Gait & Posture

1. Gait & Posture Jeremy Corbin, SPT

2. Gait Terminology Review • Gait Cycle – from heel contact/strike to heel contact/strike of the same foot again • Double support – the period of time during the gait cycle where both feet are in contact with the ground and supporting the body • Single Support – the period of time during the gait cycle where only one foot supports the body • Step length (ave for adult is 13-16 inches) distance between one foot contact to the opposite foot’s contact • Stride (ave for adult 26-32 inches) • Cadence (ave adult 110-120 steps/min) • BOS (ave for adult 2-4 inches) • Toe-out (ave for adult is 7°) • Pelvic Rotation – opposite from the thorax; 4° forward on swing LE, 4° backward on stance LE • Running – increased cadence until no period of double support • Velocity – distance covered per unit time in meters/minute; average 82 meters a minute (3 miles/hr) • Acceleration & Deceleration – rate change with respect to time

3. Gait Cycle Terminology Standard: Ranchos Los Amigos: Stance Phase: Heel strike Foot flat Mid-stance Heel off Toe off Swing Phase: Acceleration Mid-swing Deceleration Stance Phase: Initial contact Loading response Mid-stance Terminal stance Pre-swing Swing Phase: Initial swing Mid-swing Terminal swing

4. Functional Breakdown of Gait • 2 Primary Stages: • Stance - 60% of the gait cycle • Swing - 40% of the gait cycle • 3 Functional Activity Phases during Gait: • Weight Acceptance • Single LE Support • Swing LE Advancement

5. Normal Gait Cycle (for R. LE)

6. ROM Necessary for Normal Gait • Hip: • Flexion: 0-30° • Extension: 0-15° • Knee: • Flexion: 0-60° • Extension: 0° • Ankle: • Plantarflexion: 0-20° • Dorsiflexion: 0-10° • Great Toe: • Extension: 60-90°

7. Gait – Muscle Activation Patterns • Heel Strike – knee extensors, eccentric dorsi-flexors • Foot Flat – eccentric dorsi-flexors, as load gastrocs fire eccentrically to control the forward advancement of the tibia • Midstance – extensors active to stabilize limb: hip abductors stabilize the pelvis, plantar-flexors propel the body forward • Heel Off – concentric plantar-flexors • Toe Off – propulsion hip extensors and ankle plantar-flexors • Swing-phase Acceleration – concentric hip flexors and concentric quads in early swing and then quads silent • Midswing – concentric: hip flexors, knee flexors, ankle dorsi-flexors • Swing-phase Deceleration – eccentric hams to decelerate, concentric quads and & ankle dorsi-flexors to prepare for heel strike

8. Abnormal Gait Patterns • Antalgic – protective pattern; typically secondary to pain with unequal step lengths • Ataxic – staggering unsteadiness, wide BOS, exaggerated movements • Cerebellar – staggering (see ataxic) • Circumduction– outward circular motion utilized to advance the LE • Equinous – typically on the toes or high stepping • Scissor – LE crosses midline upon advancement • Steppage – high step utilizing excessive hip & knee flexion to clear the foot; foot slap may be associated with • Trendelenberg – excessive lateral flexion of the trunk or “Marilyn Monroe” • Vaulting – stance leg has to elevate thru excess PF and hip hike to advance swing LE • Tabetic– high stepping ataxic gait with foot slapping • Festinating – walks on toes as if has been pushed forward and falling, gains speed • Hemiplegic – abduct and swing LE around to advance it for gait • Parkinsonian– ↑ trunk forward flexion & knee flexion; shuffling, quick small steps

9. Gait Training Intervention • Pre-ambulation in bed/supine: • Bridging in bed • SLR’s, glute sets, hamstring sets • Heel slides • PNF in bridging for trunk dissociation • Pre-ambulation Standing in Plantigrade or // Bars: • Weight shift side to side and stagger stance w/& w/o PNF • Stepping forward and backwards w/& w/o PNF • Heel<>toe rocks/rises • Partial Squats • Tape on the floor – cue for step length • Cones or cups – utilize to work on almost any area of gait deficit • Obstacle courses

10. When good Posture goes Bad… • What happens? • Repetitive movements and sustained positions will cause faults in the movement system elements (musculoskeletal, neurological, biomechanical), which lead to movement imbalance. • Improper central neuromuscular programming of movement can cause impaired function of peripheral tissue leading to pain syndromes. • Concepts with faulty posture: • Stretch weakness – over-lengthened muscles become weak in normal position and strong in lengthened position • Tight Weakness – only strong in the shortened position and weak at normal length

11. Responses of Muscle to Injury Hyperactive musculature: • SCM, scalenes, levator scapula, upper trapezius, pectoralis minor, erector spinae, quadratuslumborum, Iliopsoas, thigh adductors, rectus femoris, TFL, hamstrings Inhibited musculature: • Deep neck flexors, lower & mid trapezius, supraspinatus, infraspinatus, transverse abdominus, multifidus, vastusmedialis and vastuslateralis, gluteal muscles (esp. posterior glute med), peronei.

13. Hyper-lordotic • Characteristics: • Lumbar spine hyperextension = short-erector spinae • Anterior pelvic tilt = short hip flexors • Relative hip flexion • Hyperextended knees • Lengthened lower abs and hip extensors = stretch weakness • Treatment: • Stretch low back muscles • Strengthen lower abs. • Stretch hip flexors. • Strengthen hip extensors.

14. Hyper-kyphosis Posture • Characteristics: • Thoracic spine in flexion. • Increased lumbar lordosis • Forward head • Short upper abdominals and latissimusdorsi • Lengthened: (stretch weakness) • thoracic spine erector spinae • middle and lower trapezius • Deep flexor cervical musculature • Treatment: • Strengthen thoracic erector spinae, mid- & lower traps • Deep C-flexors • Stretch lats • Train and Strengthen abdominals

15. Flat Back • Characterisitcs: • Lumbar spine flexion = long erector spinae, long upper back muscles, short upper abdominals • Posterior pelvic tilt • Hip extension = short hip extensors, long-weak hip flexors • Knee hyperextension • Treatment: • Strengthen low back and hip flexors • Stretch hamstrings and gluteal musculature • Train abdominals

16. Swayback • Characteristics: • Pelvis is displaced forward, forward head, cervical extension, posterior pelvic tilt, hip joint extension, and knee hyperextension. • Leads to: • Short upper abdominals, hamstrings, and gluteal musculature • Long lower abdominals, upper back, and hip flexor musculature • Treatment: • Can be associated with LLD – stand on short LE • Short LE iliopsoas strengthening with lower abs • Short LE posterior gluteus medius strengthening. • Stretch right lumbar paravertebral muscles

17. Forward Head • Characteristics: • In this posture the patient displays with cervical spine hyperextension and anterior displacement of the head relative to the upper trunk. • Short cervical spine erector spinae and upper trapezius • Long cervical flexors • Treatment: • Stretch sub-occipital musculature • Strengthen deep cervical flexors • Almost always have to incorporate scapular & thoracic intervention as well (mid-lower traps, serratus anterior, RC, thoracic extension, and abdominals!!)

18. Forward Shoulder • Characteristics: • Scapulae abducted • Short pec minor and upper trapezius • Long middle/ lower trapezius • Treatment: • Stretch pec minor, shoulder medial rotators and adductors. • Strengthen: middle, lower trapezius, and RC external rotators. • Perform pivot prone.

19. Common Joint Mobility Restrictions • Suboccipitals – limited flexion • Mid cervical – limited flexion • C-T junction – decreased • T-spine – general or specific • Hip – dependent upon the posture

20. Commonly Tight Muscles to Stretch • Suboccipitals • Levator Scapulae • Scalenes • Pect Major and Pect minor • LatissimusDorsi • Hip Flexors • Hamstrings • TFL • Gastroc/Soleus

21. Suboccipitals Self-mob & Active Stretch Pt. sitting with correct posture. Take edge of towel and place across posterior arch of C1. Stabilize by holding towel ends with hands – but keep shoulders relaxed. Instruct pt on correct chin nod with very slight retraction to generate both self-mobilization and muscle stretch.

22. LatissimusDorsi Stretch Pt. against wall feet shoulder width apart and about 1-2 feet away from wall. Pt. flattens back to wall and maintains back flat throughout stretch. Take shoulder into flexion and grab opposite elbow. Keeping elbow against wall, side bend away until a stretch is felt in the latisimus. Be mindful of cervical position.

23. Self C-T mobilization Pt. seated with counter-curve lock of L-spine and chin to Adam’s apple fro C-spine. Place index and middle fingers on either side of the transverse processes of the C-T junction. Take arms out like “chicken wings”. Ab- & Adduct elbows. Can also utilize for mid-Thoracic mobilization utilizing the edge of the chair localized to the level of the T-spine to be mobilized.

24. Hip Flexor Stretch Position 1: Pt in half kneeling. Perform posterior pelvic tilt and maintain with abdominal activation. (avoid L-hyperextension) Lean forward slightly until a stretch is felt in the iliopsoas. Position 2: Attain the Thomas Test position. L-spine must remain flat on the table throughout stretch. Can be utilized for both or either the iliopsoas or the rectus femoris. Can utilize the position to perform soft tissue, manual stretching, and HR stretching techniques.

25. Hamstring Stretch & ITB/TFL Stretch

26. Common Weak Muscles with Postural Faults • Deep C-Flexors – start seated progress to supine • Serratus Anterior – Prone or supine • Upper Trap – more to do with correct recruitment than MMT weakness… • Mid- & Lower Traps – ie ITY’s • External Rotators of the Shoulder – T-band exercises • Abdominals – transverse & obliques • GluteMedius - clams

27. “Swimmer’s” – Serratus & RC Pt. prone on elbows with abdominal activation to support L-spine. Correct C-spine position with activation of deep flexors. Contract serratus anterior & maintain position. Externally rotate humerus – taking hands out away then back to center.

28. Y’s, T’s & W’s Literally the shape of the letter…. Y’s – work lower traps; thumbs up, correct C-spine position, abdominal activation to support L-spine T’s – work middle traps; thumbs up position, correct C-spine position, abdominal activation to support L-spine W’s – work multiple muscles; same as above for C-spine & L-spine

29. Clams – Phase I,II, and III Phase I Pt sidelying with neutral L-spine. Keeping the feet together, slowly turn the entire leg into external rotation so that the patella rotates upwards slightly. Motion at the hip ONLY - do not let the pelvis or trunk move/rotate. Return to starting position. Phase II Pt sidelying (may have pillow between the legs). Slowly externally rotate the top leg so that the kneecap rotates upward. Lift the top leg out to the side in the same plane as the body. Return the leg to the pillow, making sure to keep the knee rotated outward as you lower it. Phase III Pt sidelying. Slowly externally rotate the entire LE so that the patella rotates upward. (Do not let the pelvis or the trunk move!) Lift the entire LE up (towards the ceiling), keeping the leg in line with the trunk. Keeping the leg externally rotated, slowly lower it to the floor. (If the leg doesn’t reach the floor, don’t push it.) Let the leg hang for 3-5 seconds.

30. Putting It All Together • Develop postural awareness & control – reference for correctness • Link s/s provocation to posture for pt. education - (ie UE reach with forward head/shldr; position of C-spine when turning during driving, sitting at desk, etc) • ↑ Mobility in limiting muscles and joints • Develop neuromuscular control of core and extremities and strengthen lengthened muscles in shortened/correct position • Teach & practice proper body mechanics • Learn correction of stress provoking postures/movements • Improve aerobic capacity • Instruct on maintenance