Corrective Movement Strategy for Improving Gait, Part II: Application

Co-author: Steven Schmoldt, ACE-CPT, I.M.S

The corrective strategy presented here is designed specifically to help personal training clients improve their mechanics and achieve more ideal lower extremity alignment that is necessary through the loading and mid-stance phases. Recall that in Part I, we introduced two of the biggest problems that clients experience during the gait cycle: deceleration and loading. The corrective strategy covered in Part II is an effective way to progress a client from beginning (Level 1) to the most advanced (Level 2) patterns while improving their ability to decelerate, stabilize, and then accelerate through the gait cycle.

For many clients, improving their foot control, stabilization of their thoracopelvic canister, and gluteal function through the modified side bridge and squat patterns will be all that is required to improve their gait. Clients that want and/or need to perform at a higher level must progress through the Level 2 advanced patterns to perform at a level required for higher-demanding activities such as sports. Both Level 1 and 2 patterns will follow the natural order of exercise progressions – fundamental to complex and bilateral to split to unilateral stance. All the mechanics of each progression will remain exactly the same; the only thing that changes is the pattern’s level of complexity.

Principles Versus Methods

When discussing corrective strategies, it is important to differentiate between principles and methods, as this is a common misunderstanding that leads to non-constructive debate among experts. Principles are universal laws, meaning that they apply to all clients regardless of age, gender, skill level, or specific goals. On the other hand, methods vary greatly and may or may not apply to all individuals given each person's unique challenges, skill level, and functional goals. Pilates, kettlebell training, and functional training are examples of methods, not principles. The principles of the corrective strategy that follows are based upon the three fundamental principles of the Integrated Movement System™: respiration, stabilization, and integration (Osar, 2010).

Respiration is the driving force underlying all movement and stabilization. In order of priority, proper respiration should be placed at the top of the list over all motor function and must be normalized prior to adding advanced patterns or strategies (Liebenson, 2007). Specifically, diaphragmatic breathing must be performed by establishing a “canister effect” or ensuring the lower aspect of the ribcage aligns over the pelvis. When this connection is established, diaphragmatic breathing can be optimized and makes it possible to activate the deep stabilization system (diaphragm, transversus abdominus, pelvic floor, and psoas) as opposed to over-relying on the superficial muscles (Kolar, 2009).

Joint centration is achieving optimal axis of rotation so that the segments of the kinetic chain move efficiently. Centration requires both stabilization of the approximating segments as well as the ability to dissociate or move the segments interdependently while under neuromuscular control. The lack of joint centration is the leading cause of movement dysfunction and compensatory movement patterns.

Once the client understands how to breathe and centrate the joints, he or she must be taught how to integrate these components into fundamental movement patterns: pushing, pulling, squatting, lunging, rotation, and gait. In some isolated cases, merely releasing, activating or utilizing an alternate neuromuscular technique can restore functional movements such as gait and no further re-education is needed. This generally is the person who claims “all I did is ‘XYZ’ technique and I never had a problem again.” Unfortunately, this client is atypical; most will require some level of neuromuscular re-education and a strategy for incorporating both respiration and centration into their fundamental movement patterns.

Corrective Strategy

If the client demonstrated any dysfunction in the assessments, the first thing to do is to improve any dysfunctional components of each test. For example, if poor respiratory patterns, rib cage mobility, and stabilization of the trunk over the pelvis were present, focus first on improving trunk mobility, diaphragmatic respiration, and core activation. Respiration and trunk stabilization must be improved prior to other patterns because if respiration is dysfunctional, all other movement patterns will be dysfunctional as well. If the client lacked adequate ankle and/or hip ranges of motion, focus on soft tissue release and/or activation strategies to improve their ranges. If the client displays poor stability in single-leg stance even after the corrections just listed, progress to the patterns below.

Level 1 — Primary Patterns

The basic goal of the Level 1 primary patterns is to ensure optimal alignment and loading mechanics through the kinetic chain. The primary patterns include improving respiration, setting the foot tripod, and establishing optimal gluteal function through the modified side bridge and squat patterns. Each pattern shown includes step-by-step directions for your clients

Improving Respiration

Respiration and coordination with an optimal core stabilization strategy is the first component that should be improved. Without the ability to stabilize the trunk over the pelvis as well as the ability to breathe diaphragmatically, it will be impossible to fully improve the other components. For a thorough description of optimizing respiratory and coordinating it with trunk stabilization, you can review the PTontheNet articles Assessing the Fundamentals: The Thoracic Connection, Part 1 and Assessing the Fundamentals: The Thoracic Connection, Part 2.

Setting the Foot Tripod

Once respiration has been improved and coordinated with an optimal deep stabilization strategy, show the client how to improve stabilization of the foot. This is an important step, as it will set the base for the loading response phase of gait. Recall that the loading response is one of the most problematic phases of gait for most clients, so it is important to improve each component that contributes to this phase. Setting the foot tripod (see image to the right) also encourages stretching of the intrinsic foot musculature that encourages the reflexive activation of the entire extensor chain during the loading response (Michaud, 1997).

1. Take a parallel stance with both feet approximately shoulder width apart. (Unless otherwise indicated, the client is in bare feet in order to better see and feel the feet.)
2. Place digit 1 (big toe) on the ground and, without lifting digit 1 from the floor, externally rotate the hips until digit 5 (small toe) is on the floor. (This sets the foot tripod and activates the deep gluteus maximus.)

For some clients, this is all they will initially work on while other clients will require soft tissue release and/or activation to help with this set-up. However, most clients can improve this function with some awareness and focus.

Bridge

The bridge pattern will help develop the gluteal complex in the dual role of hip extension and unilateral stabilization of the pelvis.

1. Lie on the floor with the arms approximately 45° from the body and the feet, knees and hips aligned.
2. Activate the core and lift up from the hips, maintaining alignment of the lower extremities as well as in the trunk, pelvis, and lower extremities.
3. Hold this position for a count of 5 and repeat 15 times for 3 sets.

Once the client can maintain this alignment without any compensation, progress to single-leg bridges:

1. Assume the same set-up as the basic bridge, except now the legs are together.
2. Flex one hip, knee, and ankle and hold it in this position throughout the pattern.
3. 3 sets of 10 reps. Work up to 3 sets of 15 reps.

In both versions, there should be a smooth concentric as well as a smooth eccentric phase of the movement.

Modified Side Bridge

The modified side bridge pattern, along with the advanced version, are modified positions from Kolar’s Dynamic Neuromuscular Stabilization system. They have been included to specifically address hip centration issues as well as improve gluteal control of the lower extremity.

1. Lie on one side, with the shoulder and elbow flexed to 90° each, and the hip flexed to about 80-90°.
2. Activate the core and simultaneously push the elbow and knee down into the floor, holding for 10 seconds.
3. 5-10 reps then repeat on the other side for 2 sets. (If one side of instability was noted during the single leg stance test, perform this for an extra set or two on the unstable side.)

Squat

The squat is the final pattern of Level 1 and should coordinate the components of the first three movements – proper alignment of the thorax over the pelvis (Lee, 2008) and diaphragmatic breathing, establishing and maintaining the foot tripod, and using the gluteals to stabilize the pelvis and lower extremity.

1. To monitor control of the thoracopelvic canister, places one hand on the sternum and one hand on the abdomen – the distance between the hands should remain consistent throughout the pattern.
2. Take a shoulder-width stance, align the trunk over the pelvis, activate the core, and set the foot tripod.
3. Descend into the squat as far as possible while maintaining the aforementioned alignment, then lift through the feet, adductors, and gluteals to ascend back to the starting position.
4. 2-3 sets of 20 reps.

Squat

Level 2 — Advanced Patterns

Once the primary patterns are mastered, the client should already be noticing some positive changes in both posture as well as gait pattern. From the fundamental Level 1 patterns, progress the client to more advanced patterns, including the marching bridge, the modified dead bug, advanced modified side bridge, and the split squat.

Marching Bridge

The marching bridge pattern is designed to help improve transition of weight from one leg to the other working on both control and awareness (Osar, 2006).

1. Assume the bridge position with legs approximately six inches apart.
2. Raise the pelvis to the point where the trunk, pelvis and thigh are in alignment with each other, then alternate lifting one leg at a time while maintaining a level pelvis. (There should be no loss of core control, sagittal plane loss of height (pelvis drops), frontal plane (pelvis shift laterally), or transverse plane (pelvis rotates) loss of position.)
3. 5 sets of 5 reps per leg. Work up to 3 sets of 10 reps per leg.

Modified Dead Bug

The modified dead bug is the next core progression and is one of the best patterns for stabilizing the all-important thoracolumbar (TL) junction. Due the intimate myofascial connections between the diaphragm, psoas major/minor, transversus abdominus, quadratus lumborum, and lattissimus dorsi, the TL junction is key to stabilizing the trunk, pelvis, and even the lower extremities. Loss of TL junction stabilization is responsible for many common movement dysfunctions including but not limited to hip flexor tightness, low back pain, and sacroiliac joint dysfunction. Improving stabilization of the TL junction has anecdotally improved many chronic movement dysfunctions involving loss of TL junction stabilization.

1. Lie with the head next to the wall and palms up against the wall.
2. Activate the core and flex the hips, knees, and ankles to get weight onto the TL junction.
3. Hold this position and focuses on breathing into the low back and elongating the spine (arrow) – this is key to this pattern. The client must be able to stabilize the TL junction, breathe utilizing the diaphragm, while elongating the spine.
4. 10 reps of 5 deep breaths per rep of this isometric position.

Advanced Modified Bridge

1. Assume the position for the basic bridge, except now use the forearm for support.
2. Activate the core and lift up, using the elbow and knee for support. The benefit of this version over the more traditional side bridge is that the weight is supported through the knee, which forces the gluteals to work in frontal plane stabilization.
3. Hold for a count of 5 seconds and then slowly lower to the floor, repeating for 2 sets of 5 reps. Again, ask the client to perform an additional set or two if instability was more evident on one side during the single leg stance assessment. Increase to 5 sets of 5 repetitions as optimal stabilization is achieved.

Split Squat

The split squat challenges the client’s base of support and is closer to the unilateral stance that will be required during gait. The same concepts applies to this pattern as in the earlier versions. The client should maintain the foot tripod, core activation, and diaphragmatic breathing.

• 3 sets of 15 reps per leg before moving on to additional Level 2 progressions.

Additional Level 2 Progressions

Stepping Lunge

Once the client masters the split squat pattern, progress to the stepping lunge. The stepping lunge teaches the client how to decelerate forward momentum while focusing on the mechanics described above.

• 3 sets of 10 reps per leg before moving on to the next progression.

TRX-Supported Split Squat to Single Leg Stance

This move helps connect the lattissimus dorsi and contralateral gluteus maximus (posterior oblique chain) while simultaneously stabilizing the TL junction. A yoga strap, exercise tubing, or doorframe can substitute for a TRX apparatus.

• 10 reps per leg for 2 sets.

TRX-supported split squat to single leg stance

Reverse Lunge to Single Leg Stance to Forward Lunge

This final progression of the Level 2 patterns puts together all the mechanics of the previous progressions and allows the client to work on both deceleration and acceleration of their center of gravity, and move toward single leg support.

1. Step back into a reverse lunge focusing on deceleration and alignment of the lower extremity.
2. Step forward to single leg support and then forward to a forward lunge.
3. 3 sets of 5 repetitions per leg and repeat on the other side. Progress to 3 sets of 10 repetitions.

Conclusion

Gait is one of the fundamental movement patterns requiring a synchronized orchestration between the nervous, myofascial, and skeletal systems. While often overlooked in many strength and conditioning programs, it is important to improve your clients' gait patterns, as this is the cause of many of their movement impairments. Improving gait requires adherence to the principles of human movement – normalize respiration, achieve optimal joint centration, and integrate these components into fundamental movement patterns. By teaching clients to stabilize their thoracopelvic canister, set their foot tripod, and progress through the fundamental patterns of squatting, lunging, and stepping, they will experience a renewed sense of confidence in their gait pattern and movement towards achieving their functional goals.

References

1. Kolar, P., Holubcova, Z., Frank, C., Liebenson, C. & Kobesova, A. (2009). Exercise & the Athlete: Reflexive, Rudimentary & Fundamental Strategies. International Society of Clinical Rehabilitation Specialists, Course Handouts, Chicago, IL.
2. Kolar, P., Kobesova, A. & Holubcova, Z. (2009). Dynamic Neuromuscular Stabilization: A Developmental Kinesiology Approach. Rehabilitation Institute of Chicago, Course Handouts, Chicago, IL.
3. Lee, L.J. (2008). Discover the Sports Pelvis: The Role of the Pelvis in Recurrent Groin, Knee, and Hamstring Pain and Injury. The Mid-Atlantic Physical Therapy Associates, Course Handouts, Fairfax, VA.
4. Liebenson, C. (2007). Rehabilitation of the Spine: a Practitioner's Manual. 2nd Ed. Lippincott Williams & Wilkins, Philadelphia, PA.
5. Osar, E. (2006). Complete Hip and Lower Extremity Conditioning. Self-published. Chicago, IL.
6. Osar, E. (2010). The Integrated Movement Specialist™. Course Handouts. Chicago, IL.