Human Gait - Final Exam

Massachusetts building code for stairs

"Stair riser heights shall be 7 inches maximum and 4 inches minimum. Stair tread depths shall be 11 inches minimum." -Need to be aware of stairs within patient's home - train them for the riser height *There can be much variation in stair tread and rise in patient's homes*

Differences Between Walking and Running

*No flight phase in walking - something is always touching the ground! *Running - never a double support phase

Determining Static Foot Type

*Overall position of the foot when it is at rest (normal, flat, or high arch) - Inspect arch seated with feet on floor - Inspect standing (have them march and then stand still to get true natural standing position) - Inspect with toe raise - what their arch does - looking to see if normal arch engages as foot plantarflexes

Dr. Power's gait observation algorithm: stairs and running

*READ

Knee during weight acceptance phase of stair descent

- 10-15° flexion - Knee extensors active for shock absorption

Running Demographics (2015-2016)

- 16.9 million runners in 2016 -57% female - 17 million race finishers (2016) -7.6 million 5K's (45% of all finishers) - Marathons: 59% ♂ /41% ♀ - 5K,10K,½ M: 41-46%♂ / 54-59% ♀ - Average age: 39.3♀ / 43.8 ♂ -we see running occurring across all genders across several ages and at a wide variety of distances -it's always important when You are treating a runner or you're trying to get somebody back to running to know kind of which categories of these do they fall are and particularly what speed do they prefer to run at and for how long and how far all of those details become

Developmental Sequence of Running

- Allowing one to go from immature to mature running (some people never make it to sagittal stage)

Medial Heel Whip Causes

- Almost any abnormality that reduces DF - Weakness hip IRs - Tightness hip ERs (hip rotational stability coming into initial swing) - Tightness ITB - Lacking DF for toe clearance - Hamstring imbalance - weak medial vs lateral - lateral hamstrings are stronger than medial - tibia will slightly externally rotate and cause heel to point medially (biceps fem is too strong) - Improper footwear - incredibly worn out shoes - significant wear pattern - With a specific pt. population - ACL reconstruction with their own semitendonosis from medial tibia attachment - watch for hamstring imbalance throughout their recovery

Running - Joint Adaptations Required (compared to normal walking)

- Ankle: ¨Increased PF/DF ¨Increased pronation/supination - to be able to absorb and flatten more as well as become a more rigid pushover lever - Knee: ¨Increased flexion in early stance and swing to reduce mechanical demand to make the illiacus the most efficient it can be - Hip: ¨Increased flexion and extension - Pelvis: ¨Increased transverse plane rotation by an additional 5-10 degrees - Arms: ¨Increased shoulder ROM (flexion/extension) ¨Increased elbow flexion -we're shortening those levers to allow easier and more efficient muscle activity to drive those arms forward to create the opposition necessary for the best forward momentum preservation as well as propulsion

Phases of stair ascent: Weight Acceptance (WA)

- Begins with IC of reference foot (leg we are stepping up with) -includes loading, through contralateral toe-off *Double limb stance*

Running Posture and Speed - Effects

- Body maintains forward lean throughout running gait cycle to keep their HAT anterior to the LE to assist with forward momentum - Line of progression from step to step is at or near the midline to minimize lateral shift in COG - As speed increases, LE joints increase their range of motion to decrease the vertical shift in COG - Faster runners require more flexibility and eccentric muscle strength

Initial Swing - Float: Critical Events

- COM displaced upward and forward - Rapid active hip flexion (illacus is hyperactive) - Hip adduction maintains line of progression to reduce air drag - Rapid knee flexion to shorten lever to give illiacus best mechanical advantage for activation - Active ankle DF

Terminal Swing (Foot Descent/late float): Critical Events

- COM is displaced downward - preparing to land on single limb - Active hip extension - Hip adductors prepare for foot placement - Knee rapidly extends - Progressive dorsiflexion in anticipation of heel strike

Midswing during running: Critical Events

- COM reaches highest point of trajectory - Active hip flexion peaks* and illiacus activity - Hip adduction continues - part of best trajectory for femur to move forward, and pelvic stability, and assists us in maintaining pelvic and trunk stability to work with counter-rotation for opposition -Hip adductors are as active as they are during swing to allow the trunk to continue its counter rotation stabilize the pelvis during that so everything is working in conjunction To give us the best forward propulsion possible

Plantar Fasciitis

- Can be caused by the repetitive motions of running -or excessive activity - Pain, especially on rising in morning, is the most common presenting symptom - Tenderness, along course of plantar fascia or at origin on medial aspect of calcaneal tuberosity - palpation is important in discerning which portion is affected - gives you info about where it is coming from and how to treat it - Stress in plantar fascia can be as high as 3.5x BW during MSt, when most of weight-bearing forces have been transferred from hindfoot to met heads - Excessive pronation increases traction along medial plantar fascia, predisposing it to excessive stress and injury - tender along medial portion and have pes planus - this is likely due to foot structure -can also see it as a result of gastroc/soleus tightness, decreased DF, landing hard on heel

Anterior Knee Pain - Apophysitis

- Can happen at any tendon attachment to bone that hasn't fully ossified yet - Osgood-Schlatter's disease and Sinding-Larsen-Johansson syndrome -particularly in young runners

Running Injuries: Causative Factors and Prevention

- Causative Factors: ¨High mileage ¨Previous running injury ¨Change in running surface (trails in woods to sidewalk to asphalt) change can be jarring to the system ¨Sudden change in distance (going from 2->10 miles) ¨Foot type that can predispose someone ¨Biomechanics, asymmetry ¨Type and age of running shoes - Prevention: (pt. education) ¨Surface (keeping it consistent and compliant) asphalt is better than running on concrete -best surface = rubber track ¨Frequency ¨Mileage modulation (not going from 2 miles one day to 10 the next) ¨Speed work ¨Shoes/orthotics

Iliotibial-Band Syndrome

- Caused by friction between ITB and lateral femoral condyle -Presents with tenderness in region of distal ITB - The GRF normally occurs medial to the knee joint during single-limb support in any activity ¨GRF produces an external varus moment -The ITB stabilizes knee against this external force with TFL/glut med generating an internal valgus moment to help maintain upright position ¨Peak valgus moment is 2.5x greater during running, when the knee is at the point of maximum stance-phase flexion ( ~45 degrees) - Situates the ITB directly over lateral femoral condyle where it is most susceptible to friction injury

LiteGait

- Comes in various sizes

Swing limb advancement phase of stair descent

- Contra IC --> Ref IC (includes preswing: contra IC --> ref heel off) -as left limb drops body down so right leg can make contact, left ankle has less dorsiflexion and highest flexion demand of knee and hip - Once that swinging limb has cleared the tread of the stair it began from, we see the ROM demand change and the limb lengthens by going through extension of the hip the knee and the ankle - Initially, flexion of everything was needed to shorten the limb, but for the second half of this phase we need to lengthen that limb to reduce the demand of the stance leg as much as possible

Stair ascent: mobility in SLA

- Contra IC --> reference IC - Preswing: contra IC until reference toe-off: -Ankle rapidly plantarflexes (5°DF to 20°PF) -Hip & knee ~10° flex until end of preswing - To clear stair's edge (height of risers), increased flexion -Hip flexion of: 65-70° -Knee flexion of: 80-95° -Ankle dorsiflexes to 5°-10 ° - Once clear, preparation for IC/WA on the next stair

Stair ascent: mobility during SLS

- Contralateral toe-off --> contralateral IC - Loading Response & Midstance: -Rapid hip & knee extension from LR --> MSt -Minimal hip flexion (~10°) -Minimal knee flexion (~10°) -Ankle DF decreases from 12° --> 0° as knee is extending -tibia begins to shift posteriorly -requirement is stable advancement of the bw from behind the stance limb to in front of stance limb as its continuing to lift the bw (we are transferring up and forwards)

Primary functional activity of stair descent

- Control the rate of descent *ECCENTRIC MUSCLE ACTIVATION (don't want body falling down the stairs) - Because of this, we need greater need for mobility (ROM) than strength -high GRFV that has to be dissipated to ensure adequate shock absorption that is absorbed through the increased motion in our joints

Running Across the Life Span: Later Running

- Decreased stride length and range of motion - Decreased speed -Limited by balance, strength, ROM declines - Exercise can allow seniors to be active for many years! - New research: decreases inflammation (???) -pro inflammatory molecules are decreasing in the knee joint after running between the ages of 18 and 35

Gait training and stairs

- Demonstration of technique - Simple & concise terminology & cues - Guarding - always on the "lower" side (be in front when they are descending stairs and behind them when they are ascending) - Which way will someone fall? DOWN - Surfaces - carpet may require more ROM to clear stairs and can be a challenge to balance - Assistive Devices (some work on stairs and some do not - walkers do not) - "up with the good, down with the bad" - ascending stairs - done and controlled by upper limb so want the brunt of the muscular demand to be placed on the stronger leg - eccentric control descending the stairs requires a lot of muscle activation, ROM, and control - so want the strong leg to be doing the work so it gets left behind (on the higher stairs) to lower the body down to the next stair

Overview of preparatory activities & interventions for locomotor training

- Depiction of several exercises and positions that can be used to assist with strength and controlled mobility with the primary goals of safe and effective ambulation -gait training -a lot can be interchangeable - working on balance, flexibility, or strength

Early vs. Late Midstance during running

- Early - majority of muscles still active to accept body weight from IC - Late - when COG moves anterior to the knee ¨Biceps Femoris short head - controlling knee ext ¨Iliacus - preparing for swing -knows its about to leave ground and needs to change its activity rapidly

BFSH during swing limb advancement phase of stair ascent

- Early SLA: facilitates rapid knee flexion to clear the stair - Turns off in T-Swing as quads turn on to prepare for WA

Anterior Knee Pain

- Extensor mechanism functions eccentrically to absorb 42% of energy at IC (quads take biggest brunt) - The net knee-extensor moment during the stance phase up to 5X higher during running vs. walking - Need increased knee flexion ROM required of 45° (running) vs 22° (walking) while loading places much greater amount of stress on: ¨quadriceps muscles ¨quadriceps tendon ¨patellar ligament

Knee during single limb stance phase of stair descent

- Extensors function to control rate of lowering of HAT - take on a big role of carrying passenger unit

Toe Spring

- Feature of running shoes specifically - In bare feet: the toes rest flat, the tips grasping the ground as an assist in step propulsion - Inside shoes with this, the toes are lifted slantwise upwards due to toe spring, preventing the natural ground-grasping function - Why is toe spring built into the last and shoe? ¨To compensate for lack or absence of toe flexibility at the met heads -assists with painful hallux valgus - The combination of the up-tilted toes caused by the toe spring, and the down-slanted heel and foot caused by the heel wedge angle, creating an angle apex at the ball where the two angles converge - The angle apex has a dagger-point effect on the ball, contributing to metatarsal stress symptoms and lesions because we have this angular apex creating a dagger like effect on ball of foot -something you want to look for in runners talking about metatarsal pain particularly a four foot runner and then perhaps a four foot runner will do better in a more flexible more barefoot free type shoe like a Nike free to reduce that stress to the metatarsal heads

Increased Patello-Femoral Joint Pain Female Runners

- Females have wider Q-angle and more of a femoral internal rotation and adduction to meet femoral condyles with tibial plateau -narrow stance to wider hips -patella rides a bit laterally in trochlea - in PT - would work to try to retrack the patella correctly - strengthen medial quads -tape for tracking as well

Hip during single limb stance phase of stair descent

- Flexion increases to lower HAT & opposite limb -lowers COM down onto next tread

How is Momentum Dissipated?

- Foot Mechanism - Ankle Mechanism - Knee Mechanism - Shoe Mechanism (without shoes, you need more muscular mechanisms working at the 3 other joints)

Midstance during running

- Foot and leg provide a stable platform for the body weight to pass over ¨All the body weight is borne by a single leg ¨this is when the lower limb susceptible to injury* - Foot has stopped pronating ¨If the foot is still pronating at this time there is too much movement and instability - Weight of the body has a flattening effect on the arch of the foot ¨feet are specifically adapted to resist excessive arch flattening ¨Plantar fascia -hyperflexible foot can injury plantar fascia during this phase of running

Ankle Foot Orthotics

- Foot held in fixed neutral/dorsiflexed position -can have negative impact on gait

Stair ascent: mobility required for weight acceptance

- Foot placement & loading --> toe off - At Initial Contact: -Hip flexes to 50°-60° -Knee flexes to 50°-70° (significantly more than normal gait) -Forefoot contact, BUT ankle still at 5°-10° DF - Loading Response & Midstance: -Rapid hip & knee extension from LR --> M-St -Ankle increases DF by 5° as body advances horizontally over tread distance, so we need tibial advancement which requires 10-15 degrees of DF

Anke during weight acceptance phase of stair descent

- Forefoot contact followed by rapid loading - 20° PF --> 10° DF - Controlled lowering of body & shock absorption (30 degrees of motion to absorb)

Shock Absorption: Heel Strike vs. Midfoot/Forefoot

- Forefoot run - looks less like normal gait

Phases of stair ascent: Swing Limb Advancement (SLA)

- From contralateral IC to reference IC

Phases of stair ascent: Single Limb Support (SLS)

- From contralateral toe-off to contralateral IC on next stair *Single limb stance

Proficient Running

- Happens over a length of time - Reduced stability requirements as mobility increases - load dissipation/shock absorption needs to be significantly increased - Flight phase

Gait Analysis

- Have the patient walk about 15-20 meters away from you - Observe from behind: ¨Location of heel strike ¨Foot motion during single-leg stance phase ¨Part of the foot with which they push off -can repeat this with their running *Watch for calcaneal valgus or varus

Impact - IC

- Heel Strike vs. Midfoot Strike - 80% of runners are heel strikers - 20% of runners initially strike the ground w/ their midfoot or forefoot

Heel Strike vs. Midfoot: Peak Impact Forces

- Heel strike -Calcaneus/Heel -Big Toe - Midfoot strike -Ball of foot *Needs in footwear in each group will be significantly different

Late Stance/Take Off/Propulsion during running (Just before Early Float)

- Hip: -5° - 10° hyperextension beyond neutral - Knee: 25°- 40° Flex - Ankle: 15°DF - 25°PF rapidly - Adductor Magnus - helps with pelvic stability -our absorbed and stored energy releases to propel body forward when heel lifts off ground - Windlass Mechanism - as grt toe extends - plantar fascia tightens and raises arch of foot - giving us nice rigid propulsion lever -planter flexion recoil occurring that is the primary propulsion force through the gastroc and soleus over this rigid 4 foot lever that is developed by the windlass mechanism

Midstance during running - joint angles and muscle activity

- Hip: 20°- 30° Flex - Knee: 40°- 60° Flex - Ankle: 20°- 30° DF (similar to LR)= - Gluteus Maximus - Hamstrings - Hip Adductors - Quadriceps -controlling knee flexion - Gastroc/soleus - peak activity* - Tibialis Posterior/Peroneals - stabilizing ankle as it goes through anterior tibial translation (Glute med and TFL group do not need to work as hard in this phase)

Initial Contact during running (Loading assumed)

- Hip: 45°- 50° Flex - Knee: 15°- 20° Flex (we do not run and land on a straight knee) - Ankle 0°- 15/20°DF - Gluteus Maximus - primary shock absorber at the hip* - Hamstrings assist glute max - Gluteus Medius/TFL - working hard - similar to that of walking to stabilize the pelvis laterally - Adductor magnus - plays large role - preventing hip flexion collapse - Quadriceps - peak activity* generating a lot of force to prevent knee from flexing too much - Gastroc/soleus - controlling how far forward tibia advances over the talus - Tibialis Anterior - active concentrically early to clear the toes *Mostly eccentric muscle control is occurring here

External influences on stair climbing: human anthropometrics

- Human height plays large role -Shorter individuals use greater knee flexion during ascent (92°-105°) compared to taller (83°-96°) -Shorter subjects had faster stair cadence due to less COM to be propelling up staircase - Age and joint changes

Pre-gait activities - initial

- In a pt. who is deconditioned or not able to jump right into gait - Stability, strength, and mobility within: 1. Bridging - double leg, single leg, dynamic surface, t-band around legs 2. Quadruped - achieve position - then add weight shifting, UE lift, LE lift - great way to get someone to bear weight on limbs when they are hesitant to stand 3. Sitting - long/short sitting, dynamic balance, reaching, EC 4. Kneeling - ½ kneel, high kneel - weight shifting, reaching (mimicking weight shift that occurs during gait) 5. Plantigrade - weight shifting, stability training, UE and LE movement 6. Standing - dynamic, single leg activity, stability

Proficient Running: Observations compared to walking

- Increased stride length - Narrow base of support - Trunk rotation - Opposition - swing limb is coming forward quickly and strongly at the same time the opposite UE is coming forward

Bioness (a neuroprosthesis) and WalkAides

- Input NMES into AFO devices

Biomechanics of Running Injuries

- Issues: • Force - muscle overuse • Inability to dissipate force - muscle overuse (eccentric) • Repetition

Evaluating Shoe Wear Pattern Algorithm

- Looking at the wear pattern of the shoes and then to look at the arch shape however you choose to to test it - then observing their gait to see if things come into alignment -if you get wear pattern that would indicate pes planus or floppy foot, flat arch, and over pronation - pt. would likely benefit from motion control sneakers/shoes

Take Off during running: Critical Events

- Majority of forward propulsion of body coming from swing leg and arms - Maximum hip extension - Passive knee extension - Rapid tibial advancement over foot - Foot provides rigid lever - Opposite leg in maximum lift/hip flexion for forward propulsion

Gait training in II bars

- Manually guiding pelvis to stimulate CPG - Approximating through pelvis to facilitate stability - Increasing BOS -used with lower level patients - neurological deficits/injury

Orthotics

- May be option for anatomic problems -calcaneal valgus that leads to flat foot - motion control shoes may not be enough to correct this deviation ¨Reduce frequency of movement related disorders ¨Correct skeletal alignment ¨Increase cushioning ¨Increase comfort - Should use when trying on new shoes -bring to all PT appointments - Best to use in shoes with stable base (board/mixed last) stability shoe - Injury - should inspect orthotics for wear - If unfamiliar with making orthotics, refer to podiatry

Medial/Lateral Whip - Knee Pain

- Most often seen during running - Medial - heel points medially (more common) - Lateral - heel points laterally (more related to femoral and tibial torsion)

Gait Analysis - treadmill

- Need treadmill and video camcorder - Walking and running barefoot - Running with shoes - Play back slowly to observe barefoot gait mechanics - Observe if shoe corrects or worsens barefoot gait

Initial Swing - Float

- Occurs right when toes leave ground on back leg - Hip: 0-25° Flex - Knee: 50-80° Flex - Ankle: 10-15° DF - Iliacus - incredibly active during this time to pull femur forward to generate forward momentum - TFL assists - Hip Adductors - coupling with TFL to prevent any drag - trying to make femur swing through at its straightest aerodynamic trajectory to reduce any air drag on the medial or lateral thigh - Medial Hamstrings - concentrically activating to flex the knee (which muscles?) - Tibialis Anterior - concentrically

Use of Body Weight Support

- Often used in pt. with neurological condition - Walking on a treadmill using (BWS) --> no BWS • Production of locomotor rhythm; slow speed progressing to faster speeds -involved significant amount of repetition to achieve • Forward propulsion of the body • Dynamic balance control of the moving body • Reciprocal stepping patterns & movements of pelvis and LE • Strategies to improve speed, symmetry and endurance while gradually reducing the amount of support the system provides the pt. - Eases work of PT and patient - Can be adjusted to take away more or less weight from pt.

Gait training - Overground outside

- Once they have mastered walking indoors • Exterior doors and thresholds • curbs, ramps, steps -crosswalk timing • Uneven surfaces • Walking within imposed timing requirements • Community environments • Entering/exiting transportation vehicles • Elevators, escalators, revolving doors

Repetitive Motion

- One of the biggest proponents of running injuries - When we're working with a distance runner, they're looking at taking anywhere from 1000 to 1700 foot strikes per mile remember of 3 1/2 times their body weight the force that each foot strike endures if you multiply that out a marathon runner takes an average of 25,000 steps during a race - and when you factor in all of the training that that person did too factor to prepare for that marathon - they've set themselves up to be at a high risk for repetitive injury and then they have trained all of that time, their muscles haven't recovered if they've endured micro injuries during the training, and then they put 26.2 miles of 3.5x their body weight with every step - risk for injury is quite high at that time and it's really no wonder that each year nearly 1/4 to 1/2 of all runners will sustain an injury that is severe enough to cause a change in their practice or in their performance it's all rooted in this repetition - Running one of the most popular fitness activity - incredibly mobile (can do it almost anywhere), requires minimal equipment - However..... ¨70% runners sustain an injury within 1 yr period -one fault in biomechanics could lead to overuse injury

Initial running

- Part of early childhood development - Occurs 6-7 months after walking initiated - In general, defined by: -a 50% phasing (50% of time is spent in swing, 50% of time is spent in stance) -a flight phase (leaving the ground) followed by single support

Knee during swing limb advancement phase of stair descent

- Peak flexion 105-110° needed* - Controlled by vastus lateralis initially - Followed by BFSH activity to ensure adequate flexion - Once foot cleared, progressively extends to lengthen limb to reduce the amount of drop down to the next stair - Hamstring activity starts during initial swing controlling rate of knee extension eccentrically & positioning the leg on the next lower step - Vastii & RF activity prepare for loading in WA

Hip during swing limb advancement phase of stair descent

- Peak flexion 40° needed (early in phase) - Gradual decrease to ~20° for IC - Hamstring activity starts during initial swing & continue - Hip extensors prepare for demands of next WA (not a lot of hip activity during this phase (mostly along for the ride) - but could see increased hip flexor activity if someone has weak BFSH)

High-Arch Foot

- Pes cavus - Tend to have reduced forefoot mobility - Predisposed to under-pronation - Foot remains in a supinated, rigid, position during pronation phase - Center of weight remains on lateral portion of the foot - Reduced shock absorption - Foot is more rigid - May be at greater risk for: ¨Tibial (shin) stress fx ¨Lateral hip, knee or ankle pain ¨ITB Syndrome ¨5th metatarsal stress fx

The Flat Foot

- Pes planus - Tend to have foot hypermobility - Predisposed to over-pronation - Foot remains in a pronated, unstable position during toe off - Center of weight shifted to the medial portion of the foot - Ultimate effect--increased medial foot, leg, and knee stress from excessive internal tibial rotation - Foot absorbs greater stress - May be a greater risk for: ¨post tibial tendonitis ¨anterior knee pain ¨shin splints ¨achilles tendonitis ¨metatarsal stress fx

Achilles Tendinopathy

- Presenting symptom: Pain/tenderness along the course of the tendon -important to discern if its the entire tendon or if it is only a portion of the tendon (medial? lateral?) can help you hone in on the pain biomechanics - where is it coming from - The G-S complex generates greater plantar-flexion moments about the ankle during running than it does during walking - Forefoot contact exaggerates eccentric function of the gastrocnemius-soleus-Achilles tendon complex as the heel is slowly lowered to ground - more susceptible to this - Peak forces in the Achilles tendon can range from 6-8x BW during MSt - Injuries of the Achilles tendon are caused by active muscle forces that occur during MSt rather than impact forces that occur at IC - Much more likely to be caused by muscles in midstance - controlled tibial advances rather than impact -push off will be severely affected by this - reduced PR recoil

Running: What's Involved?

- Project body vertically/horizontally -results in excess vertical displacement - need to higher our COM - Flight - Dissipate impact landing from flight phase -LR during running far surpasses LR forces during normal gait - Maintain balance in single support - Re-position limbs rapidly

How is Propulsion Produced?

- Propulsive Force: -Segment motion -Newtons 3rd law (when one segment exerts a force on a second segment, that second segment is exerting a force equal in magnitude and opposite in direction of the first segment) -we make use of segmental motion - Transfer of Momentum: -Free leg -Arms - Swing phase of running: • Entire lower limb functionally shortens by the combined movements of knee flexion and ankle dorsiflexion • Reduced mass moment of inertia reduces the torque required by the hip muscles to accelerate and decelerate the limb during the swing phase -we propel ourselves off of our back stance leg and transfer the momentum through the swinging free leg which can be assisted by the amount of flexion swinging limb gets to reduce moment of inertia and to facilitate more rapid hip flexion by hip flexors

Ankle during swing limb advancement phase of stair descent

- ROM: 20° DF --> 5° DF --> 0° --> 20° PF (for IC) (total 40 degree change) - Initial plantarflexion motion from 20° DF to 5° DF due to elastic recoil in plantarflexor muscles - Peak TA activity at initial swing to achieve 0° (neutral), f/b PF 20° at end of SLA - Co-contraction of PF & DF prepare to stabilize for WA -both lightly active at end

Ankle during single limb stance phase of stair descent

- Reaches 20° DF - TA and soleus co-contract to provide stable base & restrain descent

Progression from parallel bars with Stand walker or Loftstrands depending on trunk stability

- Relies heavily on UE to advance the walker -PT is bringing chair behind her for safety, but is letting pt. have some independence

Initial Contact during running - Critical Events

- Shock absorption - Muscular stabilization - Dorsiflexion of ankle - Rapid flexion of knee - Rapid hip extension to prevent further flexion - Adduction of hip - adductor magnus works as an extensor and adduction to narrow our stance to give us better forward trajectory and limit the amount of lateral shift in the center of gravity - Narrow BOS

IC/Midstance - Shock Absorption

- Shock absorption does not occur at one instantaneous point like in normal gait - Several tissues dissipate the force over time - first half of stance phase: ¨Achilles tendon ¨Plantar Fascia ¨Quad Mechanism ¨Hip ABductors (are also most commonly injured tissues in distance runners)

Early running

- Stability over mobility - early stability behaviors return: Arms in high/medium guard, stride length shortened, little rotation in body

Hip during weight acceptance phase of stair descent

- Stabilized at ~20° flexion - Peak gluteus maximus, gluteus medius & TFL activity

External influences on stair climbing: environmental

- Stair height, stair depth, steepness (increase in riser height with decrease in tread depth) - ROM & maximum flexion angles of hip, knee & ankle collectively increase with steeper staircases

Functional Periods of Running Gait

- Stance - Early float - Mid-swing - Late float

Midstance during running - Critical Events

- Swing limb passes stance limb to generate forward momentum - COM in front of stance foot and at its lowest point - Knee moving into extension - Rapid plantarflexion - non-contractile (PF recoil) - Prep for flight

Strategies for varying demands during gait training

- Tactile cuing • Upright Postural Alignment - AD to optimize • Foot Placement - cue them for heel-toe contact, or place foot markers on ground for targets, can use these foot markers to altered BOS • Toe Clearance (foot drop) - cue them for heel-toe contact, TC tapping ant tib, or compensate by teaching pt marching (if anterior tib will not be able to activate) • Single and Double Limb Support: •lateral/diagonal weight shifts •combine diagonal with pelvic rotation - then with stepping forward/backward continually cuing pelvic rotation • Forward Progression and Push-Off - heel and toe raises in standing, progress to heel and toe walking, walking against T-band • Trunk Counterrotation and Arm Swing - exaggerated arm swing, assisted by PT with long poles (your right hand and their right hand are holding same pole so you can assist their arm movements) • Stepping - step-up/down varied heights, stepping onto and off varied surfaces so they get that stepping quality and strength back • Stopping and Starting - on command, turning on command (gradually progress from ¼ to full) -lots of ways to intervene but also different ways too make note of which items you need to intervene for

Which balance advancements and challenges most applicable to gait?

- Tandem stance and single leg stance with perturbations

Stance Period during running

- The foot is on the ground only 0.08-0.09 sec (<1/10th sec vs walking at 6/10sec) - Forces up to 3.5x BW (varies) - people will run with forefoot strike more often when barefoot

Incidence of Injuries

- The reported overall incidence of running injuries 19.4% to 79.3% of runners - The most common site of lower extremity injuries: ¨Knee (7.2% to 50.0%) ¨Lower leg (9.0% to 32.2%) ¨Foot (5.7% to 39.3%) ¨Thigh (3.4% to 38.1%). - Less common sites of lower extremity injuries: ¨Ankle (3.9% to 16.6%) ¨Hip/pelvis (3.3% to 11.5%).

During 1 step, the stance limb supports & elevates the body as the swing limb passes:

- The riser - The tread (of the stair occupied by the stance limb) - The riser of the next higher stair - When the swinging foot makes initial contact on the next tread, the next step cycle begins

Sinding-Larsen-Johansson syndrome

- Traction Apophysitis - inferior patella tendon attachment at the inferior pole -thorough palpation is important here

Osgood-Schlatter's disease

- Traction force on tibial tubercle can result in cartilaginous injury to the underdeveloped immature tibial tubercle (in young people) -can see extra bone growth form in adulthood from this

Stair ascent

- Transition from level walking to ascent requires increased strength & joint mobility - Stance limb must preserve stability AND lift body mass WHILE swing limb flexes to advance to the next (higher) stair *CONCENTRIC MUSCLE ACTIVITY

Lateral Heel Whip Causes

- Weakness hip ERs - Tightness hip IRs - Tightness add magnus - Hamstring imbalance - weak lateral vs medial - medial (semi mem and tend) are stronger than lateral (biceps fem) causing tibia to internally rotate slightly causing heel to point laterally - Weakness hip extensors/lacking hip ext ROM

Single limb stance phase of stair descent

- contra toe off --> contra IC - Stance limb now has 1° control of descent -also get cocontraction from hamstrings - assisting with hip stabilization and shock absorption (there is a first and second part to this phase)

Phases of Running Gait

-Very similar to the names of the phases of normal gait -stance is made up of initial contact that is right when the foot makes its initial first contact to the floor or to the ground -midstance is that time between a flat foot and heel lifting off and then we have what's called late stance or toe-off this is our propulsion phase -don't necessarily have terminal stance but we have initial contact mid stance and late stance to off -at this point we lose contact with the ground so that the foot goes into initial swing initial swing we are floating at the beginning of initial swing our other foot is not in contact with the ground mid swing is occurring here as the knee flexes and starts to drive forward we see mid swing phase and that is occurring while the contralateral limb is in contact and then at terminal swing we're floating at the end of terminal swing as the other contralateral them lifts off the ground and that leads is allowing foot dissent to occur there preparing in late swing for initial contact again -naturally all of these are occurring at an incredibly rapid rate so we tend to breakdown running gait into larger chunks and functional periods

Terminal Swing (Foot Descent/late float)

-When the limb begins to descent bc it needs to reach ground to be the next stance limb - Hip: 45-50° Flex (extends) - Knee: 15-20° Flex - Ankle: 0-15° DF (these numbers match initial contact angles) - Gluteus Maximus - TFL reamin active throughout swing - Hip Adductors - Quadriceps - Hamstrings - concurrent shift - working eccentrically to allow knee extension but at IC, they work concentrically at the hip - one side lengthens as other side shortens - allows for motion change - helps to avoid any passive/active insufficiency in the hamstrings as they are controlling knee extension - but also need to be kicking on in preparation for hip extension in closed chain - Gastroc/soleus - preparing - Tibialis Anterior - kicks on -foot is not on the ground at this point, so all these muscles are working in anticipation to prepare for all 3.5x BW force to transmit through the leg

Determining Static Foot Type: The Wet Test

-assesses foot arch at rest 1. Place piece of paper on floor 2. Wet bottom of feet and stand on paper 3. Match your foot prints, as best you can, to one of the foot types pictured on the right

Midswing during running

-following initial swing - Hip: 40-55° Flex to 75-80° - Knee: 105 - 125° Flexion (sprinters will have more of a flexed knee) - Ankle: 0-15° DF - Iliacus - still quite active concentrically - turns off once we approach terminal swing - Hip Adductors - continuing to modify femur position for best aerodynamics - Tibialis Anterior - concentrically active to keep ankle dorsiflexed

Stair descent occurs via:

1° Knee: Greatest demand - flexion ROM & muscle control 2° Ankle dorsiflexion: fulcrum for modification limb alignment -Hip: assists with lowering of body down to next step & advancing the limb

Stance:Swing ratio in running

30:70

Common step levels in clinics

4", 6", 8"

Each foot hits the ground

50-70 x's/min

Stance:Swing ratio in walking

60:40

Balance is necessary in which phases of gait?

All phases! (most notably SLS)

Anterior tibialis during swing limb advancement phase of stair ascent

As foot lifts: dorsiflexion for foot clearance (clear edge of next tread)

BFSH during single leg stance phase of stair ascent

Assists w/knee flexion at end of SLS in preparation for what is to come

BFLH & Semimembranosus during single leg stance phase of stair ascent

Augment control of hip & knee extension

GRF/COP in Running

Darkening of lines indicate force changes throughout stance phase -forefoot runners - COP starts laterally and more around the base of the 5th met and out through the metatarsal heads - Peak vertical force in mid-stance occurs in same area - typically over the first 3 metatarsal heads in both scenarios -forefoot runners just dont take pressure in through the heel

Glut Max, Add Longus during single leg stance phase of stair ascent

Decreasing concentric hip extension

Quadriceps during single leg stance phase of stair ascent

Decreasing concentric knee extension

Anterior tibialis during single leg stance phase of stair ascent

Dorsiflexion for foot clearance (late) as it prepares for swing

Gastroc-soleus during swing limb advancement phase of stair ascent

Early SLA: Increased activation to transfer body weight to the leading limb (responsible for rapid PF)

Shoe Wear Patterns

Generalized running gait can be determined from wear pattern -determine someone's gait and running style without ever watching them run -rigid foot - stays rigid and does not conform to ground so they will be less likely to bear their weight evenly across their foot so you will see more of lateral boarders of shoe worn off - normal foot - just a little bit of lateral calcaneus wear - especially if they are heel strike runner. In a forefoot strike, you would see wearing over metatarsal heads - floppy foot - excessively roll towards midline when it bears weight - so you will see more medial than lateral wearing - medial calcaneal and medial met head wearing - having to generate more propulsion force through less of a four foot rigid rocker and they have to push even harder on their metatarsal heads to generate that forward motion

Gastroc-soleus during single leg stance phase of stair ascent

Increased activation to control tibia - prevents tibia from falling forward

Vastii & hip extensors during swing limb advancement phase of stair ascent

Late SLA: active in preparation for WA

Hamstrings during weight acceptance phase of stair ascent

Low level activation augments hip extension & resists excessive anterior tibial movement

Gait Training with Facilitation

Not using table as AD, it's facilitating HAT forward momentum to continue to generate stepping pattern and CPG

Quadriceps during weight acceptance phase of stair ascent

Peak activity for shock absorption* begin to extend knee almost immediately

Weight acceptance phase of stair descent

Ref IC --> just before contra toe off

Single leg balance in which phases of gait?

Single limb stance, swing limb advancement

Kinematics of stair climbing

Stair ascent typically occurs on forefoot and toes, midfoot and heel do not contact the tread -weight bearing from our forefoot forward (balls of our feet) -in most cases, the midfoot and heel do not make contact with stairs - but depends on tread depth

Lower Gluteus Max and Adductor Magnus during weight acceptance phase of stair ascent

Strong hip extension

Upper Gluteus Max Gluteus Medius during weight acceptance phase of stair ascent

Strong lateral pelvic stabilization (assisting glute med)

Soleus during weight acceptance phase of stair ascent

Strongly active until contralateral toe off (controls tibial advancement as limb is loaded) -eccentrically during loading (PF occurs right at the end)

Tandem balance in which phases of gait?

Terminal stance/double limb support phases

The most common site of chronic running injury

The extensor mechanism of the knee (quads)

Dr. Power's gait observation algorithm: examination

Where do the deficits lie? Could it be improved? Are we treating to change? Or do you have to compensate for something that cannot be changed/improved?

Most running injuries have a

biomechanical origin

There is a significant correlation between

infrequent change of running shoe and injury -running shoes do have a shelf life!

Forces of running are highest during

mid stance and late stance

Shock absorption

momentum dissipation

Regular exercise is important to

overall health, productivity and longevity - Potential of significantly reducing health care costs

Stair

refers to the structure we walk on

Stair tread

the depth of the horizontal surface *important to know this dimension in our patient's homes/work environment*

Most chronic injuries associated with running are more likely to be related to

the forces of mid and late stance rather than in heel strike

Step

the human performance - what the person is doing on the stairs

Distribution of Forces on the Foot While Running

this occurs regardless of heel strike or forefoot strike *Highest pressure - 1st, 2nd, and 3rd metatarsal heads

Stair riser

vertical height of the stair *important to know this dimension in our patient's homes/work environment*

Impact force ______________ body weight !

~ 3.5 x's

Common Running Injuries

¨Patellar pain syndrome ¨Tibial stress syndrome ¨Achilles tendonitis ¨Plantar fasciitis ¨ITB Syndrome -General treatment includes strength training of knee flexors and extensors - focusing on muscle and tendonis junctions (what strength training can benefit tendonis junctions?)

Running injuries

• An acute ________________ occurs when a sudden crisis causes failure either through aberrant tissue or as a result of high strain rates. • In contrast, a chronic _______________ is characterized by a slow, insidious onset that implies an antecedent subthreshold spectrum of build up of multiple minor moments of structural damage with persistent symptoms that do not resolve • This damage eventually leads to a crisis episode, often heralded by pain or signs of inflammation, or both.

To increase difficulty in initial pre-gait activities:

• Apply perturbations in any direction -close eyes so they become dependent on their other senses • varied surfaces • Vary BOS • Closed environment vs. open environment - Reaching with upper and lower extremities - dual task performance

Neuromuscular Electrical Stimulation (NMES): Clinical Applications

• Effects may be a direct result of muscle strengthening • Influenced by the increased general excitability of the motor neuron pool produced by motor level electrical stimulation • Enhancing descending control of muscle recruitment (particularly beneficial for pt. with foot drop - underactive anterior tib) • Sensory input always produced by motor level stimulation • Provide a cue for the patient to initiate a movement or activate a muscle group • Promote reflexive motor contraction • Sensory stimulation without motor level stimulation may also enhance brain plasticity and cortical motor output • Patterned sensory level stimulation, using an intermittent sensory stimulus, with an on:off time without stimulation of muscle contractions • Enhance motor control by promoting reciprocal inhibition of antagonist muscles • May be integrated into the performance of functional activities by stimulating contractions at the time during an activity when the muscle should contract

Patient Education: Strategies for older patients

• Encourage avoidance of obstacles • Slower speeds, shorter steps • Older adults have decreased COM/COP movement - indicating conservative strategy to reduce mechanical load on stance limb. • Older adults w/delayed postural responses to slips & trips -remaining ambulatory is a significant indication for longevity of life

Pre-gait activities - progression

• Focus on natural rhythm and speed of walking • Encourage even steps • Break up synergy pattern - Position UE in opposition to its synergy to influence LE during gait -with hemiplegic gait - we usually see UE in flexion synergy and LE in extension synergy • Practice walking: •Forward •Backward •Sideways •Cross-stepping •Travel training in environment • Practice Stairs: •Step-ups •Stair climbing •Step-overs

Gait intervention concepts: retraining impairments vs treating to improve:

• Gait strategies • Functional performance (squats, weight shifting) • Both effective - research conflicts

Overgound BWS gait training

• Indoor walking, level surfaces with BWS --> no BWS • Can help introduce the use of AD for ambulation on level surfaces • Can go into elevation activities: step-ups • Opening doors and passing through doorways (if system is able to get through doorways)

Progression of skills across gait training

• Load (WB) • Postural control (controlled balance) • Speed (cadence, velocity) • Endurance • Independence • Adaptability - can they adapt to a changing environment?

Gait intervention concepts: treatment for postural control

• Postural alignment of HAT - optimize this so they can control their COM over LE • Extensor support while loading - knee control, AFO • Stepping up (short stool) -Use of (A) devices

Gait Interventions include:

• Pre-gait activities - Neuromuscular control • Therapeutic exercise • Functional training in self-care & home management • Functional training in community & work (job, school, play) integration • Manual therapy • Modalities • External equipment: orthotics, AD etc

Pre-gait activities: Parallel Bar (|| bars) Progression

• Sitting <--> standing • Standing balance and limits of stability (LOS) training • Stepping, side-stepping, cross stepping in || bars • Use of gait pattern, forward progression, and turning in || bars • Sitting <--> standing w/AD (w/in or out of || bars) • Standing balance and weight shifting activities w/AD • Use AD (with appropriate gait pattern) for forward progression and turning as had been practiced -patient can feel confident and stable while in bars which can free up the PTs hands

Mobility gait training

• Treadmill - full weight, partial support (PWS) •part vs whole task training - helps break down the gait cycle for those who are highly neurologically involved • Stand up/sit down transfers • Kicking a ball • Walk balance beam • Retro-walking • Restive gait • Marching in place • Toe rises • Endurance training (bike) - to bolster their cardiovascular endurance if gait is not possible for endurance training

Task-specific training to improve walking ability (post stroke)

• Treadmill training: •Promote activation of spinal neural circuits •Creates a "Forced Use" situation •PBWSTT •Varying results due to intensity, speed & duration • Functional Mobility Tasks: •Functional tasks (e.g., repetitive rise from a chair, stepping up and down a stepper) •Aerobic component •A variety of challenging walking activities with substantial postural control demands

Gait training - Overground indoors

• Walking forward and backward • Resisted progression - can be used to help facilitate muscle (http://www.youtube.com/watch?v=twKfTsRKLhs) •Retrogait •Resisted retro-gait • Side-stepping and cross-stepping • Braiding • Stair climbing • Falling techniques - particularly with someone you might expect to fall - want to teach them how to fall safely and how to get back up safely •Elevation activities •Different surfaces

Gait interventions: questions to ask

• Where are the patients problems? Complaints? • Major issues? • Minor issues? • What needs to be addressed? • What are the PATIENT'S goals? • What are YOUR goals? - Blend your goals with patient goals • How are you going to get the patient to where he/she needs to be? - Are you treating to CHANGE or COMPENSATE?

Outpatient gait interventions

•Ensure necessary ROM at all joints - joint mobilizations, soft tissue stretching - overcome residual synergy? use your gait analysis to determine which joints you want to focus on •Open chain LE strengthening - SLR, clamshells, LAQ, SAQ, ankle t-band •Closed chain LE strengthening (more closely related to gait) - heel raise (and slowed lowering), toe raise (and slowed lowering), squats, lunges, hip hikes, step-ups/downs, glute walking •Weight transfer - maximizing hip ext, MTP ext - stability at end ranges •Swing phase - clearing toe, maximizing hip and knee flex •Core mobility/stability - pelvic rotation, trunk counterrotation in double and single limb -some people cannot put their open strength to use in a closed chain situation and can have gait deviations

Gait intervention concepts: stages of motor control

•Mobility •Stability •Controlled Mobility •Skill • Generally use with all patients • Start with essentials for (I) home • What is your patient's primary goal? *Can be very useful for pt. who has fear of falling down stairs or lacks muscle control to descend stairs BACKWARDS *Sometimes we have to help a patient COMPENSATE in a safe way for problems that cannot be improved (degenerative diseases)