1 To comply with professional boards/associations standards: • I declare that I (or my family) do not have a financial relationship in any amount, occurring in the last 12 months with a commercial interest whose products or services are discussed in my presentation. Additionally, all planners involved do not have any financial relationship. •Requirements for successful completion are attendance for the full session along with a completed session evaluation. •PESI and all current accreditation statuses does not imply endorsement of any commercial products displayed in conjunction with this activity. Session 402: Gait Strategies: How the Determinants of Gait Impact Function, Mobility & Safety Trent Brown, MOT, OTR/L, ATP, BCG Financial: Trent Brown is an adjunct professor at the University of Utah. He receives a speaking honorarium from PESI, Inc. Non-financial: Trent Brown is a credential holder of a board certification in gerontology (BCG) from the AOTA. Objectives 1. List the 6 Determinants of gait and how they impact the phases of gait and reduce energy expenditure during gait 2. Review current evidence justifying the utilization of the 6 determinants of gait in the clinical setting 3. Demonstrate activities, exercises, and treatment strategies to improve each of the 6 determinants of gait
Transcript
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To comply with professional boards/associations standards:• I declare that I (or my family) do not have a financial relationship in any amount, occurring in the last 12 months with a commercial interest whose products or services are discussed in my presentation. Additionally, all planners involved do not have any financial relationship.•Requirements for successful completion are attendance for the full session along with a completed session evaluation.•PESI and all current accreditation statuses does not imply endorsement of any commercial products displayed in conjunction with this activity.
Session 402: Gait Strategies: How the Determinants of Gait Impact Function, Mobility & SafetyTrent Brown, MOT, OTR/L, ATP, BCG
Financial: Trent Brown is an adjunct professor at the University of Utah. He receives a speaking honorarium from PESI, Inc.Non-financial: Trent Brown is a credential holder of a board certification in gerontology (BCG) from the AOTA.
Objectives
1. List the 6 Determinants of gait and how they impact the phases of gait and reduce energy expenditure during gait
2. Review current evidence justifying the utilization of the 6 determinants of gait in the clinical setting
3. Demonstrate activities, exercises, and treatment strategies to improve each of the 6 determinants of gait
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Sections1. History of Movement and Gait
Development/Research
a) Energy expenditure vs. conservation
b) Determinants – Phase – Curtate Cycloid
c) Metabolic cost of transport
d) What the phases of gait neglect
Sections2. Evidence Behind Each “Determinant”
a)Why falls don’t occur during gait
b)The new “Determinants”
Sections3. Treatment Strategies for Each “Determinant”
a) Sit-Stand
b) Lateral Pelvic Tilt
c) Knee Flexion at Midstance
d) Knee/Ankle/Foot Interactions
e) Pelvic Rotation/Hip Flexion
f) Reciprocal Arm Swing
4. Documentation Example and Questions
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Section 1: History of Gait and Development Research
Section 1 History of Movement and Gait Development
1. History of Movement: Saunders wanted to answer the question: Why we walk the way we do (COM Cycloid)
a) Minimize COM motion (conserve energy) from point A to B
1) Lateral Pelvic Tilt (Frontal Plane)
2) Knee Flexion at Mid-stance
3) Knee, Ankle, Foot Interactions
4) Pelvic Rotation (Transverse Plane)
5) Hip Flexion (ROM-passive) (Most early gait authors disagreed)
6) Physiological Valgus of the knee (approximately 5*)
Section 1 History of Movement and Gait Development
1. History of Movement: Rancho Los Amigos refuted “Determinants” (1984)
a) Stance Phase
1) Initial contact (heel strike)
2) Loading response
3) Mid-stance 57-58% gait
4) Terminal stance
5) Pre-swing (toe-off)
b) Swing Phase1) Initial swing
2) Mid swing 42-43% gait
3) Terminal swing
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Section 1 History of Movement and Gait Development
1. History of Movement: Multiple authors began studying why the evolution into “phases of gait” correlated with increased falls (mechanical emphasis) and a reduction in energy conservation
Section 1 History of Movement and Gait Development
1. History of Movement: Multiple authors began studying why the evolution into “phases of gait” correlated with increased falls (mechanical emphasis) and a reduction in energy conservation
Section 1 History of Movement and Gait Development
(Betram, 2015)
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Section 1 History of Movement and Gait Development
1. History of Movement: Multiple authors researched “curtate cycloid” idea of a wheel rolling on a flat surface with a point “rigidly” fixed to the wheel (dancers, gymnasts, smooth walkers)
Section 1 History of Movement and Gait Development
1. History of Movement:
COM cycloid “determinants” theory
Prolate cycloid “phases of gait” theory
Curtate cycloid “new” theory
Section 1 History of Movement and Gait Development
1. History of Movement: COM displacement with curtate/COM cycloid approaches = energy conservation
(Delabastita et al., 2016)
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Section 1 History of Movement and Gait Development
1. History of Movement: Based on evidence refined the past 4-5 years, “gait” experts and researchers are returning to a more COM based approach
In other words, we walk to get from point A to point B using as little energy as possible.
Why?
That energy is preserved for other more energy requiring tasks, activities, or occupations.
Section 1 History of Movement and Gait Development
2. What are the Phases of Gait Missing?
• Pelvic Rotation (and reducing pelvic rotation)
• Hip Int/Ext Rotation (+/-8*)
• Hip AB/AD duction (+/-7*)
• Eversion/Inversion (Initial Contact = Foot Inversion Toe Off = Foot Eversion)
Joint Torque (Moments) is partially neglected in “phases of gait”
T Σ = T external + T gravitational + T intersegmental + T muscle
Section 1 History of Movement and Gait Development
2. What are the Phases of Gait Missing? Pirker and Katzeschlager (2018) also argue the following “functions and systems” are often neglected in the “phases of gait”
• Locomotor function
• Balance and postural reflexes
• Sensory function
• Sensorimotor integration
• Motor control
• Musculoskeletal apparatus
• Cardiopulmonary functions
Disturbances in any of these “systems” then require compensation (i.e. poor proprioception may be compensated by increased visual awareness)
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Section 1 History of Movement and Gait Development
2. What are the Phases of Gait Missing? A centrally integrating system comprised of:
1. Frontal Cortex
2. Basal Ganglia Peduncoluponotine Nucleus
3. Brain Stem (PPN)
4. Cerebellum
Interpret the afferent signals and send neural signals via an efferent system including pyramidal tracts, peripheral nerves, and muscles which initiate an action
The brain stem “centers” knows as the midbrain motor centers (PP nucleus) is primarily responsible for mobility (locomotion, sit-stand, side-step)
Section 1 History of Movement and Gait Development
2. What are the Phases of Gait Missing?
• Cognitive control: relevant for circumnavigating obstacles and choosing the “optimal” route thus conserving energy
• Cognitive Perception: frontal executive functions, visuospatial perception and attention all contribute to safe mobility
• Psychological factors: depression and anxiety lead to slower (more dangerous) mobility and reaction
• Multi-task paradigm: elderly persons who stop walking while talking have significantly higher risk of falling
Section 2: Evidence Behind Each Determinant
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Section 2 – Evidence Behind the Determinants
1. Why don’t people fall during gait?
Typically people fall or “fail” during:
• attempt to begin gait (not neurologically prepared)
• once they’ve reached a destination (fatigue)
• attempt a different form of mobility (side-stepping, stairs, pivoting, etc.) 2* poor proprioception
***Further justification for COM control emphasis during mobility training***
(current authors may be right!!!)
Section 2 – Evidence Behind the Determinants
1. Parameters for clinical examination of mobility
Section 2 – Evidence Behind the Determinants
2. Evidence behind each “Determinant”
Based on the literature and current evidence, it seems the 6 “Determinants” must be revisited but modifications are needed.
1. Sit-stand (Anterior/Posterior Pelvic Tilt) (60 per day)
2. Lateral Pelvic Tilt in the Frontal Plane
3. Knee Flexion at Mid-stance
4. Knee - Ankle - Foot Interactions
5. Pelvic Rotation in the Transverse Plane with Hip Flexion in the Sagittal Plane
It also requires 10-15* posterior pelvic tilt (from maximum anterior point) to bring the upper trunk back to neutral during hip hinge
Section 2 – Evidence Behind the Determinants
2. Evidence behind each “Determinant”
Sit-Stand (Anterior/Posterior Pelvic Tilt)Evidence: Age related changes in the pelvis and thorax is one of the greatest risk factors in reduced gait coordination, mobility, and speed.
After thoracopelvic assisted training/movement implemented in Tx: (in this study a machine was used but manual is as effective)
6 sessions: 32% increased TUG by > 4 seconds
21% improved 10-meter walk velocity from community ambulation to functional community ambulation
12 Sessions: 53% increased TUG by > 4 seconds
(Springer, et al. 2018)
Section 2 – Evidence Behind the Determinants
2. Evidence behind each “Determinant”
Sit-Stand (Anterior/Posterior Pelvic Tilt)Evidence: Yamako , et al. (2017) evaluated the correlation between sit-stand and mobility. Slower Sit-Stand movement/control and speed correlates with reduced motor performance, strength, and speed (walking speed is considered a high indicator for safety)
Evaluated subjects ages 20-89 with speed and control completing sit-stand
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Section 2 – Evidence Behind the Determinants
2. Evidence behind each “Determinant”
Sit-Stand (Anterior/Posterior Pelvic Tilt)
Evidence: Millor et al., (2017) argues sit-stand better identifies ambulation, mobility, and frailty than fall tests and gait speed (718 elderly subjects)
Section 2 – Evidence Behind the Determinants
2. Evidence behind each “Determinant” Lateral Pelvic Tilt (7*)Evidence: What is the most important muscle for single leg stance (lateral pelvic stability)?
***42% of gait, > 50% stairs, > 50% transfers is spent on one leg***
Section 2 – Evidence Behind the Determinants
2. Evidence behind each “Determinant” Lateral Pelvic Tilt (7*)Evidence: What muscle(s) are required to allow lateral pelvic tilt and how does it impact gait?
Study analyzed 16 individuals on flat, and inclined surfaces to compare stability versus mobility contraction
Findings:
• Gluteus Medius exhibits maximum contractile force during mid-stance of single leg stance
• Gluteus Medius contracts concentrically during initial elevation and then eccentrically to stabilize during descent of the pelvis during swing phase on the opposite side
• Inclined angle of 5* maximizes glut med stability/contraction
(Jeong, et al. 2014)
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Section 2 – Evidence Behind the Determinants
2. Evidence behind each “Determinant” Lateral Pelvic Tilt (7*)Evidence: What exercises/activities elicit greatest glut med response for anterior, medial, and posterior fibers?
Study analyzed 10 postmenopausal women completing 7 glut med exercises (4 stabilizing and 3 dynamic) to find which elicited greatest response (EMG methods)
Findings:
• The 3 “stabilizing/isometric” exercises yielded the greatest activity for all 3 tier areas of glut med
• Clam/Dip test mobility exercises elicit the least amount of activity
(Ganderton et al., 2017)
Section 2 – Evidence Behind the Determinants
A, B & C
most effective
G = least effective
Section 2 – Evidence Behind the Determinants
2. Evidence behind each “Determinant” Knee Flexion at Midstance (8-10*)Evidence: How does knee pain (OA or other Dx) impact knee flexion at mid-stance and how does this impact gait?
Study compared subjects with knee pain compared to subjects without knee pain during stance phase of gait.
Findings:• Subjects with knee pain exhibited increased knee flexion at initial contact
• Subjects with knee pain exhibited increased knee flexion during mid-stance
• This resulted in a larger “dip” of COM during gait
• Increased knee flexion provided a “feeling” of greater stability although greater effort required
“hip and trunk stability were significantly deficient with this population”
(Favre & Jolles, 2016)
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Section 2 – Evidence Behind the Determinants
2. Evidence behind each “Determinant” Knee Flexion at Midstance (8-10*)
Evidence: How does knee flexion control (8-10*) gait affect balance and speed among patients with hemiparesis
Study compared 30 subjects with hemiparesis over 8 weeks. Studied subjects completing single leg closed chain WB tasks pre/post on affected side
Findings:
• Stride length improved from 55.36 to 62.33 (quantified numbers, not inches)
• Velocity improved from 67.79 to 71.19 cm/s
• TUG improved from 22.72 to 19.96
(Young, et al. 2018)
Section 2 – Evidence Behind the Determinants
2. Evidence behind each “Determinant” Knee/Ankle/Foot InteractionsEvidence: Is Dorsiflexion (DF) ROM correlated with Heel-rise (Plantarflexion) time?
• Ankle DF and Heel-rise time are “significantly” correlated
• In other words, increased DF = increased Heel-rise (toe-off)
End Game = increased Stride/Step Length
Section 2 – Evidence Behind the Determinants
2. Evidence behind each “Determinant” Knee/Ankle/Foot InteractionsEvidence: How do ankle/foot interactions impact stairs (step-to or step over step)?
• Full heel contact (entire foot on step) increases core contraction and stability reducing falls.
• Increase power to generate force during stair mobility to allow for step over step pattern and reduce amount of time spent on stairs
• Overallo More stability on stairs
o Reduced time spent on stairs Reduced Fall Risk
o Increased force production and power
(Kang et al., 2017)
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Section 2 – Evidence Behind the Determinants
2. Evidence behind each “Determinant” Knee/Ankle/Foot InteractionsEvidence: How do ankle/foot interactions impact stairs (step-to or step over step)?
This requires increased
anterior pelvic tilt/hip flexion
glut med stability, appropriate
gastroc/soleus lengthening,
and COG over BOS
Section 2 – Evidence Behind the Determinants
2. Evidence behind each “Determinant” Knee/Ankle/Foot InteractionsEvidence: How do ankle/foot interactions impact stairs (step-to or step over step)?
***Stabilizers are activated with heel contact (internal oblique and TA)***
***Mobilizers are activated without heel contact (external oblique and RA)***
Section 2 – Evidence Behind the Determinants
2. Evidence behind each “Determinant” Pelvic Rotation in Transverse Plane with Hip Flexion in Sagittal Plane
Evidence: Ambulation and Functional Reach are directly correlated with the coordination of trunk and pelvis
This study examined phases of gait during axial rotation between young and older populations
Findings:
• Angular Displacements and Stability reduced as age increased during axial trunk rotation (swing phase)
2. Evidence behind each “Determinant” Pelvic Rotation in Transverse Plane with Hip Flexion in Sagittal Plane
Evidence: UE ROM/mobility and pelvic rotation are strongly correlated
This study examined pelvic rotation with individuals experiencing LBP and reduced mobility compared with “healthy” subjects.
Findings:
• “Improved pelvic flexibility for coordinated trunk movements will help subjects with LBP”…and reduced mobility patterns.
(Sung PS. 2014)
Section 2 – Evidence Behind the Determinants
2. Evidence behind each “Determinant” Pelvic Rotation in Transverse Plane with Hip Flexion in Sagittal PlaneEvidence: (Hip Flexion) Will subjects with hip flexion contracture exhibit dysfunctional gait patterns?
This study examined the affect of hip flexion contracture on pelvic tilt, hip extension, and hip flexion during all phases of gait
Findings:
• Pelvic tilt, psoas length, hip flexor ability, and hip extension in toe-off were clinically reduced with hip flexor contracture
• Why? Hip flexion (“swing phase” should be a “passive” event for the LE)
***more active for central core***
(Choi, 2011)
Section 2 – Evidence Behind the Determinants
2. Evidence behind each “Determinant” Reciprocal Arm SwingEvidence: What happens with restricted UE swing compared to free arm swing under different velocities for children with CP?
This study used normal developing children and children with bi-lateral or unilateral CP. Measurements were taken for COM “sway” with restricted and unrestricted UE swing during normal and high walking speeds.
Findings: • Typically “normal developing children” had increased sway with fixed UE swing = increased rigidity and
LOB and substantially increased sway with high walking speeds
• CP groups had substantially increased sway with restricted arm swing and high walking speeds
• Trunk Rotation also increased for both groups
(Delabastita, et al. 2016)
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Section 2 – Evidence Behind the Determinants
2. Evidence behind each “Determinant” Reciprocal Arm Swing
Section 2 – Evidence Behind the Determinants
2. Evidence behind each “Determinant” Reciprocal Arm SwingEvidence: Will emphasizing UE/arm swing activities improve gait speed, balance, and efficiency?
This study used subjects with hemiparesis and compared a control group (received reciprocal UE ex’s 3 x 30 minutes for 4 weeks) with subjects who just did NDT based UE movements.
Findings:
• Control group demonstrated significant change in 10 meter walking test from 12.51 sec to 8.17 sec. to complete
• Control group demonstrated increased distance in 6-minute walk test from 152.38 meters to 188.00 meters
(June-Seok & Hyun-Joo, 2014)
Section 2 – Evidence Behind the Determinants
2. Evidence behind each “Determinant” Reciprocal Arm SwingEvidence: Will Center of Mass (COM) displacement increases in kinematic patterns with constrained arm swing?
Measured peak and base distances and ground reaction forces of 20 “healthy” subjects.
Findings:
• COM displacement increased 1 CM for constrained arm
• Reduced stride and foot contact
***Vertical COM displacement = increased energy expenditure***
(Yang, et al. 2015)
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Section 2 – Evidence Behind the Determinants
2. Evidence behind each “Determinant” Reciprocal Arm Swing
Section 2 – Evidence Behind the Determinants
2. Evidence behind each “Determinant” Reciprocal Arm Swing• According to multiple research articles, 8-20% of force required for safe/normal
ambulation (no Assistive Device) is generated in the arm swing
• Morris & Allison (2006) looked at which core muscles contract with the reciprocal arm swingo As the arm swings behind the rectus abdominis is the most active
o As the arm swings forward, the internal oblique and erector spinae are the most active
• After extensive EMG testing, this article concludes the Rectus Abdominis muscle fatigues quickly resulting in an increase of erector spinae and oblique muscle power of 30% to compensateo The result of this is reduced stabilization of the core and reduced swing of the arms
Section 2 – Evidence Behind the Determinants
2. Evidence behind each “Determinant” Reciprocal Arm SwingEvidence:
• In addition, 30% more of the force required for safe or normal gait is generated in the core to stabilize the pelvis and ribs
• Therefore, LE strength/power is approximately 50-62% of the force required for gait
• Force generated from the reciprocal arm swing during gait is directly proportional to step length
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Section 3: Treatment Strategies for Each Determinant
Section 3 – Treatment Strategies for Each “Determinant”
Place Pt. in side lying with top knee bent and supported by clinician. As Pt. lifts knee, superior iliac crest manipulated posterior. As Pt. pushes “down” iliac crest manipulated anterior.
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Section 3 – Treatment Strategies for Each “Determinant”
Section 3 – Treatment Strategies for Each “Determinant”
Pelvic Rotation in Transverse Plane with Hip Flexion in Sagittal PlaneName: Superior/Central Core Toby Twister (Walking Toby Twister)
Section 3 – Treatment Strategies for Each “Determinant”
Pelvic Rotation in Transverse Plane with Hip Flexion in Sagittal PlaneName: Supported Walking Toby Twister
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Section 3 – Treatment Strategies for Each “Determinant”
Pelvic Rotation in Transverse Plane with Hip Flexion in Sagittal PlaneName: Supported Walking Toby Twister
Section 3 – Treatment Strategies for Each “Determinant”
Pelvic Rotation in Transverse Plane with Hip Flexion in Sagittal PlaneName: Supported Walking Toby Twister
Section 3 – Treatment Strategies for Each “Determinant”
Pelvic Rotation in Transverse Plane with Hip Flexion in Sagittal PlaneName: Supported Walking Toby Twister
•
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Section 3 – Treatment Strategies for Each “Determinant”
Reciprocal Arm SwingName: Seated Swing
Section 3 – Treatment Strategies for Each “Determinant”
Reciprocal Arm SwingName: Stand Swing
Section 3 – Treatment Strategies for Each “Determinant”
Reciprocal Arm SwingName: Standing Swingers
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Section 4: Documentation Example and Questions
Section 3 – Treatment Strategies for Each “Determinant”
Documentation Example (Teaser)Therapist completed 3 x 10 chair squats and side lying clam exercise 3 x 10 to prepare patient for stairs. Pt. then exhibited LOB x 3 while transporting functional object during stair ascent task with a step to pattern.
vs.
Pt. demonstrates increased fall risk with object transportation while ascending/descending stairs. Pt. scored ___ on stairs portion of FGA demonstrating safe stair mobility but scored ____on FGA obstacle portion of demonstrating reduced single leg stance balance and confidence levels. Clinician provided visual stance and glance activity with alternating LE’s as support leg while completing visual location movements on 6” step. Following mastery, clinician provided 4 lb. weighted ball with same activity and no LOB observed with alternating R-L step up. Pt. was then able to complete 4 steps while holding unweighted laundry basket demonstrating step-to pattern to ascend and step over step pattern to descend. Pt. also exhibited increased confidence levels with object transportation to stance phase of gait with increased visual awareness of environment and heel contact during descent.
