3/27/17

1

C r i s t i a n a K . C o l l i n s , P T , P h D , C F M T , N C S

M a r c h 2 0 1 7

THE ROLE OF THE PELVIS IN GAIT

OBJECTIVES

•  Upon completion of the course the participant will be

able to:

•  explain the kinematics of the pelvis in gait

•  discuss the changes noted in gait as a result of pain, in particular,

low back pain

•  describe the PNF diagonal patterns of the pelvis

•  discuss the 3-dimensional role of the pelvis in gait

•  discuss how to address pelvic motion to optimize its role in gait and

decrease pain while improving function

2

3/27/17

2

NORMAL GAIT

4

Normal Gait

5

Normal Kinematics Temporal and Spatial Components of Gait

3/27/17

3

GAIT EVALUATION & ANALYSIS

6

EFFICIENT GAIT

7

3/27/17

4

EFFICIENT GAIT

8

Normal and Efficient… Are these the same?

DOES PAIN AFFECT GAIT?

10

3/27/17

5

DOES PAIN AFFECT GAIT?

•  Low Back Pain (LBP) & Gait:

•  Individuals with LBP tend to walk slower Keefe & Hill, 1985; Lamoth & Meijer, 2002; Spenkelink et al, 2002

•  Individuals with LBP have: • decreased hip extension range • decreased stride time • altered onset of firing of hip extensor muscles • altered onset of the firing of lumbar erector spindle muscles

Vogt, Pfeifer & Banzer, 2003

12

DOES PAIN AFFECT GAIT?

•  Individuals with LBP have compromised energy mechanisms Carvalho, Andrade & Peyre-Tartaruga, 2015

•  Patients with LBP have increased EMG activity in lumbar paraspinals during swing phase when these muscles are supposed to be silent. There is also an increase in EMG activity in the rectus abdominals

Arendt-Nielsen et al, 1995; Vogt et al, 2003; Lamoth et al, 2006

14

3/27/17

6

DOES PAIN AFFECT GAIT?

•  Sagittal plane coordination of the lower extremities, pelvis and trunk are affected by LBP – the patterns and variability of the coordination across these segments is altered by low back pain

Ebrahimi et al, 2017

•  In individuals with LBP, the pelvis-thorax coordination is less out of phase when walking at higher speeds (in normals, horizontal thorax and pelvis rotations are in phase at slower speeds but become anti-phase when walking at higher speeds) Muller, Ertelt & Blickhan, 2015

16

DOES PAIN AFFECT GAIT?

•  LBP reduces (or eliminates) the adaptation of trunk-pelvis coordination necessary with changes in gait speed. This is believed to affect gait stability. It is possible that the altered coordination and motor control occur as a result of an effort to stabilize the pelvis and spine and prevent unexpected perturbations Lamoth et al, 2006; Seay et al, 2011;

van den Hoorn et al, 2012

17

3/27/17

7

DOES PAIN AFFECT GAIT?

•  Patients with chronic LBP have less pelvis rotation and unchanged thorax rotation while walking and running on level and uneven ground Muller et al, 2015

•  Individuals with LBP show significantly less overall lumbar rotation Gombatto et al, 2015

19

So…

What does it all mean to us as PTs?

20

3/27/17

8

A question I want to answer…

What is the role of the pelvis in gait?

21

and…

What is the role of the pelvis in gait?

Can we affect gait, and therefore pain, through

neuromuscular re-education of the pelvis?

22

3/27/17

9

What is the role of the pelvis in gait?

24

“During each stride the pelvis moves asynchronously in all three directions. The site of action is the supporting hip joint. All the motion arcs are small, representing a continuum of postural change. Motion at the junctions of the pelvic bones and sacrum has not been noted during walking.”

Perry & Burnfield, 2nd ed, 2010.

What is the role of the pelvis in gait?

27

Pelvic Tilt (sagittal plane): 2.79° to 4°

Pelvic drop/list(frontal plane): 4° to 7.72°

Pelvic rotation (transverse plane): 10° to 10.4°

Simonsen, 2014; Vogt et al, 2002; Whittle & Levine, 1999; Taylor et al, 1996; Taylor et al, 1999; Thurston & Harris, 1983.

3/27/17

10

But…

WE DON’T WALK IN ONE DIMENSIONAL

PLANES!

28

PELVIS - PNF

• Anterior Elevation (AE)

• Posterior Depression (PD)

• Anterior Depression (AD)

• Posterior Elevation (PE)

29

3/27/17

11

PELVIS DURING GAIT

•  Heel strike

•  Loading Response to Mid-Stance to Terminal Stance

•  Pre-Swing (Toe-off)

•  Initial to Mid-Swing

•  Terminal Swing into HS

30

PELVIS DURING GAIT

•  Heel strike: pelvis AD

•  Loading Response to Mid-Stance to Terminal Stance: pelvis PD

•  Pre-Swing (Toe-off): relative pelvis PE (PE & AE)

•  Initial Swing to Mid-Swing : pelvis AE

•  Terminal Swing into HS: pelvis AD

3/27/17

12

PELVIS DURING GAIT

• Heel Strike:

pelvis anterior

depression

32

PELVIS DURING GAIT

•  Loading Response to Mid-stance to terminal stance: pelvis posterior depression

33

3/27/17

13

PELVIS DURING GAIT

• Pre-swing (Toe-off): relative pelvis PE

with possible co-contraction of PE & AE.

34

PELVIS DURING GAIT

•  Initial to mid-swing:

pelvis anterior elevation

35

3/27/17

14

PELVIS DURING GAIT

•  Terminal swing into HS:

pelvis anterior depression

36

PELVIS DURING GAIT

•  Heel strike: pelvis AD

•  Loading Response to Mid-stance to terminal stance: pelvis PD

•  Pre-swing (Toe-off): relative pelvis PE (PE & AE)

•  Initial Swing to Mid-swing : pelvis AE

•  Terminal Swing into HS: pelvis AD

3/27/17

15

RECIPROCITY DURING GAIT

39

•  Pelvis Anterior Elevation •  Scapula Posterior Depression

•  Pelvis Posterior Depression •  Scapula Anterior Elevation

Current study…

•  Phase 1: •  The role of the pelvis in gait – normal vs chronic LBP? •  Kinematics of gait – Zeno mat •  Motion of the pelvis – G-Walk sensor •  EMG activity – hip extensors (g.max) and hip abduction (g.med)

•  Phase 2: •  The effect of pelvic PNF patterns on gait and pain in

individuals with chronic LBP compared to a core stabilization program

42

3/27/17

16

GAIT OBSERVATION

•  Trunk walker: efficient gait

•  Movement of the extremities is initiated by the scapula and pelvis on a dynamically stable trunk. Proximal stability allows for efficient distal mobility

•  Pelvic walker:

•  movement of the pelvis occurs mostly on the frontal plane or the transverse plane

•  Hip walker:

•  movement of the limbs is driven by the hip

49

PNF INTERVENTION FOR PELVIS

•  PNF patterns: •  Pelvic & Scapula

patterns: •  Anterior elevation •  Posterior depression •  Anterior depression •  Posterior elevation

54

•  PNF techniques: •  Rhythmic Initiation •  Combination of

Isotonics •  Repeated Stretches •  Dynamic Reversals

3/27/17

17

Research Plans/Ideas…

•  Examination of the three dimensional role of the pelvis in gait: •  Video analysis, including accelerometers on the pelvis and EMG on trunk musculature

in: •  Children who have not had a traumatic incident and are pain free

•  Adults 20-50 yo who have no c/o LBP

•  Adults 20-50 yo who have chronic LBP

•  Evaluate role of pelvis on efficiency of gait in terms of temporal and spatial components of gait, COM displacement during ambulation, as well as cardio-pulmonary function.

•  Gait analysis of individuals with chronic LBP before and after PNF interventions aimed at re-establishing efficient pelvic function.

•  Role of the pelvis in gait in individuals with other diagnosis – MS & NM

•  Role of the pelvis in walking vs running

55

Questions…

57

3/27/17

18

References

•  Adler, S., Beckers, D., & Buck, M. (2008). PNF in Practice: an illustrated guide (3rd ed.). Germany: Springer. •  Barzilay, Y., Segal, G., Lotan, R., Regev, G., Beer, Y., Lonner, B. S., . . . Elbaz, A. (2016). Patients with chronic non-specific low back pain who reported reduction in pain and improvement in function also demonstrated an improvement in gait pattern. Eur Spine J,

25(9), 2761-2766. doi:10.1007/s00586-015-4004-0 •  Crosbie, J., de Faria Negrao Filho, R., Nascimento, D. P., & Ferreira, P. (2013). Coordination of spinal motion in the transverse and

frontal planes during walking in people with and without recurrent low back pain. Spine (Phila Pa 1976), 38(5), E286-292. doi:10.1097/BRS.0b013e318281de28 •  Devan, H., Hendrick, P., Ribeiro, D. C., Hale, L. A., & Carman, A. (2014). Asymmetrical movements of the lumbopelvic region: is this

a potential mechanism for low back pain in people with lower limb amputation? Med Hypotheses, 82(1), 77-85. doi:10.1016/j.mehy.2013.11.012

•  Ebrahimi, S., Kamali, F., Razeghi, M., & Haghpanah, S. A. (2017). Comparison of the trunk-pelvis and lower extremities sagittal plane inter-segmental coordination and variability during walking in persons with and without chronic low back pain. Hum Mov Sci, 52, 55-66. doi:10.1016/j.humov.2017.01.004

•  Gaffney, B. M., Murray, A. M., Christiansen, C. L., & Davidson, B. S. (2016). Identification of trunk and pelvis movement compensations in patients with transtibial amputation using angular momentum separation. Gait Posture, 45, 151-156. doi:10.1016/j.gaitpost.2016.01.015

•  Gombatto, S. P., Brock, T., DeLork, A., Jones, G., Madden, E., & Rinere, C. (2015). Lumbar spine kinematics during walking in people with and people without low back pain. Gait Posture, 42(4), 539-544. doi:10.1016/j.gaitpost.2015.08.010

•  Hodges, P. W., & Richardson, C. A. (1997). Relationship between limb movement speed and associated contraction of the trunk muscles. Ergonomics, 40(11), 1220-1230. doi:10.1080/001401397187469 •  Hoogenboom, B. J., & Voight, M. L. (2015). Rolling Revisited: Using Rolling to Assess and Treat Neuromuscular Control and

Coordination of the Core and Extremities of Athletes. Int J Sports Phys Ther, 10(6), 787-802. •  Johnson, G., & Johnson, V. S. (2016). Functional Gait. Clinical Course. Institute of Physical Art.

•  Perry, J., & Burnfield, J. (2010). Gait Analysis: normal and pathological function: Slack, Inc.

58

References

•  Russell Esposito, E., & Wilken, J. M. (2014). The relationship between pelvis-trunk coordination and low back pain in individuals with transfemoral amputations. Gait Posture, 40(4), 640-646. doi:10.1016/j.gaitpost.2014.07.019 •  Seay, J. F., Van Emmerik, R. E., & Hamill, J. (2011a). Influence of low back pain status on pelvis-trunk coordination during walking

and running. Spine (Phila Pa 1976), 36(16), E1070-1079. doi:10.1097/BRS.0b013e3182015f7c •  Seay, J. F., Van Emmerik, R. E., & Hamill, J. (2011b). Low back pain status affects pelvis-trunk coordination and variability during

walking and running. Clin Biomech (Bristol, Avon), 26(6), 572-578. doi:10.1016/j.clinbiomech.2010.11.012 •  Stokes, V. P., Andersson, C., & Forssberg, H. (1989). Rotational and translational movement features of the pelvis and thorax during adult human locomotion. J Biomech, 22(1), 43-50.

•  Sung, P. S. (2014). A kinematic analysis for shoulder and pelvis coordination during axial trunk rotation in subjects with and without recurrent low back pain. Gait Posture, 40(4), 493-498. doi:10.1016/j.gaitpost.2014.06.001

•  Taylor, N., Goldie, P., & Evans, O. (2004). Movements of the pelvis and lumbar spine during walking in people with acute low back pain. Physiother Res Int, 9(2), 74-84. •  Taylor, N. F., Goldie, P. A., & Evans, O. M. (1999). Angular movements of the pelvis and lumbar spine during self-selected and slow

walking speeds. Gait Posture, 9(2), 88-94. •  Thurston, A. J., & Harris, J. D. (1983). Normal kinematics of the lumbar spine and pelvis. Spine (Phila Pa 1976), 8(2), 199-205. •  Tojima, M., & Torii, S. (2016). Changes in lumbopelvic rhythm during trunk extension in adolescent soccer players. Gait Posture, 52,

72-75. doi:10.1016/j.gaitpost.2016.11.026 •  Vogt, L., Pfeifer, K., & Banzer, W. (2002). Comparison of angular lumbar spine and pelvis kinematics during treadmill and

overground locomotion. Clin Biomech (Bristol, Avon), 17(2), 162-165. •  Whittle, M. W., & Levine, D. (1999). Three-dimensional relationships between the movements of the pelvis and lumbar spine during normal gait. Human Movement Science, 18, 681-692.

•   

59