Gait help: How and where to carry a cane, and why.

Test Question from this photo:

This lady on the right is using her cane and purse correctly IF, she has a degenerative hip on the RIGHT or LEFT ?

Answer: LEFT hip

Why, because the cane in the right hand pressing down creates a ground reactive force back up through the cane, helping to tip her torso to the left, the passive cane-generated lean in effect reduces the left gluteus medius compressive load across a painful degenerative hip. Result, less painful gait.

But, she is also brilliant to use the purse in the left hand, to effectively PULL her torso over the left hip (again, limiting g.medius joint compressive forces through more passive means).
End result, less compressive pain loading across a degenerative joint.
*IF we were her daughter we would help by putting a 10 pound brick in the purse, just to help of course.

IF she however has a painful degenerative right hip, school her.

Gait changes with your weight change?

Does a sudden gain in one's weight change their gait? Well, in this study, another form of weight change sure seemed to change the gait of these ladies.

The primary aim of this study was investigate the changes in gait and postural control as factors of stability during walking. Gait and posture of thirty-five (35) pregnant women and the results indicated that there were significant associations noted between:
- step width,
- lateral trunk lean, and
- medio-lateral deviations in center of gravity and center of pressure.

They found among other things, that the lateral trunk lean is the primary factor women use in pregnancy to keep the center of gravity closer to the base of support. "Postural changes and those in gait kinematics were largely affected by the relative mass gain, rather than the absolute mass. Considering the importance of relative mass gain, more attention during healthy pregnancy should be given to monitoring the timing of onset of musculoskeletal changes, and design of antenatal exercise programs targeting core strength and pelvic stability."

We concur, we can see this lateral trunk lean in clients all the time who have challenges in hip-pelvis-core stability in the frontal plane. Stability work, primarily of the hips is critical for these clients. This work often serves pregnancy clients well, it helps to fend off some of the late term pelvis and low back problems as the frontal mass develops.

If this is new information for you, you should head over to our website/blog and start your learning process with the fundamentals of the "cross over gait" because that in essence is what we are talking about here.

https://www.ncbi.nlm.nih.gov/pubmed/29254847

Hum Mov Sci. 2017 Dec 15. pii: S0167-9457(17)30750-9. doi: 10.1016/j.humov.2017.12.011. [Epub ahead of print]  Changes in gait and posture as factors of dynamic stability during walking in pregnancy.  Krkeljas Z1.

The Power of Facilitation: How to supercharge your run.

While running intervalsone morning, something dawned on me. My left knee was hurting from some patellar tracking issues, but only on initial contact and toe off. I generally run with a midfoot strike. I began concentrating on my feet, lifted and spread my toes and voila! my knee pain instantly improved. Very cool, and that is why I am writing this today. 

Without getting bogged down in the mire of quad/hamstring facilitation patterns, lets look at what happened.

I contracted the long extensors of the toes: the extensor digitorum longus and the extensor hallicus longus; the short extensors of my toes: the extensor digitorum brevis, the extensor hallucis brevis: as well as the dorsal interossei.the peroneus longus, brevis and tertius were probably involved as well.

Do you note a central theme here? They are all extensors. So what, you say. Hmmm… 

Lets think about this from a neurological perspective:

In the nervous system, we have 2 principles called convergence and divergence. Convergence is when many neurons synapse on one (or a group of fewer) neuron(s). It takes information and “simplifies” it, making information processing easier or more streamlined. Divergence is the opposite, where one(or a few) neurons synapse on a larger group. It takes information and makes it more complicated, or offers it more options.

In the spinal cord, motor neurons are arranged in sections or “pools” as we like to call them in the gray matter of the cord. These pools receive afferent information  and perform segmental processing (all the info coming in at that spinal cord segment) before the information travels up to higher centers (like the cerebellum and cortex). One of these pools fires the extensor muscles and another fires the flexor muscles.. 

If someone in the movie theater keeps kicking the back of our seat, after a while, you will say (or do) something to try and get them to stop. You have reached the threshold of your patience. Neurons also have a threshold for firing.  If they don’t reach threshold, they don’t fire; to them it is black and white. Stimuli applied to the neuron either takes them closer to or farther from threshold.  When a stimulus takes them closer to firing, we say they are “facilitating” the neuron. If it affects a “pool” of neurons, then that neuronal pool is facilitated. If that pool of neurons happens to fire extensor muscles, then that “extensor pool” is facilitated.

When I consciously fired my extensor muscles, two things happened: 1. Through divergence, I sent information from my brain (fewer neurons in the cortico spinal pathway) to the motor neuron pools of my extensor muscles (larger groups of motor neurons) facilitating them and bringing them closer to threshold for firing and 2. When my extensor muscles fired, they sent that information (via muscle spindles, golgi tendon organs, joint mechnoreceptors, etc) back to my cerebellum, brain stem and cortex (convergence) to monitor and modulate the response.

When I fired my extensor muscles, I facilitated ALL the neuronal pools of ALL the extensors of the foot and lower kinetic chain. This was enough to create balance between my flexors and extensors and normalize my knee mechanics.

If you have followed us for any amount of time, you know that it is often “all about the extensors” and this post exemplifies that fact.

 Next time you are running, have a consciousness of your extensors. Think about lifting and spreading our toes, or consciously not clenching them. Attempt to dorsiflex your ankles and engage your glutes. It just may make your knees feel better!

When the going gets rough, we have a tendency to look down...

While working with a patient with runners dystonia the other day, I had one of those epiphanies. I thought I would share it with you here. Here is some food for thought. 

We remember that we have 3 systems that keep us upright in the gravitational plane: The visual system, the vestibular system and the proprioceptive system. As we age, we seem to become more dependent on the visual system, but that is a story we have told before here, and could certainly been expanded on in another post or three... 

The long story today involves the vestibular system. It is a part of the nervous system that lives between your ears (literally) and monitors position, velocity and angular acceleration of the head. There are three hula hoop type structures called “semicircular canals” (see picture above) that monitor rotational, tilt position and angular acceleration, as well as two other structures, the utricle and saccule, which monitor tilt and linear acceleration. 

The vestibular apparatus (the canals and the utricle and saccule) feed into a part of the brain called the floccular nodular lobe of the cerebellum, which as we are sure you can imagine, have something to do with balance and coordination. This area of the cerebellum feeds back to the vestibular system (actually the vestibular nucleii, all 4 of them! superior, inferior, medial and lateral); which then feed back up to the brain (medial, inferior and superior nuclear pathway) as well as down the spinal cord (the lateral pathway) to predominantly fire the extensor muscles.

So, what do you think happens if we facilitate (or defaciltate) a neuronal pool? We alter outcomes and don’t see a clear picture. Most actions in the nervous system are a system of checks and balances, or positives and negatives, and the one the one that predominates, is the one that wins : )

Look at the picture above. Notice the lateral semicicular canals are 30 degrees to the horizontal? If you are standing up and extending your head , that lateral canal becomes vertical and the fluid inside (emdolymph) cannot flow, making it much less useful to the nervous system. Thats why it is hard to stand with your head extended and eyes closed and maintain balance (go ahead and try it, feeling is believing). Conversely, when we flex our head forward(like looking down to see what our footing looks like), we move this lateral canal onto a more physiologically advantageous position, enhancingour balance.  If you are on uneven ground, have an injury or are having issues with proprioception (like many folks do), this actually helps the vestibular system (as well as the proprioceptive and visual systems) to work more efficiently. 

OK, have that? Now one more concept..

So if we look down, we put a slow stretch into our neck extensor muscles, which just happen to have some great postural receptors in them, called muscle spindles, along with mechanoreceptors in the capsules of the joints. So, facilitating (ie. exciting) these receptors, fires more information into our cerebellum, the queen of balance in the nervous system. What do you think happens? Even better balance and coordination! The 2 systems work together, summate to improve movement and balance!

Wow. All this from head position…The key here is to realize what and why you are doing what you are doing....

Dominance of the lumbosacral girdle over the cervicothoracic is probably preserved in humans

. . . dominance of the lumbosacral girdle over the cervicothoracic is probably preserved in humans
This suggests that arm swing is, to a notable degree, subservient to leg swing.

Research thus far has strongly suggested two pieces to arm swing, a passive and an active swing component. Without muscle activity, passive swing amplitude and relative phase decrease significantly. As phase decreases, it is referred to as in-phase swing pattern of the arms. The Goudriaan et al paper referenced below concluded that "muscle activity is needed to increase arm swing amplitude and modify relative phase during human walking to obtain an out-phase movement relative to the legs."
But it is more complicated that this . . . .

Research continues to suggest that interlimb coordination is achieved at the brainstem and cortical level, which this study suggests as to why we can dual task and walk with something in our hands, carry objects and even walk and run with said objects and changes in our gait . . . . because, the program is running off a top down neurologic mediated process with predictable, economically CPGs(central pattern generator) in place.
"The coordination of arm and leg movements takes the form of an in-phase relationship between diagonal limbs [64]. The dominance of the lumbosacral girdle over the cervicothoracic is probably preserved in humans as well. For example, Sakamoto et al. [65] showed that during combined arm and leg cycling, the cadence of the arms was significantly altered when leg cycling cadence was changed. The opposite, however, was not true, i.e. the arms did not affect the leg cadence."-Preece et al.

Human Movement Science 45 (2016) 110–118
The coordinated movement of the spine and pelvis during
running
Stephen J. Preece, Duncan Mason, Christopher Bramah
School of Health Sciences, University of Salford, Salford, Manchester M6 6PU, United Kingdom

Gait Posture. 2014 Jun;40(2):321-6. doi: 10.1016/j.gaitpost.2014.04.204. Epub 2014 May 6.
Arm swing in human walking: what is their drive? Goudriaan M1, Jonkers I2, van Dieen JH3, Bruijn SM4.

You cannot make gait corrections based on "visual assessment and oral instructions"

our Christmas #facepalm of the day

These clients changed their gait habits with visual and verbal cues. We can only hope that for the rest of their lives they have this software and someone walking beside them to give them the visual and verbal cues for the rest of their lives so that they can continue to walk "normally" again, which is likely a compensation to their compensatory deficits (instead of earning the changes through championing their way through their deficits.)

Uggg. We have said this over and over again, and will say it again here.
You cannot make gait corrections based on "visual assessment and oral instructions" (as this paper mentions). This is borderline foolish. A person's gait has changed for a reason, they did not do it consciously. Thus, they should not lean towards a simple conscious correction. Their body made the adaptive changes one can see on gait evaluation because of an adaptive deficit, weakness, pain, compensatory motor strategy etc. There is a reason their gait has changed. Thus, the fix must come from addressing these causes, not merely from a visual cue or a verbal instruction. This is foolish. This is what is wrong with the gait assessment world. This is why you cannot and should not give corrective exercises from a gait analysis, not until you examine your client clinically for deficits, weakness, faulty motor patterns, sensory deficits, etc. This is just not prudent work without the clinical evaluation, hands on stuff, smart stuff.
These clients changed their gait habits with visual and verbal cues. We can only hope that for the rest of their lives they have this software and someone near by to give them the visual and verbal cues for the rest of their lives so that they can walk normally again (instead of earning the changes through championing their way through their deficits.)
#facepalm of the day

http://www.jbiomech.com/article/S0021-9290(17)30570-5/abstract

A gait retraining system using augmented-reality to modify footprint parameters: Effects on lower-limb sagittal-plane kinematics . Sami Bennour, Baptiste Ulrich, Thomas Legrand, Brigitte M. Jolles, Julien Favre

The "interference effect", between strength and endurance. Some Alex Hutchinson thoughts.

"I asked the coaches to name the single biggest change in elite triathlon training in 2017 compared with a decade earlier. The answers had nothing to do with wearable tech or secret workouts. Instead both gave the same answer: strength training." -Alex Hutchinson

This article by Alex discusses the "interference effect", between endurance and strength training.
According to Hutchinson, the most interesting point, in his view, is "Baar’s suggestion that you should design your strength workout to use heavy weights so that you reach failure after relatively few reps. This will maximize the metabolic signals for muscle growth, while minimizing the calories burned and metabolic stress."
And, "As you get stronger and hit the upper end of these ranges before hitting failure, increase the weight for the next workout."

As Hutchinson suggests at the end of this nice article, is that you shouldn't freak out unless you are in beast mode on a regular basis. He says that unless you are not undergoing endurance training 4+ times a week, or pushing beast mode 80%VO2 max sessions, you are unlikely to impact your strength gains with 4+ endurance sessions.

Find the article here:

https://www.outsideonline.com/2270846/how-build-strength-and-endurance-simultaneously

We hope you are standing up while you read this….

A newborn’s brain is only about one-quarter the size of an adult’s. It grows to about 80 percent of adult size by three years of age and 90 percent by age five (see above). This growth is largely due to changes in individual neurons and their connections, or synapses.

The truth is, most of our brain cells are formed at birth, In fact, we actually have MORE neurons BEFORE we are born. It is the formation of synapses, or connections between neurons, that actually accounts for the size change (see 1st picture above). This is largely shaped by experience and interaction with the environment.

Do you think children’s brains are less active than adults? Think again, your 3 year old’s brain is twice as active as yours! It isn’t until later in life that you actually start dialing back on some of those connections and those pathways degenerate or fade away…a process scientists call “pruning”.

How does this apply to gait? Gait depends on proprioception, or body position awareness. Your brain needs to know where your foot is, what it is standing on and so on. Proprioception, as we have discussed in other posts, is subserved by muscle and joint receptors called mechanoreceptors (muscle spindles, golgi tendon organs and type 1-4 joint mechanoreceptors to be exact). This information is fed to 2 main areas of the brain: the cerebral cortex and the cerebellum. These 2 parts of the central nervous system are interconnected on many levels.

The cerebellum is intimately associated with learning. Try this experiment. you will need a tape recorder (guess we are showing our ages, digital recorder), a timer and a moderately difficult book.

Sit down and pick a section of the book to read. start the recorder and timer and read aloud for 2 minutes. Stop reading, stop the recorder and stop the timer.

Stand up, somewhere you won’t get hurt if you fall. Stand on 1 leg (or if available, stand on a BOSU or rocker board). Open the book to a different spot. Start the timer, the recorder and start reading again for 2 minutes.

Sit back down and grab a snack. Listen to the 2 recordings and pay attention to the way you sound when you were reading, the speed, fluency and flow of words. Now think about recall. Which passage do you remember better?

The brain works best at multitasking and balance and coordination activities intimately affect learning. Having children sit in a class room and remain stationary and listen to a lecture is not the best way to learn. We always tel our students to get up and move around…

This article looks at this relationship in a slightly different way.

The Gait Guys….Sorting it out so you don’t have to.

We hope you are still standing : )

Scand J Med Sci Sports. 2011 Oct;21(5):663-9. doi: 10.1111/j.1600-0838.2009.01027.x. Epub 2010 Mar 11

Motor coordination as predictor of physical activity in childhood.

Lopes VP, Rodrigues LP, Maia JA, Malina RM.

Source

Department of Sports Science, Research Center in Sports Sciences, Health Sciences and Human Development (CIDESD), Bragança, Portugal. vplopes@ipb.pt

Abstract

This study considers relationships among motor coordination (MC), physical fitness (PF) and physical activity (PA) in children followed longitudinally from 6 to 10 years. It is hypothesized that MC is a significant and primary predictor of PA in children. Subjects were 142 girls and 143 boys. Height, weight and skinfolds; PA (Godin-Shephard questionnaire); MC (Körperkoordination Test für Kinder); and PF (five fitness items) were measured. Hierarchical linear modeling with MC and PF as predictors of PA was used. The retained model indicated that PA at baseline differed significantly between boys (48.3 MET/week) and girls (40.0 MET/week). The interaction of MC and 1 mile run/walk had a positive influence on level of PA. The general trend for a decrease in PA level across years was attenuated or amplified depending on initial level of MC. The estimated rate of decline in PA was negligible for children with higher levels of MC at 6 years, but was augmented by 2.58 and 2.47 units each year, respectively, for children with low and average levels of initial MC. In conclusion MC is an important predictor of PA in children 6-10 years of age.

© 2009 John Wiley & Sons A/S.

Iliocapsularis Update

We have written before about one of our favorite muscles for dysfunctional hips, the iliocapsularis. See here and here to catch up.

As you are probably (hopefully?) aware it has its proximal attachment at the anterior-inferior iliac spine and the anterior hip capsule (1), though it does not attach to the labrum (2). Its inserts distally just south of the lesser trochanter, sometimes inseting into the iliofemoral ligament and/or the trochanteric line of the femur (3,4). It is innervated by a branch of the femoral nerve (L2-4) (4) and is believed to raise the capsule of the hip with hip flexion and be an accessory stabilizer of the hip (1, 2-4, 5)

Since our last article, there has been a few papers published, so here's the update. There has been only one EMG study to date of the iliocapsularis. It found the greatest muscle activity occurred during resisted hip flexion at 90° and lowest activity during hip extension (6). This fits well with its believed function.

We had discussed previously how it becomes hypertrophied with dysplastic hips (1). A newer study (7) looked at comparing its size in developmentally dysplastic hips vs hips with pincer/CAM type lesions, looking at the iliocapsularis/rectus femoris ratio with it being increased (again) in dysplastic hips.

Finally, 2 new(er) anatomical study (8, 9) confirmed its extensive attachment to the hip capsule, along with the gluteus minimus, reflected head of the rectus femoris, obturator externus and conjoined tendon of the iliopsoas. A bonus of the study revealed the hip capsule was thickest posterosuperior and superolateral on the acetabular side and anterior on the femoral side.

And here is a video on how to needle it...

1. Babst D, Steppacher SD, Ganz R, Siebenrock KA, Tannast M. The iliocapsularis muscle: an important stabilizer in the dysplastic hip. Clin Orthop Relat Res. 2011 Jun;469(6):1728-34. doi: 10.1007/s11999-010-1705-x. Epub 2010 Dec 3.link to full text: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3094621/

2. Anatomy of the iliocapsularis muscle. Relevance to surgery of the hip.Ward WT, Fleisch ID, Ganz R Clin Orthop Relat Res. 2000 May; (374):278-85.

3. HOLLINSHEAD W. H. (ed), Anatomy for surgeons: the back and limbs, vol. 3, Harper & Row, New York, 1969, 707.

4. SUJATHA D’COSTA, LAKSHMI A. RAMANATHAN, SAMPATH MADHYASTHA, S. R. NAYAK, LATHA V. PRABHU, RAJALAKSHMI RAI, VASUDHA V. SARALAYA, PRAKASH An accessory iliacus muscle: a case report Romanian Journal of Morphology and Embryology 2008, 49(3):407–409 link to full text : http://www.rjme.ro/RJME/resources/files/490308407409.pdf

5. Retchford TH1, Crossley KM, Grimaldi A, Kemp JL, Cowan SM Can local muscles augment stability in the hip? A narrative literature review. J Musculoskelet Neuronal Interact. 2013 Mar;13(1):1-12. link to full text: http://www.ismni.org/jmni/pdf/51/01RETCHFORD.pdf

6. Lawrenson P, Grimaldi A, Crossley K, Hodges P, Vicenzino B, Semciw AI. Iliocapsularis: Technical application of fine-wire electromyography, and direction specific action during maximum voluntary isometric contractions. Clin Orthop Relat Res. 2015 Dec;473(12):3725-34. doi: 10.1007/s11999-015-4382-y.

7. Haefeli PC, Steppacher SD, Babst D, Siebenrock KA, Tannast M. An increased iliocapsularis-to-rectus-femoris ratio is suggestive for instability in borderline hips. Clin Anat. 2015 Jul;28(5):665-71. doi: 10.1002/ca.22539. Epub 2015 Apr 14.

8. Walters BL, Cooper JH, Rodriguez JA. New findings in hip capsular anatomy: dimensions of capsular thickness and pericapsular contributions. J Musculoskelet Neuronal Interact. 2013 Mar;13(1):1-12.

9. Cooper HJ, Walters BL, Rodriguez JA1.Anatomy of the hip capsule and pericapsular structures: A cadaveric study. Arthroscopy. 2014 Oct;30(10):1235-45. doi: 10.1016/j.arthro.2014.05.012. Epub 2014 Jul 23.

image credit: Haefeli, Pascal Cyrill et al. “An increased iliocapsularis-to-rectus-femoris ratio is suggestive for instability in borderline hips.” Clinical orthopaedics and related research 473 12 (2015): 3725-34.

Early motor experiences.

The early locomotor experience , a free play spontaneous study
Once again, we learn from our mistakes, or we should at least.
This natural locomotion study suggests that better walkers spontaneously walk more and fall less.

"Twelve- to 19-month-olds averaged 2,368 steps and 17 falls per hour. Novice walkers traveled farther faster than expert crawlers, but had comparable fall rates, which suggests that increased efficiency without increased cost motivates expert crawlers to transition to walking. After walking onset, natural locomotion improved dramatically: Infants took more steps, traveled farther distances, and fell less. Walking was distributed in short bouts with variable paths--frequently too short or irregular to qualify as periodic gait. Nonetheless, measures of periodic gait and of natural locomotion were correlated, which indicates that better walkers spontaneously walk more and fall less. Immense amounts of time-distributed, variable practice constitute the natural practice regimen for learning to walk."

Psychol Sci. 2012;23(11):1387-94. doi: 10.1177/0956797612446346. Epub 2012 Oct 19.
How do you learn to walk? Thousands of steps and dozens of falls per day.
Adolph KE1, Cole WG, Komati M, Garciaguirre JS, Badaly D, Lingeman JM, Chan GL, Sotsky RB.