Download Handout - Mary Massery

APTA CSM 2017, San Antonio, TX
Sponsors: Academies of Pediatric and Neurologic PT
Saturday, February 18th, 8:00 – 10:00 am
“Braking Bad”
Eccentric Control from
Talking to Walking
Mary Massery, PT, DPT, DSc
Owner, Massery Physical Therapy, Glenview, IL
Nechama Karman, PT, MS, PCS
Chief Clinical Educator, Mobility Research, Great Neck, NY
FINAL HANDOUT

The APTA requires handouts by December.

For the participants’ convenience, the updated
handout is posted on Mary Massery’s website:
http://www.MasseryPT.com
(at the bottom of home page under “News”)
Mary Massery: [email protected]
www.MasseryPT.com
PDF processed with CutePDF evaluation edition www.CutePDF.com
1
Conflict of Interest





Mary Massery – No conflict of interest

Nechama Karman – Chief Clinical
Educator, Mobility Research (LiteGait)
So why are we here?
To propose a paradigm
shift linking postural
control, breathing, and
glottal control to eccentric
control necessary for gait
and other upright activities.
MM: Glottal control as a
primary modulator of trunk
pressures needed for trunk
eccentric control.
NK: Detailed application to
gait analysis and proposed
eccentric interventions.
Mary Massery: [email protected]
www.MasseryPT.com
“Braking Bad”
Eccentric control
from talking to
walking
2
Demo: Stand-to-sit



Let’s start at the end!
 Linking glottal control to
eccentric trunk / LE control
 Stand-to-sit demonstration
Your “normal” legs became
weaker and exhibited poorer
motor control by disengaging
the vocal folds.
Hmmm … better head back
to the beginning.
Pressure!

Successful coordination of postural stability and
respiratory mechanics depends on how well the
patient with motor impairments:
 Generates
trunk pressure
 Regulates trunk pressure
 Maintains trunk pressure
 And successfully manages those
pressures in both the thoracic
and abdominal cavities.
Mary Massery: [email protected]
www.MasseryPT.com
3
Postural stability and respiration

Trunk stability and breathing:
 Both
necessary components of
gait

Trunk pressures must be
modulated during the entire
gait cycle
What modulates trunk pressures?




Mary Massery: [email protected]
www.MasseryPT.com
High School Science Fair
Project 
Concept of negative & positive
pressure inflating & deflating
balloon (lungs)
But a human rib cage & trunk
isn’t rigid like a bottle, and …
there is another chamber
beneath the thorax (abdomen)
4
What modulates trunk pressures?
So, the internal
pressure of the
balloon (lungs) won’t
be held at a constant
level through
deflation unless …
What modulates trunk pressures?



Mary Massery: [email protected]
www.MasseryPT.com
There is a valve at the top to
restrict expiratory airflow (vocal
folds), and …
A slow compressive external
force to stabilize the balloon
(elastic recoil and muscle
support)
ECCENTRIC CONTROL!
5
Vocal Folds & Glottal Structures:
“Gate-Keepers” for Trunk Pressures
Wait …
I thought this presentation was
about gait, not talking
Mary Massery: [email protected]
www.MasseryPT.com
6
A Postural Control Model Using
a Soda-Pop Can
Vocal Folds
ITP
Thoracic Cavity
Diaphragm
IAP
Abdominal Cavity
Pelvic Floor
Massery 2005
Walking and talking
It’s all connected!
Mary Massery: [email protected]
www.MasseryPT.com
7
Research: Relationship of breath
control to IAP force production

Hagins et al 2004:


11 young, healthy adult subjects, lifting light loads
(35% maximum isometric lift) and heavy loads (70%)
in stance.
Compared 4 different breathing patterns during lift to
stance posture and load:




Natural breathing
Max inhalation, hold
Max exhalation, hold
Max inhalation, steady exhalation
Research: Relationship of breath
control to IAP force production

Results
IAP increased significantly more with heavier loads
than lighter loads (p<.002).
 “Max inhalation, hold” breathing pattern produced
significantly greater IAP (p=.017) than any of the 3
other breathing conditions.

Hagins 2004
Mary Massery: [email protected]
www.MasseryPT.com
8
Research: Relationship of breath
control to IAP force production

How did the authors rule in/out the role of the glottis
and gas volume on force production?

Other 3 breathing conditions failed to increase IAP!



“Max exhalation-hold” - glottal closure but inadequate lung
volume to compress the gas.
“Max inhalation-exhalation” - max lung volume but no
compression of the gas (no glottal closure).
“Natural breathing” pattern: mid range volume, no
compression.
Hagins 2004
Research: Relationship of breath
control to IAP force production

Discussion
Without the glottal valve, the
diaphragm’s stability is limited,
succumbing to the upward forces
from abdomen, lowering the
potential peak of IAP!
 My interpretation - IT’S THE
WHOLE CAN!

Hagins 2004
Mary Massery: [email protected]
www.MasseryPT.com
9
Research: Relationship of ITP to
IAP to limb force production

Sooooo … by extension, glottal control affects ITP,
which affects IAP, which affects limb force production.


Tayashiki 2016


Connecting talking to walking!
Using isometric abdominal bracing training program (8 wks)
 IAP increased compared to controls (no training)
 Hip extensor strength and power increased without adding
an external load
Take-away: control of ITP (includes glottis and diaphragm),
along with control of IAP, can significantly impact limb-force
production!
Modulation of Pressure

Orlikoff 2008
 Sub-glottal
pressure was sustained during voicing /a/
for >6 seconds in spite of losing lung volume
 Voice pitch and quality was maintained regardless of
increasing postural demand (lifting 0, 6, 11, 15 lb wts
on outstretched arms)
 Modulation of vocal fold adduction controlled airflow
while allowing simultaneous voice and postural stability!
Mary Massery: [email protected]
www.MasseryPT.com
10
Modulation of Pressure


My extrapolation: controlled
release of inspiratory muscles
(eccentric trunk control) against
the top valve (glottis) was
necessary to stabilize thorax
during the sustained task
contributing to consistent subglottal pressures!
For voice? Or for postural
stability? Hmmm … likely both!
Emerging Research:
Vocal Folds as Postural Stabilizers

Lead to my research (2013):
 Even
very small perturbations to standing
balance required the engagement of the
glottis to stabilize the trunk and minimize
trunk displacement (balance/falls)
 Without
the top valve (glottis),
compression of gas is impaired, limiting
ITP & IAP, and limiting modulation of
trunk pressures over the variable lung
volumes of breathing
Massery 2013
Mary Massery: [email protected]
www.MasseryPT.com
11
New definition of “Core”

Core stability extends from the
vocal folds on top, to the pelvic
floor on the bottom, and
includes every muscle in
between!
My perspective on dynamic control

Need more than static stability to stand

Need control of stability over time and
over variable conditions including lung
volume for effective balance!

Hence, the glottis becomes the fine motor
regulator of sustained trunk pressure
throughout the respiratory cycle and is
coordinated with postural demands to
create dynamic balance control.

Eccentric release of the trunk muscles
during exhalation is necessary for control
of the spine/posture throughout the gait
cycle
Mary Massery: [email protected]
www.MasseryPT.com
12
Are you having fun yet? 


Possibility for new research/collaboration with SLPs
Graham 2016 – glottal insufficiency and perceived
breathiness of classically trained singers can be
identified.
 Would we see balance deficits as well?
 Could we try postural stabilization interventions to
improve vocal control?
 Or the reverse, should we be adding voicing as
an intervention for our patients with balance/falls
deficits?
Are you having fun yet? 

Zhang 2015 – regulation of sub-glottal pressure
across a large range of voice conditions is necessary
for normal human communication and is achieved via
vocal fold adduction and tone regulation.
 Can we correlate vocal fold deficits with impaired
trunk control, balance, gait?
 Examples: unilateral/bilateral paralysis (CVA, post
sx injuries), poor neuromotor timing (TBI, CP),
tracheostomies, etc.
Mary Massery: [email protected]
www.MasseryPT.com
13
Understanding glottal control:
Bernoulli principle
As liquid or air moves through a constricted passage,
the velocity of the fluid increases and the pressure
perpendicular to the direction of flow decreases.
Bernoulli Principle
Upper airway
Vocal folds

Clinical examples of impaired
adduction function of vocal
folds
 Unilateral / bilateral
paralysis (CVA, post sx
injuries)
 Poor neuromotor timing
(TBI, CP)
 Tracheostomies, etc.
Lungs
Mary Massery: [email protected]
www.MasseryPT.com
14
Bernoulli Principle

Upper airway
Vocal folds


Lungs

If the vocal folds can not
adduct adequately to regulate
ITP and airflow, then the lungs
and respiratory/postural
muscles are forced to play that
role via concentric
contractions rather than
eccentric contractions to
voice.
IAP & ITP will only be
maintained temporarily.
Potentially adversely
influencing spinal stability and
pelvic floor support.
In turn, reducing UE and LE
force production.
Breath control for speech

Eccentric control




Normal, quiet, everyday speech against partially adducted vocal folds
Vocal folds - lower tone
Low level activity of abdominals
Concentric control
Forceful speech, i.e. yelling, coughing, or grunting against partially
adducted vocal folds
 Vocal folds - high tone
 Active, concentric recruitment of abdominals and other trunk flexors


Passive control



Breathy, short duration speech. Open glottis.
Vocal folds – very low tone
No active recruitment of abdominals needed
Mary Massery: [email protected]
www.MasseryPT.com
15
Breath control for speech

Breath-hold control


Oops, full adduction results in glottal closure, so there is
no voice! 
Breath-hold is used for momentary trunk stability but not
sustained activity
Principles of Interventions

Match the type of breath control with the
type of trunk control for a specific task
 Eccentric
trunk training - sustained voicing
 Concentric trunk training - forceful voicing
 Passive - resting
 Add vocal resistance with higher level
eccentric or mid-range training
Mary Massery: [email protected]
www.MasseryPT.com
16
Demo: Apply concepts right now!
1.
2.
Breathing during stand to sit transfer (done previously!)
Breathing while lifting / lowering arm (or leg or trunk …)
 Breath-hold – static, natural response to sudden
onset of load
 Eccentric control – dynamic, voicing, sustained
pressure throughout ROM. Resistance on top of arm

PNF Agonistic Reversal - verbal command: “make me work”
 Concentric
control – forceful (O’Connell 2016, tennis)
Resistance on bottom of arm.
 Passive control – drop arm. (Not typically wanted )
Demo: Apply concepts right now!
3.
Eccentric or mid-range tasks are generally paired
with eccentric breath!
 Voicing or pursed lip exhalation used during
movement
 Stimulate voicing with sensory techniques:


percussion, vibration, karate chops, etc.
Babies love it!
Mary Massery: [email protected]
www.MasseryPT.com
17
Application: challenging gait problem



Hannah, 14 y/o
Athetoid CP
Limited verbal skills

Help Hannah
navigate the stairs
using breath control
Application: challenging gait problem

Ascending





Inhale-hold, step-up.
On landing, caregiver to give
extra trunk support.
Hannah exhale and catch
her breath.
Repeat each step.
Descending



Inhale before stepping down.
Hannah to vocalize or use
pursed lipped exhalation
stepping down.
Pause each landing. Catch
breath. Repeat.
Mary Massery: [email protected]
www.MasseryPT.com

Help Hannah
navigate the stairs
using breath control
18
Application: challenging gait problem

Hannah, 14 y/o



Hannah, now 21 y/o
Lives independently
Employs her own caregivers
Summary

Postural control, breathing, and glottal control are linked!

Glottal control is necessary to modulate trunk pressures
(ITP & IAP), which in turn, stabilizes the spine and trunk
in upright for optimal limb function and balance.

Recognizing this relationship, PTs should consider
purposely adding eccentric breath techniques with
eccentric or mid-range trunk control interventions to
maximize spinal control, and balance (and so much
more!)

Nechama Karman is next: application to gait!
Mary Massery: [email protected]
www.MasseryPT.com
19
Final handout available: http://www.MasseryPT.com
REFERENCES
1.
2.
3.
4.
5.
6.
7.
8.
9.
Adolph KE, Cole WG, Komati M, Garciaguirre JS, Badaly D, Lingeman JM, Chan GL,
Slotsky RB. (2012). How do you learn to walk? Thousands of steps and dozens of falls
per day. Psychol Sci 1;23(11):1387-94.
Blanpied P, Levins JA, Murphy E. (1995) The effects of different stretch velocities on
average force of the shortening phase in the stretch-shorten cycle. JOSPT. 21(6):345-53.
Butler, J.E., A.L. Hudson, and S.C. Gandevia, The neural control of human inspiratory
muscles. Prog Brain Res, 2014. 209: p. 295-308.
Cowan, MM, Stilling, DS, Naumann, S, Colborne, GR. (1998). Quantification of agonist
muscle co-activation in children with spastic diplegia. Clin Anat. 11(5):314-9.
Damiano DL, Moreau N. (2008). Muscle thickness reflects activity in CP but how well
does it represent strength? Dev Med Child Neurol 50(2):88.
Damiano, DL, Martellotta, TL, Sullivan, DJ, Granata, KP, Abel, MF. (2000). Muscle force
production and functional performance in spastic cerebral palsy: relationship of cocontraction. Arch Phys Med Rehabil. 81:895-900.
Damiano, DL, Martellotta, TL, Quinlivan, JM, Abel, MF. (2001). Deficits in eccentric versus
concentric torque in children with spastic cerebral palsy. Med Sci Sport Exerc. 33:117-22.
Hodges PW, Heijnen I, Gandevia SC. Postural activity of the diaphragm is reduced in
humans when respiratory demand increases. The Journal of physiology. Dec 15
2001;537(Pt 3):999-1008.
Hodges PW, Heijnen I, Gandevia SC. Postural activity of the diaphragm is reduced in
humans when respiratory demand increases. The Journal of physiology. Dec 15
2001;537(Pt 3):999-1008.
Mary Massery: [email protected]
www.MasseryPT.com
20
REFERENCES
10.
11.
12.
13.
14.
15.
16.
17.
18.
Hall AL, Bowden MG, Kautz SA, Neptune RR. (2012). Biomechanical variables related to
walking performance 6-months post-stroke rehabilitation. Clin Biomech 27(10):1017-22.
Hodapp, M, Vry, J, Mall, V, Faist, M (2009). Changes in soleus H-reflex modulation after
treadmill training in children with cerebral palsy. Brain 132;37-44.
Ikeda, AJ, Abel, MF, Granata, KP, Damiano, DL. (1998). Quantification of cocontraction in
spastic cerebral palsy. Electromyor Clin Neurophysiol. 38:497-504.
Kaplan, SL. (1995). Cycling patterns in children with and without cerebral palsy. Dev Med
Child Neurol. 37:620-30.
Loucks, T.M., et al., Human brain activation during phonation and exhalation: common
volitional control for two upper airway functions. Neuroimage, 2007. 36(1): p. 131-43.
Massery M, Hagins M, Stafford R, Moerchen V, Hodges PW. Effect of airway control by
glottal structures on postural stability. J Appl Physiol (1985). Aug 15 2013;115(4):483-490.
Mattern-Baxter, K, Bellamy, S, Mansoor JK. (2009). Effects of Intensive Locomotor
Treadmill Training on Young Children with Cerebral Palsy. Pediatr Phys Th 21:308-19.
McCain, KJ, Pollo,FE, Baum, BS, Coleman, SC, Baker, S, Smith, PS. (2008). Locomotor
treadmill training with partial body-weight support before overground gait in adults with
acute stroke: a pilot study. Arch Phys Med Rehabil, 89(4):684-91.
McCain KJ, Smith, PA, Polo FE, Coleman SC, Baker S. (2011). Excellent outcomes for
adults who experienced early standardized treadmill training during acute phase of
recovery from stroke: A case series. Top Stroke Rehab. 18(4):428-36.
REFERENCES
19.
20.
21.
22.
23.
24.
25.
26.
27.
Moreau NG, Knight H, Olson MW. (2016) A potential mechanism by which torque is preserved in
cerebral palsy during fatiguing contractions of the knee extensors. Muscle Nerve 52(2):297-303.
Moreau NG, Holthaus K, Marlow N. (2013). Differential adaptations of muscle architecture to
high-velocity versus traditional strength training in cerebral palsy. Neurorehabil Neural Repair
27(4):325-34.
Moreau NG, Falvo MJ, Damiano DL. (2012). Rapid force generation is impaired in cerebral palsy
and is related to decreased muscle size and functional mobility. Gait Posture 35(1):154-8.
Mulroy SJ, Klassen T, Gronley JK, Eberly VJ, Brown, DA and Sullivan, KJ (2010). Gait parameters
associated with responsiveness to treadmill training with body weight support after stroke: An
exploratory study. Physical Therapy 90(2)209-223.
O’Dwyer, N, Nielson, P, Nash, J. (1994). Reduction of spasticity in cerebral palsy using feedback
of the tonic stretch reflex: a controlled study. Dev Med Child Neurol. 36(9):770-86.
Olney, SJ (1985). Quantitative evaluation of cocontraction of knee and ankle muscles in normal
walking. In Winter, DA, Norman, RW, Wells, RP, Hayes, KC, Patla, AE (Eds) Biomechanics IX-A
Champain, IL: Human Kinetics.
Perry J, Burnfield JM. (2010). Gait Analysis: Normal and Pathological Function. New Jersey:
Slack Incoporated.
Phadke, CP, Wu, SS, Thompson FJ, Behrmann AL. (2007) Comparison of soleus H-reflex
modulation after incomplete spinal cord injury in 2 walking environments: treadmill with body
weight support and overground. Arch Phys Med Rehabil. 88:1606-13.
Schmid, A, Duncan, PW, Studenski, S et. al. Improvements in speed-based gait classification are
meaningful. Stroke, 2007; 38:2096-100.
Mary Massery: [email protected]
www.MasseryPT.com
21
REFERENCES
28.
29.
30.
31.
32.
33.
34.
35.
36.
Sutherland DH (2005). The evolution of clinical gait analysis part III – kinetics and energy
assessment. Gait Posture 21(4):447-61
Staes, F.F., et al., Physical therapy as a means to optimize posture and voice parameters in
student classical singers: a case report. J Voice, 2011. 25(3): p. e91-101.
Sutherland DH, Olshen R, Biden E, Wyatt M. (1988) The Development of Mature Walking in
Clinics in Developmental Medicine 104:178-182. Cambridge University Press (Mac Keith
Press);London.
Trueblood, PR. (2001). Partial body weight treadmill training in persons with chronic stroke.
Neurorehabilitation 16: 141-153.
Unnithan, VB. Dowling, JJ, Frost, G, Volpe, AB, Bar-Or, O. (1996) Co-contraction and phasic
activity during gait in children with cerebral palsy. Electromyogr Clin Neurophysiol. 36:487-94.
Yang, JF, Stein, RB, James, KB. (1991). Contribution of peripheral afferents to the activation of the
soleus muscle during walking in humans. Exp Brain Res. 87:443-52
van der Krogt, MM, Doorenbosch, AM, Becher, JG, Harlarr, J. (2010). Dynamic spasticity of
plantar flexor muscles in cerebral palsy gait. J Rehabil Med. 42:656-663.
van der Krogt, MM, Doorenbosch, AM, Becher, JG, Harlarr, J. Caroline (2009). Walking speed
modifies spasticity effects in gastrocnemius and soleus in cerebral palsy gait. Clinical
Biomechanics 24:422-428. (1592-1606).
van der Krogt, MM, Doorenbosch, AM, Harlarr, J. (2009)The effect of walking speed on
hamstrings length and lengthening velocity in children with spastic cerebral palsy. Gait & Posture,
29:4 (640-44).
Wu J, Looper J, Ulrich, DA, Angulo-Barroso, RM. (2010). Effects of Various Treadmill
Interventions on the Development of Joint Kinematics in Infants With Down Syndrome. Physical
Therapy, 90(9) 1265-76.
ADDITIONAL REFERENCES
37.
38.
39.
40.
41.
42.
Graham, E., V. Angadi, J. Sloggy and J. Stemple (2016). "Contribution of Glottic
Insufficiency to Perceived Breathiness in Classically Trained Singers." Med Probl
Perform Art 31(3): 179-184.
Hagins, M., M. Pietrek, A. Sheikhzadeh, M. Nordin and K. Axen (2004). "The effects
of breath control on intra-abdominal pressure during lifting tasks." Spine 29(4): 464469.
Massery, M. (2005). "Musculoskeletal and neuromuscular interventions: a physical
approach to cystic fibrosis." Journal of the Royal Society of Medicine 98(Supplement
45): 55-66.
Orlikoff, R. F. (2008). "Voice production during a weightlifting and support task." Folia
Phoniatrica et Logopedica 60(4): 188-194.
Tayashiki, K., S. Maeo, S. Usui, N. Miyamoto and H. Kanehisa (2016). "Effect of
abdominal bracing training on strength and power of trunk and lower limb muscles."
Eur J Appl Physiol 116(9): 1703-1713.
Zhang, Z. (2015). "Respiratory Laryngeal Coordination in Airflow Conservation and
Reduction of Respiratory Effort of Phonation." J Voice.
Mary Massery: [email protected]
www.MasseryPT.com
22
The End
Mary Massery:
[email protected]
Nechama Karman:
[email protected]
Mary Massery: [email protected]
www.MasseryPT.com
23
2/9/17
BrakingBad:
EccentricControlfromTalkingto
Walking
NechamaKarman,PTMSPCS
NoBrakes/EccentricControl
2
1
Nechama Karman:
Karman [email protected]
2/9/17
Elementsandimpedimentstoenergy-efficientgait
Motorlearningandspecificityoftraining
SelecHonoftrainingparameterstopromoteenergy-efficientgait
Locomotorbiomechanicsandnormalgait
Whywedowhatwedo
Pathologicgait
Whysomedon’tdowhatwedo
Whatworks
EvidencetosupportspecificintervenHons
COMMONGAITPROBLEMSIN
NEUROLOGICALPOPULATIONS
HighCostofNeurologicGait
Hemiplegic
• 
• 
• 
• 
.29m/s+.27(acute)
.58m/s+.38(chronic)
Metaboliccost50-67%higher
6MWT.73+.36or.74+.25m/s)
Normal
•  1.49m/s
•  6MWT1.83+.19m/s
2
Nechama Karman:
Karman [email protected]
2/9/17
Whyisenergycosthigh?
•  Alteredbodygeometryàalteredforces
acHngonthesystem
•  AbnormalHmingofgaitevents
–  FailuretotakeadvantageofGRFs
–  Co-contracHonissues
•  FearoffallingàlackofconservaHonof
momentum
•  Compensatorystrategies:biomechanically
inefficient
5
KeyElementsofNormalGait
Development
• 
• 
• 
• 
• 
• 
Upright,symmetricalposture
Reciprocalpaaern
Symmetric(swing&stanceHme;steplength)
Rhythmic(steadyrate)
Arm-swing
NormalLEbiomechanics
–  Trailinglimb
–  Mid-stancelimbloading
6
3
Nechama Karman:
Karman [email protected]
2/9/17
FlexibilityRequiresEccentric
Control
•  4gaitcyclestoaltergaitpaaern
•  Abilitytorespondtonovel/unpredictable
condiHons
•  ConservaHonofmomentum
7
RepeaHngTheme:SpecificityofTraining
•  HowtomakeourintervenHonsspecificenoughso
thattheoutcomesofour"preparatory
intervenHons"arefuncHonallyapplicablewithinthe
contextofgaittraining?
–  e.g.ROMaccessibleatthespeedofgaitcycle?
–  Length/TensionRelaHonships
–  Byfibertype?
–  AutomaHcityvs.conscious
–  ContracContype(concentric,isometric,eccentric)
–  Speed/TimingofcontracCon(orco-contrac.on)
–  Powervs.ForceProducHon
–  Stabilityvs.Mobility
4
Nechama Karman:
Karman [email protected]
2/9/17
MuscleFuncHons:Gait
•  Accelerate:Concentric
•  Deccelerate:Eccentric
•  Stabilize:Isometric
9
SwingPhaseofGait
•  Primemoverproblems
–  AccelleraHon
–  DecelleraHon
•  Stancephaseissues–
–  Ipsilateral
–  Contralateral
•  ContribuHonofuninvolvedlimbottheproblemaHcgait
paaern
•  Delayofswing–pushbacktofront(minimalloadingof
involvedLE)
•  Absenceofrockers
10
•  WeightshiiawayfrominvolvedLE
5
Nechama Karman:
Karman [email protected]
2/9/17
Pre-contracHlemusclelengtheninginfluences
contracHleforces
•  Pre-stretchyieldsgreatercontracHlepower
(Cavagna)
•  Speed-dependence
–  Normalwalkingspeedyieldshighestaverageconcentric
forcesinsoleus(50°/secondstretchwith180°/second
concentricvelocity)-Blanpied
•  StretchingasaresultofgroundreacHonforceor
inerHalforce
–  Latestance:soleus&gastrocnemius
–  Latestance:hipflexors
MulH-arHcularMuscles
•  Moredifficulttocontrol-morelikelytofuncHon
pathologically
•  Usuallyfast-twitch
•  FuncHonsasenergytransfer straps reducing
energycostofwalkingby~20%
–  DemandsprecisecontrolofHmingandintensityofacHon
•  Rapid,coordinatedandlinkedmoHonsofthe
jointstheyspan
–  ParHcipateininter-dependentsystemoflinkedsegments
andGRFsforopHmalfuncHon
6
Nechama Karman:
Karman [email protected]
2/9/17
NormalGait
•  Rhythmicallymodulatedemgpaaern
•  Reflexpathwayscontribute30-60%ofsoleus
muscleacHvaHoninearlystance.
•  Di-synapHcreciprocal1a-inhibiHonbetankle
flexors&extensorsstronglymodulatedcausing
reflexdepressionduringswing,avoidingcocontracHon
•  Withvoluntarytoe-walking,demonstrate
increasedcalfmuscleacHvityinterminalswing
(prepfortoe-landing)
13
NormalGait:3Rockers
•  HeelRocker:Preservesmomentumwithshock
absorpHon
•  AnkleRocker:Fromforefootcontact,
conHnuedHbialprogression,passiveankleDF
duetomomentum,weightprogressiontoMT
heads
–  Kneestabilityinmid-stancecontrolledbygastrocsoleuscomplex!
•  ForefootRocker:heelrise,toeextension
14
7
Nechama Karman:
Karman [email protected]
2/9/17
HeelRocker
•  Heelstrike(neutralDF)tofoot-flat(10°DF)
•  Eccentriccontrol–preHbialmuscles
15
AnkleRocker
•  Anklein10°PFinloadingresponse
•  To5°ofDF
•  FacilitatesforwardprogressionofCOMover
BOS
16
8
Nechama Karman:
Karman [email protected]
2/9/17
ForefootRocker
•  5°-10°DF
•  ProgressionofCOMbeyondBOS
17
FactorsaffecHnggaitinCorHcal
Injury
•  Weakness
–  InadequateforceproducHon
•  AbnormaljointposiHon,kinemaHcsorROM
–  AffectsleverarmfuncHon
•  Musclehypoextensibility
–  StaHc
–  Dynamic
•  Excessivemuscleco-contracCon
•  Posture/posturalreacHons
9
Nechama Karman:
Karman [email protected]
2/9/17
GaitParameters
•  UsuallymeasuredatthespaHo-temporal
OR
•  Jointlevel
NOT
•  AtMusclelevel
19
SpasHcity
•  Avelocity-dependentincreaseinmuscletone,
resulHngfromhyperexcitabilityofthestretch
reflex. (Lance)
–  Tone:Passive
–  SpasHcity:VelocityDependent
•  Clinicallymeasuredwithpassivetests:MAS,
Tardieu
•  ExpressionofspasHcityduringdynamictasks
maydifferfromthatduringpassivetestsin
physicalexaminaHon.
•  WalkingspeedßàSpasHcity
20
10
Nechama Karman:
Karman [email protected]
2/9/17
DynamicSpasHcity
•  AssesseddirectlyduringphysicalacHvity(gait)
•  StudytherelaHonship(coupling)betweenmusclestretch
velocityandmuscleacHvity.
–  Decreasedthreshold:velocityatwhichmuscleacHvityis
evoked.
–  Increasedgain:changeinmuscleacHvityrelaHvetochange
instretch.
•  DifferentexpressionofspasHcityin:
–  Gait
–  Phasesofgait
–  Betweenmuscles
•  Meaure:calculateemg-velocityraHo
(peakemg:peakstretchvelocity)
21
DynamicSpasHcity
•  Reducedstretch-velocityinspasHcmuscles
maybe:
–  directresultsofspasHcity,or
–  compensaHonstrategytopreventexcessive
spasHcity events. •  RFàsHff-kneegait
•  HSàcrouchgait
22
11
Nechama Karman:
Karman [email protected]
2/9/17
SoleusH-reflex-monosynapHc
•  ElicitedwithHbialnervesHmulaHon
–  Bypassmusclespindles
•  SoleuscontracHon
•  InNORMALgait:generalreflexdepression
–  Modulatedthroughoutgaitcycle
–  Maximuminstancephase
–  Suppressedduringswing
•  Developmental:6-13yrs(ampdecreasesingait)
–  rhythm@6yrs,
–  depressionfully@13yrs.
•  Instanding/sivng:noreflexdepression
23
H-ReflexTrainability/PlasHcity
•  Task-specificfuncHonaladaptaHon(ofCNS):
–  Balancetraining
–  Cycling(single16minsessioneffectslast48hrs)
–  Co-contracHontraining
•  HMraHosmallerduringmid-stanceandmid-swingduringTM
walkingwithBWSvsOG
•  Persistenceindicatespre-synapHcmechanism-likely
inhibiHonofsoleus1aafferents(CNSmodulaHon)
•  LTleadstorepeHHvestretch-shorteningofsoleusmuscle,
causingrepeHHvefiringofmusclespindles,inducingreflex
change.
24
12
Nechama Karman:
Karman [email protected]
2/9/17
PathologicGait
•  Paraplegia:(emg)
–  lessdynamicacHvaHonpaaerninsoleus
–  InappropriateHbialisant.acHvaHon
–  WithTMtraining:amplitudeofsoleusemgin
stanceincreases,Hbantdecreases (Dietz,1995)
•  Adults(spasHcity):severedisturbanceof
modulaHonofshort-latencyreflexes
25
Co-ContracHon
•  ThesimultaneousacHvaHonofagonist&
antagonistmusclegroupscrossingthesame
jointandacHnginthesameplane
•  TrendsinCo-ContracHon(Damiano,1993),
reviewarHcle:
–  Developmental
–  Motorcontrol
–  Pathological
13
Nechama Karman:
Karman [email protected]
2/9/17
ClinicalImplicaHons
•  Co-contracHonisatypicalpaaernforchildren&
adultsinournatural&funcHonalmovements
•  Excessiveco-contracHonexists&isaproblemfor
children&adultswithCNSimpairments
•  RepeHHveacHviHes,whichrequirereciprocal
inhibiHonseemthemostlikelymechanismto
decreaseexcessiveco-contracHon
•  Many(100 s-1000 s)repeHHveacHviHesmaybe
necessarytoimpactexcessiveco-contracHon
TheBoaomLine
WhatWeKnow
Task-specific training programs (including BWSTT) improve walking
function, and have been associated with increases in strength, endurance
and walking speed. Self-selected walking speed increased significantly and
similarly after each of the 3 BWSTT interventions in the STEPS trial, but not
after the cycle-UE intervention. NewInformaCon
Participants with high-response to BWSTT intervention displayed greater
increases in terminal stance hip extension angle and hip flexion power after
intervention, and greater intensity of soleus muscle EMG activity during
walking.
WhatThisMeanstoYou
Changes in both hip and ankle biomechanics
during late stance are
associated with greater increases in gait
speed, and are likely due to neural
adaptation rather than strength gains for most muscle groups. Emphasis
on hip extension in late stance during BWSTT may facilitate these specific
components of walking mechanics. 14
Nechama Karman:
Karman [email protected]
2/9/17
PhasesofGait
29
30
15
Nechama Karman:
Karman [email protected]
2/9/17
31
TheBoaomLine
WhatWeKnow
BWSTT has been shown to be effective in improving post-stroke hemiparetic
walking ability, with most improvements in walking speed maintained 3-6
months following completion of training. Hemiparetic subjects with asymmetric
step lengths have lower self-selected walking speed than those with symmetric
step lengths. Post-training gains in walking speed are retained at follow-up. NewInformaCon
Subjects who had symmetric paretic and non-paretic step lengths post-training
and subjects who had higher daily step activity at the end of training tended to
continue to increase walking speed following rehabilitation. There was no
relationship between post-training self-selected over-ground walking speed, hip
flexor and ankle plantar flexor moments, or AP GRFs and increased speed at
follow-up.
WhatThisMeanstoYou
A relationship exists between step length
asymmetry and changes in speed
following training. The long-term effectiveness of rehabilitation training cannot
be determined by changes in self-selected walking speed at the end of training.
Motor control deficits that lead to persistent asymmetry and low daily step
activity at the end of rehab interventions are associated with poorer outcomes.
16
Nechama Karman:
Karman [email protected]
2/9/17
Outcomes
PSRwasnegaHvelycorrelatedwithSpeedRaHo
PPwasunrelatedtoSpeedRaHo
Post-trainingSSOGWSwasunrelatedtoSpeedRaHo
DailystepacHvitywasposiHvelyrelatedtoSpeedRaHo
1/3ofsubjectsdidnotachievemeaningfulchangeinWS
frompretopost-treatment:Halfofthese
demonstratedimprovementsinSSWSatfollow-up(SR
=.96-1.30).
•  PareCc&non-pareCc…
– limbjointmomentimpulsesduringlateSLS/pre-swing
– APGRFduringlateSLSorpre-swing
…werenotrelatedtoSR
33
• 
• 
• 
• 
• 
Conclusions
•  Speedchangesbetweenpost-trainingandfollow-up
wereunrelatedtowhetherornotasubjecthad
aaainedaclinicallymeaningfulincreaseinself
selectedwalkingspeed(SSWS)frompre-toposttraining…
•  andwasunrelatedtotheirpost-trainingwalking
speed.
•  Indica.ngthatachievingclinicallymeaningful
changesinSSWSfrompre-topost-treatmentwas
notnecessarytoimprovewalkingspeedatfollow
up.
34
17
Nechama Karman:
Karman [email protected]
2/9/17
KinemaHcsOutcomes:Symmetry
(McCain,2008)
35
PhasesofGait
TOE OFF
36
18
Nechama Karman:
Karman [email protected]
2/9/17
MuscleFuncHons-
NormalGaitCycle
37
MatchingtheintervenHontotheproblem
Ankleandfoot
Impactupthechain
Puvngitalltogether
FuncHonwithinthegaitcycle
Capturingtheessence
Outcomesmeasurement,interpretaHonandreporHng
SPECIFICJOINTSANDTIMING
ISSUES
38
19
Nechama Karman:
Karman [email protected]
2/9/17
Ankle Problems •  Inadequateflexibilityofcalfmuscles(speeddependent?)
–  Medialborder toe-off • 
• 
• 
• 
InadequateacHvaHonofdorsiflexors
Powerdevelopment(slowforcegeneraHon)
Ontoolong (Hmingoffiring),co-contracHon
Concentric-only(orisometric)strategies(no
eccentricmechanisms)
NORMAL SUBJECT
Level Ground Ambulation
R AT
L AT
R Quad
Level Ground Ambulation
with Postural Support
L Quad
Treadmill Ambulation
with Postural Support
20
Nechama Karman:
Karman [email protected]
2/9/17
STROKE SUBJECT
Level Ground
Ambulation with
Assistive Device
Sound AT
Involved AT
Sound Quad
Level Ground
Ambulation with
Postural Support
Involved Quad
Treadmill Ambulation
with Postural Support
SoleusH-Reflex&CalfMuscle
SpasHcity
•  ModulaHonduringswinginmaturegait
•  NotsuppressedwhenspasHcityispresent
•  SuppressionduringswingfollowingTM
training
21
Nechama Karman:
Karman [email protected]
2/9/17
AFOs:HelporHindrance?
•  FixedanklemayinterferewithiniHaHonof
swing
–  InabilitytoDFankle,extendhalluxduringlate
stancewhenkneeisflexed
–  Trailinglimbpromoteskneeflexion
•  Roleoffirstrayingait
•  GRFs
AFOWhip 44
22
Nechama Karman:
Karman [email protected]
2/9/17
AFOWhip 45
GaitBiomechanics:Knee
•  Contact:
–  Flexed<5°atheelstrike
–  Flexesto18°(cushioning)
•  Mid-stance:Extendsfrom18°flexedtonearfullextension
•  Propulsion:Rapidlyflexesaierheelliito37°
flexedattoe-off
•  Swing:FlexionconHnues
–  peakinginthefirst50%ofswingphase(clearance)
–  thenextendsunHlheelstrike
46
23
Nechama Karman:
Karman [email protected]
2/9/17
MuscleFuncHons:Gait
•  SwingPhase:OpenKineHcChain
–  EarlySwing:acceleraHon
•  Hipflexors
•  Tibialisanterior
–  LateSwing:addiHonofdecellera;on
•  Hipflexors
•  Kneeext
•  DF(allintrinsic&extrinsic)
•  HS(decellerates)
47
MuscleFuncHons:Gait
•  StancePhase:ClosedKineHcChain
–  Heel-strike:
•  HSoff,quadson
•  hipext(g.med,max)
•  kneeflex(ecccontrol,quads)
•  ankle/foot(antHb,toeextensors-ecccontrol)
–  Earlymid-stance:
•  gmed(stab),
•  quadsoff(passiveext)
•  ankleDF(eccentrictricepssurae)
–  Latemid-stance:
•  PeakgastrocnemiusacHvity
•  FHL(stabilizedfootagainstGRFs.)
–  Toe-off:anteriorHbialis
48
24
Nechama Karman:
Karman [email protected]
2/9/17
Psoasvs.RectusFemoris
•  SelecHvemotorcontrol
•  Useofshortvs.longmuscletoflexhip…
Jointmechanics-knee
•  RelaHonshipbetweencenterofmassandaxis
ofrotaHonoftheknee
•  GRFseffectonkneeintrailinglimbposturevs.
prematureiniHaHonofswing
•  SaggitalplanemoHonvs.compensaHonin
otherplanes
–  Roleofpelviccontrolinfrontalplane(bungees)
–  RoleoffootposiHon
25
Nechama Karman:
Karman [email protected]
2/9/17
PracHcalconsideraHonsintheclinicalsevng
Methods,BarrierstoimplementaHon
Whattolookfor
MOVEMENTANALYSIS
Whatisa“meaningfulchange”
ingait?
• 
• 
• 
• 
Improvedsymmetry?
Normalizedcadence?
Increasedstridelength?
Increasedenergyefficiency
26
Nechama Karman:
Karman [email protected]
2/9/17
WhyBother?
SelecHonofappropriateintervenHons
Goalsevng
EvaluaHonofintervenHons/programs
CorrelaHonofimpairmentstofuncHonal
limitaHons
•  JusHficaHonofintervenHons/
recommendaHons
• 
• 
• 
• 
KinemaHcs
•  RelaHonshipofbodysegmentsto:
–  Eachother
–  Environment
•  Whatishappeningduringthegaitcycle
•  LEjointsegments
–  Pelvis
–  Hips/thighs
–  Knees/shanks
–  Ankles/feet
•  Jointangles:3dimensions–sagiaal,frontal,
transverse
27
Nechama Karman:
Karman [email protected]
2/9/17
KineHcs
•  Forces,moments,energy,poweraroundthe
joints(associatedwithkinemaHcs).
•  WHYaparHcularjointmoHonisoccuring
•  GroundreacHonforces(GRFs)
–  Muscular
–  GravitaHonal
–  InerHal
•  GRFsandkinemaHcsusedtocalculate
momentsandpowers…
DynamicsEMG
•  DemonstratesmuscleacHvityduringgait
–  On/offperiods,co-contracHon
–  NOTdiagnosHc(cannotgiveforceorstrength
measurement)
•  sEMG:RF,VL,MedialHS,Ant.Tib,peroneals,
medialgastroc
•  Fine-wireEMG:Post.Tib.
28
Nechama Karman:
Karman [email protected]
2/9/17
SpaHotemporalParameters
•  Stride:iniHalcontact,toiniHalcontactofsame
foot.
•  Step:iniHalcontact,toiniHalcontactof
oppositefoot
–  namedfortheleadingfoot
•  Walkingspeed(m/sec)
•  Cadence(steps/min)
•  Step/stridelength:measuredinlineof
progression(x-axis)
SpaHotemporalParameters
• 
• 
• 
• 
StepHme
DoublelimbsupportHme
SinglelimbsupportHme
SwingHme
29
Nechama Karman:
Karman [email protected]
2/9/17
ObservaHonal(video)gaitanalysis
• 
• 
• 
• 
Clearviewofgait
With/withoutorthoses
With/withoutfootwear
AssisHvedevices
PhysicalMotorExaminaHon(PT)
• 
• 
• 
• 
• 
ROM
MuscleLength
SpasHcity(MAS,Tardieu)
Musclestrength,selecHvity
Anthropometrics
30
Nechama Karman:
Karman [email protected]
2/9/17
SelfSelectedSpeed
For any individual, given their set of unique “resources”
Self-selected (comfortable) walking speed…
§  Is most energy efficient
§  minimizes metabolic cost per unit distance walked
Ability to increase walking speed…
§  index of “functional reserve”
§  allows individual to better meet demands of activity and
environment
IntervenHonStrategies
31
Nechama Karman:
Karman [email protected]
REFERENCES (NECHAMA KARMAN)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
Adolph KE, Cole WG, Komati M, Garciaguirre JS, Badaly D, Lingeman JM, Chan GL, Slotsky RB.
(2012). How do you learn to walk? Thousands of steps and dozens of falls per day. Psychol Sci
1;23(11):1387-94.
Blanpied P, Levins JA, Murphy E. (1995) The effects of different stretch velocities on average force of
the shortening phase in the stretch-shorten cycle. JOSPT. 21(6):345-53.
Cowan, MM, Stilling, DS, Naumann, S, Colborne, GR. (1998). Quantification of agonist muscle coactivation in children with spastic diplegia. Clin Anat. 11(5):314-9.
Damiano DL, Moreau N. (2008). Muscle thickness reflects activity in CP but how well does it represent
strength? Dev Med Child Neurol 50(2):88.
Damiano, DL, Martellotta, TL, Sullivan, DJ, Granata, KP, Abel, MF. (2000). Muscle force production and
functional performance in spastic cerebral palsy: relationship of co-contraction. Arch Phys Med Rehabil.
81:895-900.
Damiano, DL, Martellotta, TL, Quinlivan, JM, Abel, MF. (2001). Deficits in eccentric versus concentric
torque in children with spastic cerebral palsy. Med Sci Sport Exerc. 33:117-22.
Hall AL, Bowden MG, Kautz SA, Neptune RR. (2012). Biomechanical variables related to walking
performance 6-months post-stroke rehabilitation. Clin Biomech 27(10):1017-22.
Hodapp, M, Vry, J, Mall, V, Faist, M (2009). Changes in soleus H-reflex modulation after treadmill
training in children with cerebral palsy. Brain 132;37-44.
Ikeda, AJ, Abel, MF, Granata, KP, Damiano, DL. (1998). Quantification of cocontraction in spastic
cerebral palsy. Electromyor Clin Neurophysiol. 38:497-504.
Kaplan, SL. (1995). Cycling patterns in children with and without cerebral palsy. Dev Med Child Neurol.
37:620-30.
Massery M, Hagins M, Stafford R, Moerchen V, Hodges PW. Effect of airway control by glottal structures
on postural stability. J Appl Physiol (2013). Aug 15 2013;115(4):483-490.
Mattern-Baxter, K, Bellamy, S, Mansoor JK. (2009). Effects of Intensive Locomotor Treadmill Training
on Young Children with Cerebral Palsy. Pediatr Phys Th 21:308-19.
McCain, KJ, Pollo,FE, Baum, BS, Coleman, SC, Baker, S, Smith, PS. (2008). Locomotor treadmill training
with partial body-weight support before overground gait in adults with acute stroke: a pilot study. Arch
Phys Med Rehabil, 89(4):684-91.
McCain KJ, Smith, PA, Polo FE, Coleman SC, Baker S. (2011). Excellent outcomes for adults who
experienced early standardized treadmill training during acute phase of recovery from stroke: A case series.
Top Stroke Rehab. 18(4):428-36.
Moreau NG, Knight H, Olson MW. (2016) A potential mechanism by which torque is preserved in cerebral
palsy during fatiguing contractions of the knee extensors. Muscle Nerve 52(2):297-303.
Moreau NG, Holthaus K, Marlow N. (2013). Differentail adaptations of muscle architecture to highvelocity versus traditional strength training in cerebral palsy. Neurorehabil Neural Repair 27(4):325-34.
Moreau NG, Falvo MJ, Damiano DL. (2012). Rapid force generation is impaired in cerebral palsy and is
related to decreased muscle size and functional mobility. Gait Posture 35(1):154-8.
Mulroy SJ, Klassen T, Gronley JK, Eberly VJ, Brown, DA and Sullivan, KJ (2010). Gait parameters
associated with responsiveness to treadmill training with body weight support after stroke: An exploratory
study. Physical Therapy 90(2)209-223.
O’Dwyer, N, Nielson, P, Nash, J. (1994). Reduction of spasticity in cerebral palsy using feedback of the
tonic stretch reflex: a controlled study. Dev Med Child Neurol. 36(9):770-86.
Olney, SJ (1985). Quantitative evaluation of cocontraction of knee and ankle muscles in normal walking.
In Winter, DA, Norman, RW, Wells, RP, Hayes, KC, Patla, AE (Eds) Biomechanics IX-A Champain, IL:
Human Kinetics.
Perry J, Burnfield JM. (2010). Gait Analysis: Normal and Pathological Function. New Jersey: Slack
Incoporated.
Phadke, CP, Wu, SS, Thompson FJ, Behrmann AL. (2007) Comparison of soleus H-reflex modulation after
incomplete spinal cord injury in 2 walking evironments: treadmill with body weight support and
overground. Arch Phys Med Rehabil. 88:1606-13.
Schmid, A, Duncan, PW, Studenski, S et. al. Improvements in speed-based gait classification are
meaningful. Stroke, 2007; 38:2096-100.
Nechama Karman:
Karman [email protected]
24. Sutherland DH (2005). The evolution of clinical gait analysis part III – kinetics and energy assessment.
Gait Posture 21(4):447-61
25. Staes, F.F., et al., Physical therapy as a means to optimize posture and voice parameters in student classical
singers: a case report. J Voice, 2011. 25(3): p. e91-101.
26. Sutherland DH, Olshen R, Biden E, Wyatt M. (1988) The Development of Mature Walking in Clinics in
Developmental Medicine 104:178-182. Cambridge University Press (Mac Keith Press);London.
27. Trueblood, PR. (2001). Partial body weight treadmill training in persons with chronic stroke.
Neurorehabilitation 16: 141-153.
28. Unnithan, VB. Dowling, JJ, Frost, G, Volpe, AB, Bar-Or, O. (1996) Co-contraction and phasic activity
during gait in children with cerebral palsy. Electromyogr Clin Neurophysiol. 36:487-94.
29. Yang, JF, Stein, RB, James, KB. (1991). Contribution of peripheral afferents to the activation of the soleus
muscle during walking in humans. Exp Brain Res. 87:443-52
30. van der Krogt, MM, Doorenbosch, AM, Becher, JG, Harlarr, J. (2010). Dynamic spasticity of plantar flexor
muscles in cerebral palsy gait. J Rehabil Med. 42:656-663.
31. van der Krogt, MM, Doorenbosch, AM, Becher, JG, Harlarr, J. Caroline (2009). Walking speed modifies
spasticity effects in gastrocnemius and soleus in cerebral palsy gait. Clinical Biomechanics 24:422-428.
(1592-1606).
32. van der Krogt, MM, Doorenbosch, AM, Harlarr, J. (2009)The effect of walking speed on hamstrings
length and lengthening velocity in children with spastic cerebral palsy. Gait & Posture, 29:4 (640-44).
Nechama Karman:
Karman [email protected]