Reach: Transporting the hand to the target. Requires Scapular stability and Elbow extension.
• Grasp:
  • Power Grip: Holding a hammer (uses extrinsic muscles).
  • Precision Grip: Holding a pen (uses intrinsic muscles).
• Release: Often harder than grasp for spastic patients (requires extensor activity).
• Manipulation: In-hand dexterity.
• Closed Chain Activity: Weight bearing on hands (e.g., Push-ups on wall). Increases shoulder stability (Approximation).

Lower Limb Function

• Bridging: Lying supine, lifting hips. Strengthens Glutes/Hamstrings, breaks extensor synergy.
• Triple Flexion: Flexion of Hip, Knee, and Ankle simultaneously (Swing phase mechanics).
• Triple Extension: Extension of Hip, Knee, Ankle (Push-off mechanics).

🏆 Golden Points

• Center of Gravity (COG): Moves from a wide/low position (Lying) to a high/small position (Standing). The transition is the greatest challenge in rehab.
• Dorsiflexion: Essential for "Sit-to-Stand." If ankles are restricted (plantarflexed), the patient cannot bring their COG forward over their feet to stand up.
• Visual Feedback: Using mirrors is a key component of re-education to correct posture and gait deviations.

⚠️ Precautions

• Orthostatic Hypotension: Drop in BP when moving from Lying to Standing rapidly.
• Sensory Loss: Patients with diabetic neuropathy rely on vision for balance.
• Cognitive Deficits: Instructions must be simple for patients with apraxia or dementia.

📝 20 High-Yield MCQs

Q1. Which movement is crucial for the "Momentum Transfer" phase of Sit-to-Stand?

A. Posterior Pelvic Tilt B. Anterior Tibial Translation (Dorsiflexion) C. Knee Extension D. Trunk Extension

Rationale: The tibia must move forward over the foot (dorsiflexion) to bring the body's Center of Mass over the Base of Support (feet). Without this, the patient falls backward.

Q2. The "Log Rolling" technique for moving from lying to sitting is indicated for:

A. Spinal Surgery / Back Pain patients B. Paraplegic patients C. Patients with strong abdominals D. Amputees

Rationale: Log rolling keeps the spine in neutral alignment (no twisting/rotation), protecting surgical sites or painful discs.

Q3. What percentage of the gait cycle is the Stance Phase?

A. 40% B. 60% C. 50% D. 80%

Rationale: In normal walking, the foot is on the ground (Stance) for 60% of the cycle and in the air (Swing) for 40%.

Q4. Bridging exercises (lifting hips in supine) primarily strengthen the:

A. Quadriceps B. Gluteus Maximus and Hamstrings C. Iliopsoas D. Abdominals

Rationale: Bridging involves hip extension, which is the primary action of the Gluteus Maximus and Hamstrings. It is essential for the stance phase of gait.

Q5. Which gait deviation is caused by weak dorsiflexors?

A. Trendelenburg Gait B. High Steppage Gait / Foot Drop C. Ataxic Gait D. Scissoring Gait

Rationale: Weak dorsiflexors prevent the foot from clearing the ground during swing. The patient compensates by flexing the hip and knee excessively (High Steppage).

Q6. The "Limits of Stability" in sitting refers to:

A. How far a patient can reach without changing the Base of Support B. How long a patient can sit C. The strength of the back muscles D. The width of the chair

Rationale: It is the maximum distance a person can lean their COG outside their BOS without falling or needing to take a step/support.

Q7. Closed Kinetic Chain exercises for the Upper Limb (e.g., wall push-ups) mainly improve:

A. Fine motor skills B. Shoulder Joint Stability C. Hand writing D. Reach velocity

Rationale: Weight bearing (Approximation) stimulates joint receptors and co-contraction of rotator cuff muscles, enhancing stability.

Q8. Trendelenburg Gait is characterized by:

A. Forward trunk lean B. Pelvic drop on the swing (unaffected) side C. Pelvic drop on the stance (affected) side D. Backward trunk lean

Rationale: Weak Gluteus Medius on the stance leg cannot hold the pelvis level, causing it to drop on the opposite (swing) side.

Q9. Which muscle is the primary "Pusher" during a transfer from bed to wheelchair for a paraplegic patient?

A. Biceps B. Triceps / Latissimus Dorsi C. Trapezius D. Wrist flexors

Rationale: The patient must lift their body weight by extending the elbows (Triceps) and depressing the shoulder girdle (Lats).

Q10. What is the main goal of "Weight Shifting" activities in sitting?

A. Pressure relief and preparation for movement B. Strengthening the quads C. Increasing heart rate D. Stretching hamstrings

Rationale: Weight shifting unloads one side (preventing pressure sores) and frees up that side to move (e.g., lifting the leg or taking a step).

Q11. Triple Flexion of the lower limb involves:

A. Hip Flexion, Knee Flexion, Ankle Dorsiflexion B. Hip Flexion, Knee Extension, Ankle Plantarflexion C. Hip Extension, Knee Flexion, Ankle Dorsiflexion D. Flexion of 3 toes

Rationale: This pattern shortens the limb to allow it to clear the ground during the Swing Phase of gait.

Q12. Which phase of gait requires the most balance (Single Limb Support)?

A. Initial Contact B. Mid Stance C. Pre-Swing D. Loading Response

Rationale: In Mid Stance, the body weight is balanced over a single foot while the other leg is in the air. This is the point of minimum stability and maximum demand on balance.

Q13. A patient leans forward excessively at the hip while walking (Gower's sign). This indicates weakness of:

A. Gluteus Maximus (Hip Extensors) B. Hip Flexors C. Quadriceps D. Gastroc-Soleus

Rationale: Leaning forward moves the line of gravity anterior to the hip joint, locking it in extension passively, compensating for weak Gluteus Maximus (Gluteus Max Lurch is usually backward, but Gower's involves using hands to push up due to weak proximal muscles). Wait, strictly "Gluteus Maximus gait" involves a backward lurch. A forward lean usually compensates for weak Quadriceps (to lock knee) OR weak hip extensors if using hands. However, in standard gait analysis, a backward lurch = Weak Glute Max. A lateral lurch = Weak Glute Med.

Q14. Prehension (Grasp) requires which wrist position for maximum strength?

A. Flexion B. Extension (20-30 degrees) C. Radial Deviation D. Ulnar Deviation

Rationale: Slight wrist extension puts the finger flexors in an optimal length-tension relationship (preventing active insufficiency) to generate maximum grip force.

Q15. "Tandem Standing" involves:

A. Standing on one leg B. Heel of one foot touching toe of the other (Heel-to-toe) C. Feet wide apart D. Standing on toes

Rationale: Tandem standing narrows the BOS significantly in the medial-lateral direction, challenging balance. It mimics the narrow base required for walking.

Q16. Orthostatic Hypotension is a risk during which transfer?

A. Supine to Standing/Sitting B. Sitting to Supine C. Standing to Sitting D. Turning in bed

Rationale: Moving quickly from a horizontal to a vertical position causes blood to pool in the legs. If the baroreceptor reflex is delayed (common in bedridden patients), BP drops, causing dizziness.

Q17. Which gait pattern is typically taught to a paraplegic patient using crutches?

A. Swing-Through Gait B. 2-Point Gait C. 4-Point Gait D. Reciprocal Gait

Rationale: Swing-through (or swing-to) gait allows the patient to lift the body using the arms and swing the legs forward. It is fast but requires good upper body strength and balance.

Q18. To facilitate "Reach" in a stroke patient, the therapist should encourage:

A. Scapular Protraction and Elbow Extension B. Scapular Retraction and Elbow Flexion C. Wrist Flexion D. Trunk Extension

Rationale: The typical spastic synergy is retraction/flexion. Functional reach requires breaking this synergy by protracting the scapula and extending the elbow.

Q19. Initial Contact (Heel Strike) requires which ankle position?

A. Plantarflexion B. Neutral or slight Dorsiflexion C. Inversion D. Eversion

Rationale: To make contact with the heel first (essential for shock absorption and forward progression), the ankle must be held in neutral or slight dorsiflexion by the Pretibial muscles.

Q20. What is the "Antalgic Gait"?

A. Painful gait with shortened stance phase on the affected side B. Waddling gait C. Drunken gait D. High stepping gait

Rationale: "Antalgic" means "against pain." The patient spends as little time as possible on the painful leg, leading to a quick, shortened step on that side.