Arm swing asymmetry: It can be a huge window of education into your client.

Arm swing asymmetry: It can be a huge window of education into your client, if you can get past the dumb stuff we’ve all done (and believed) for decades.
I have beaten you down with arm swing principles over the past few years, sorry about that, but, the beating will continue because it is important to know what arm swing tells you, and what it does not tell you (hint hint for all those improperly coaching arm swing changes). We did an entire tele seminar on the Stage 1 principles of of arm swing (#218) on www.onlinece.com and www.chirocredit.com if you wish to take that archived lecture. Heck $19, how can you lose (see photo).  Arm swing is intimately dependent upon scapular stability, thoracic mobility, breathing, cervical spine function, pelvis stability and clearly ipsilateral and contralateral leg swing not to forget to mention spinal stability. The first signs of spine pain or instability and the counter rotation of the shoulder and pelvic girdles become more phasic, instead of their normal anti phasic nature (moving in opposite directions). This phasic nature reduces spinal shear loads.

Neurologic diseases in their early, middle and late phases can give us a clearer window into how the nervous system is tied together.
Arm swing asymmetry during gait may be a sensitive sign for early Parkinson’s disease.

Here is what this Plate et al study found :
-Arm swing amplitude as well as arm swing asymmetry varied considerably in the healthy subjects.
-Elderly subjects swung their arms more than younger participants. -Only the more demanding mental load caused a significant asymmetry
-In the patient group, asymmetry was considerably higher and even more enhanced by mental loads.
-Evaluation of arm swing asymmetry may be used as part of a test battery for early Parkinson’s disease.

Some facts you should consider:
Parkinson’s Disease will be well advanced before the first signs of motor compromise occurs. So early detection and suspicion should be acted upon early when possible. Reductions or changes in arm swing may be the first signs of neuralgic disease expression and progression. Dual tasking may bring out neurologic signs early, so talk to your clients or have them count backwards to distract the motor programs. Look for one sided arm swing impairment, and when present, be sure to examine all limbs, especially the lower limbs, for impaired function. After all, the arms are like balasts, they can help with postural stability simply by abducting or modifying their swing.  Arm swing changes can include:
– crossing over the body
– more forward sagittal swing and less posterior swing
– more posterior sagittal swing and less anterior swing
– shoulder abduction during swing (and with attributes of the prior two mentioned above)
– less swing with adduction stabilized with torso
– modified through accentuations or dampening of shoulder girdle rotation oscillations, thus less arm swing but more torso swing to protect the glenohumeral and other joints
– and others of course

Arm swing and arm swing symmetry matter. Don’t be a dunce and just train it out or tell your client to do things to change it before you identify the “why” behind it. If it were that simple Ivo and I would have long grown tails and begun eating more bananas. Or maybe we would have already moved to the islands by now. That was random wasn’t it. That’s what Jimmy Buffett said.

“Now he lives in the islands, fishes the pilin’s
And drinks his green label each day
He’s writing his memoirs and losing his hearing
But he don’t care what most people say.
Through eighty-six years of perpetual motion
If he likes you he’ll smile then he’ll say
Jimmy, some of it’s magic, some of it’s tragic
But I had a good life all the way.
And he went to Paris looking for answers
To questions that bother him so.”  -Jimmy Buffett

Hope this helps, now back to that rum.
-Shawn Allen

Gait Posture. 2015 Jan;41(1):13-8. doi: 10.1016/j.gaitpost.2014.07.011. Epub 2014 Aug 8.
Normative data for arm swing asymmetry: how (a)symmetrical are we?  Plate A1, Sedunko D2, Pelykh O3, Schlick C4, Ilmberger JR5, Bötzel K6.
http://www.ncbi.nlm.nih.gov/pubmed/25442669

Global body compensations in ACL deficient knees.

ALERT: Ok, this is big.
It is a huge comment on what the brain and reflexive patterns impart on posture and gait when perceived functional instability is present.
This study aimed to investigate the gait modification strategies of trunk over right stance phase in patients with right anterior cruciate ligament deficiency.
* Here is what you need to ABSOLUTLY keep in mind when you read it. The 3D capture it telling you what they are DOING to strategize, not what is WRONG or what needs CORRECTING (our mantra it seems, sorry to keep beating this concept to death). This again hits home what I have been preaching for quite some time, that arm swing (and you can translate that to trunk movements, thorax, head posture, breathing etc) should not be coached or corrected unless you are absolutely sure there are clean symmetrical lower limb biomechanics (yes, you can easily and correctly argue that you can concurrently work on all parts). IF there is something going awry in a lower limb, compensations will occur above, they have to occur. So be absolutely sure you are not making therapeutic interventions above without making therapeutic corrections below. If you are working on a shoulder/upper quarter problem and are not looking for drivers in the lower limbs or in gait, well … . . good luck making lasting effects. Other than breathing, it can be argued well that gait locomotion is our 2nd most engaged motor pattern that we have driven to subconscious levels , and compensations are abound (but not without a cost), so we can dual++ task.
If you want to dive deeper into this, search our blog and look for my articles on Anti-phasic gait. This is essentially what this study was looking at, and confirming, that there is a distortion in the NORMAL opposite phase movements (anti-phasic) of the “shoulder girdle” and “pelvic girdle” when something goes wrong in a lower limb.
– Dr. Allen

Findings from Shi et al when there was a chronic right ACL deficiency:
-trunk rotation with right shoulder trailing over the right stance phase was lower in all five motion patterns
– trunk posterior lean was higher from descending stairs to walking when the knee sagittal plane moment ended
– trunk lateral flexion to the left was higher when ascending stairs at the start of right knee coronal plane moment when descending stairs at the maximal knee coronal plane moment and when descending stairs at the end of the knee coronal plane moment
– trunk rotation with right shoulder forward was higher at the minimal knee transverse plane moment and when the knee transverse plane moment ended
– during walking, trunk rotation with right shoulder trailing was lower at other knee moments during other walking patterns

http://www.ncbi.nlm.nih.gov/pubmed/27131179

The diaphragm and chronic ankle instability.

I have been treating the global manifestations of unaddressed chronic ankle sprains for decades now. I am never unsurprised to find frontal plane hip weakness and dysfunction of the same side obliques , shoulder and spinal stabilizers. Here is one more piece of proof that unaddressed ankles are monster problems, slowly eroding the stability of the system.
But, shame on those who attempt to simplify this, just correcting the breathing and throwing some corrective spinal stability work at this problem. This approach will fail, repeatedly. At some point the ankle has to be addressed and the impaired supra spinal programming. Gait will have to be retrained as well, forget to do this and your efforts will be muted.
-Dr. Allen

“Previous investigations have identified impaired trunk and postural stability in individuals with chronic ankle instability (CAI). The diaphragm muscle contributes to trunk and postural stability by modulating the intra-abdominal pressure. A potential mechanism that could help to explain trunk and postural stability deficits may be related to altered diaphragm function due to supraspinal sensorimotor changes with CAI.”

Reference:

Diaphragm Contractility in Individuals with Chronic Ankle Instability.

Terada, Masafumi; Kosik, Kyle B.; McCann, Ryan S.; Gribble, Phillip A.  Medicine & Science in Sports & Exercise:

http://journals.lww.com/acsm-msse/Abstract/publishahead/Diaphragm_Contractility_in_Individuals_with.97497.aspx

Hip Biomechanics: Part 6 of 6, The Conclusion (for now)

A Piece of the Functional Puzzle: Hip Rotation

As we have already mentioned, stabilization of the hip is complicated in its own right, but when we ask it to participate in balanced single limb movement and stability in the frontal/coronal, sagittal and axial planes all at once, the delicate balancing act of of these components is sheer genius.

Through our collective clinical experiences it has become apparent over time that vertical and horizontal gravity dependent postural examination can open insight into a deeper functional disturbance in patients.  For example, an externally rotated right lower limb as evidenced by an accentuated external foot flare should initiate the thought process that there is either an anatomically short right limb (external rotation increases leg length), tight right posterior hip capsule, short gluteals or other posterior hip musculature (piriformis, obterators, gemelli), weak internal hip rotators, weak stabilizers of this internal hip rotation, or possibly an over-pronating right foot which shortens the limb and hence the need for the externally rotated and lengthened right limb (ie. failed compensattion).  What we mean by this last component is that there are really two basic types of presentations, those that are compensations to an underlying problem and those that are failed compensations. In consideration of all scenarios, our traditional thinking has directed us to believe we are dealing with a limb posture that has occurred to lengthen the limb in question.  However, perhaps the compensation is deeper in its root cause.  For example, the traditional thinking in alignment restoration of this postural deviation is to stretch the piriformis, glutes and iliopsoas and perform deep soft tissue work such as myofascial release methods, stripping, post-isometric release and mobilization or manipulation to the affected tissues and associated joints to ensure normal function.  These efforts are meant to restore the limbs rotational anomaly and hopefully the cause of the leg length compensation. However, many clinicians will attest to the fact that these methods are frequently unsuccessful or at least limited in their short or long term effectiveness towards complete symptom and postural deficit resolution.  Frequently our patients enter into the cyclical office visits several times a year to address symptoms associated with the root cause.  Thus, we must delve deeper into the source of the problem, perhaps those above methods are focused at resolving the neuroprotective compensation and not the lack of strength or stability of internal hip rotation.  This approach will require the therapist to investigate the open and closed kinetic chain functions of these external and internal hip rotators and look further and more deeply for the source.

In the open kinetic chain (swing phase of gait) the primary and secondary external rotators turn the lower limb outwards in relation to a fixed pelvis established by a sound core; this is late swing phase. This external rotation is, at this point, largely assistive in driving foot supination to gain a rigid foot lever to toe off from.  In the closed kinetic chain scenario, with the foot engaged with the ground, the activation of these same muscles will cause the same movement at the hip-pelvis interface but in this case the pelvis/torso will rotate.  For example, in observance of a closed chain right lower limb, upon activation of the glutes, piriformis and accessory external hip rotators the client’s pelvis and thus torso will rotate to the left (counterclockwise rotation) along the vertical body axis about the fixed right limb.  With this functional thinking we must now embrace the fact that our traditional perspectives of body function assessment in the frontal and sagittal planes must be largely discarded.  It is a rare occurrence that we move in a single plane of motion without any component of rotation.  This being accepted, we must return to our client’s left pelvis rotation and understand that torso rotation must occur in the opposite direction if gait is to be normal with proper arm swing and propulsion.  This rotation can occur from activation of not only component muscles at the hip-pelvis interval but also from the abdominal obliques, thoracic spine and rib cage.  Therefore, one could hypothesize that a client’s external rotation of the right lower limb in stance or gait might not be a primary problem with the piriformis, glutes or accessory muscles rather it could be a compensation for either a one sided over-active or  weak abdominal oblique system/sling/chain or abnormal thoracic rotation, or a combination of both.  Assessment of a patient’s passive and active torso and thoracic/rib rotation might open a window into one of a range-driven deficit or weakness/inhibition. Shoulder mobility assessment is going to be necessary as well because it can and will effect torso/rib cage mobility, arm swing is a huge predictor and indicator in faulty gait assessment and it is one frequently overlooked (type in “arm swing” into our blog SEARCH box and you will be excited to read the research on arm swing in gait). The practitioner must always embrace the thought that the client’s core might not only present as weak but to a higher level that of imbalanced, which is a combination of weakness, stretch weakness, strength, over-activation, inhibition and impaired movement patterns (including breathing).  This imbalance can come from such parameters as pain, handed dominance activities, lower limb dominance issues, occupational demands or others as discussed below.

What we continue to find as our clinical experiences expand is that many deficits in the body are driven by a functional core weakness/imbalance or forces not dampened across a weak core and from impaired gait biomechanics.  In this case, the absence of balanced core abdominal strength and torso rotation renders a weaker or inhibited core rotation/lateral bend on one side and it is this deficit that is often compensated in the pelvis as a tight hip/pelvis soft tissues unilaterally (expressed perhaps as the unilateral externally rotated limb). This will often alter function, strength and mobility in single leg stance during the gait cycle and enable a compensatory cheat into one or several of the cardinal planes of motion. This is of course but just one scenario. Taking the example above, a right externally rotated lower limb with associated tight and/or painful right piriformis muscle, we frequently (but yes, not always) see a loss of rotation range or strength into left torso rotation.  This can be seen on supine rolling patterns looking for upper or lower limb driver deficits. This scenario might be showing little to no progress with therapy but may do so with focused work on supine rolling patterns.  Therapeutically facilitating oblique abdominal strength to improve range and strength into left thoracic/rib cage rotation over time may reflexively reduce the piriformis spasm and rotational deficit in the right lower limb without even applying much direct therapy to this area.  In other words, our experience shows that improving the thoracic rotation into the side of limitation can have some neurologic response of inhibition/relaxation on the tight posterior hip compartment.  We would be remiss if we were to neglect that this oblique abdominal weakness could coincide with a slight anterior pelvic tilt in the sagittal plane on that side (which promotes weakness of the internal hip rotators since the lower abdominals help anchor them).  We would see a slight bellowing of the left abdominal group and a slight increased anterior pelvic tilt on the same side.  This asymmetrical pelvis posture would load the superior aspect of the right piriformis and force it into spasm due to the sustained pelvic obliquity and slight drop in the anterior direction.  This spasm can inhibit the gluteal group and further complicate the problem.  Keep in mind that a weak left oblique abdominal system would facilitate a tendency towards a sway back position, stretch weak left iliopsoas, and the anterior femoral glide syndrome of the hip (not to mention weak internal hip rotators).  As previously touched upon, activities of daily living such as sleep, stance and sit positions, driving style, handedness, respiration,  functional and anatomical leg length differences, unidirectional floor transfers and simply imbalances in the hip rotators can all cause this imbalance and thus piriformis dysfunction.  In summary, the key to the body in the above scenario is in its ability to create and control rotation.  The ribs, thoracic spine, foot and hips are the most important rotators of the body and their relationship is well established.  Even something as simple as respiration mechanics can be dysfunctional as a result of excessive computer use, reading, driving, sedentary lifestyle and sporting history (one sided dominant sports).  For these reasons, most individuals will be unable to rotate effectively and without compensation patterns so the rotational deficits frequently are expressed either upwards into the thoracic spine, ribs and shoulders (one way to see these problems is to look at shoulder posture and arm swing during gait) or they are expressed caudally into the pelvis at the hips. 

We are sure there is more in us on hip biomechanics but for now this 6 part series will have to suffice. We are putting it aside for now and will move back to some other issues on gait and  human movement so we do not get stale.  We hope you enjoyed our 6 part series.

Shawn and Ivo  (not just your average gait analysis doctors)

The Roll of Breathing and Diaphragm Control in Gait, Running and Human Locomotion

In this video you will see many great things. This video of Rickson Gracie is a testament to free fluid movement and body control.  Great athletes do not just practice one thing.  There is some great demonstrations of breathing and diaphragm control at the 3 minute mark, and we will try to parlay this nicely into today’s brief discussion on the Diaphragm.

Abnormal stabilizing function of the diaphragm may be one etiological factor in spinal disorders.  Today we have included a link to an abstract by the great and brilliant Dr. P. Kolar who we have studied under.  It considers the correlation between the dynamics of the diaphragm in posture and chronic spinal disorders.  What they found seemed to indicate that poor diaphragm positioning, posturing and control correlated well in their sampling of chronic low back pain clients. The study found smaller diaphragm movements and a higher diaphragm positioning/posturing.  The study found maximum changes in the rib (costal) intervals and middle areas of the diaphragm which asks one to consider the absolute critical importance of thoracic mobility. Extension, lateral flexion and rotation are frequently reduced in chronic back pain clients but we find it rampant in many clients and athletes.  We also find and encourage you to look for, assess, and normalize your clients abdominal oblique, transverse abdominus and rectus abdominus control.  Failure to properly and adequately anchor the lower rib cage to the pelvis via the abdominal wall (the whole wall, circumferentially around the entire torso to the spine) will result in asymmetrical breathing patterns.  And abnormal breathing patterns lead to abnormal spine motion and mobility. We frequently have to treat and instruct proper breathing patterns to help normalize lateral and posterior rib cage expansion and decent in athletes and clients, particularly those with low back issues but that is not an exclusive group to this problem. Tomorrow we will show you some simple but great videos showing rolling patterns and we will want you to think back to today’s blog post here on how loss of thoracic mobility in extension, rotation and lateral bend as well as loss of symmetrical abdominal skill and strength can impair a primitive movement pattern like rolling. This is a pattern that is first developed as a child to learn to turn over. It is a precursor to pressing up the torso like in a push up, which is of course a precursor to crawling, then cruising and then walking.

See, we were finally able to come full circle !  From breathing and the diaphragm to gait…… it is all connected.  Any faulty strategy or pattern driven into the body, even breathing, can impair gait.  Because with gait we have to attach anti-phasic arm swinging with leg swinging. Anything that disturbs this anti-phasic patterning, such as low back pain, will drive contralateral arm-leg swing to phasic patterning. Don’t think this is important to athletes and humans ? Well, you must have missed our 2 part blog series on Arm Swing.  We provide those links here. Part 1 link and Part 2 link

If you are an athlete, coach, or in the medical movement assessment or gait analysis field……heck, if you study the human body at all and you are not looking at or into arm swing you are not doing what we are doing. And you are missing the bigger boat. So many “gait specialists” and “gait analysis” programs are not even capturing the arm swing let alone looking at it and discovering its critical importance. Did you miss our dialogue on frozen shoulder and impaired contralateral hip dysfunction ?  If you look for it, which many in the therapy world are not, you will see why we treat that opposite lower limb.  Maybe the rest of the folks around the world will catch on in time.  We are slowly getting there, we now have readership in 23 countries, and growing.  If only we had more time, the apocalypse of December 21, 2012 is coming on fast !

The article also found maximal changes in the middle diaphragm areas which suggests looking at the psoas, quadratus lumborum and crus because of their fascial blending into the diaphragm from below.  Thus, investigation of many muscles from below must also be a part of your assessment or training.  But we will save this discussion for another blog post.

We hope you can see that after a year of blog posts (over 500) that you can begin to see the method of our obvious madness.  That being that everything is important for human gait. Remember, we will blend this blog post into the roll assessments you will see on tomorrows post.  So ya’ll come back now……. ya hear ? 

In closing, it is blog posts like this one that we always hope will go viral on the internet. Especially because it has links to two previous articles we wrote on arm swing which we feel are so very important and commonly overlooked.  And we have more arm swing stuff to share, we just need more time.  Consider linking this article to your website, sending it to friends in the fields we discussed. This information is important. It is why we take the time every day to write and share our 40+ years of clinical experience for free. Because the world needs to know this stuff so more people can be helped all over the world.  Consider sharing this with someone or linking it to your Facebook page or website or slap it up on someones forum to create dialogue. Thanks.

The leg bone is connected to the thigh bone…. as the song goes…….

Shawn and Ivo

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here is Kolar’s abstract……

J Orthop Sports Phys Ther. 2011 Dec 21. [Epub ahead of print]

Postural Function of the Diaphragm in Persons With and Without Chronic Low Back Pain.

Abstract

OBJECTIVES:To examine the function of the diaphragm during postural limb activities in patients with chronic low back pain and healthy controls.

BACKGROUND: Abnormal stabilizing function of the diaphragm may be one etiological factor in spinal disorders, but a study designed specifically to test the dynamics of the diaphragm in chronic spinal disorders is lacking.

METHODS: Eighteen patients with chronic low back pain due to chronic overloading, ascertained via clinical assessment and MRI examination, and 29 healthy subjects were examined. Both groups presented with normal pulmonary function test results. A dynamic MRI system and specialized spirometric readings with subjects in the supine position were used. Measurements during tidal breathing (TB), isometric flexion of the upper or lower extremities against external resistance together with TB (LETB and UETB) were performed. Standard pulmonary function tests (PFT) including respiratory muscles drive (PImax and PEmax) were also assessed.

RESULTS: Using multivariate analysis of covariance, smaller diaphragm excursions (DEs) and higher diaphragm position were found in the patient group (p’s<.05) during the UETB and LETB conditions. Maximum changes were found in costal and middle points of the diaphragm. In one-way analysis of covariance, a steeper slope in the middle-posterior diaphragm in the patient group was found both in the UETB and LETB conditions (p´s<0.05).

CONCLUSION: Patients with chronic low back pain appear to have both abnormal position and a steeper slope of the diaphragm, which may contribute to the etiology of the disorder. J Orthop Sports Phys Ther, Epub 21 December 2011. doi:10.2519/jospt.2012.3830.

A brief gait review from a youtube clip we found:

at :03 notice the shrugged shoulders and trapezius activation, forcing respirations to the upper lung fields. This also facilitates the scalene muscles in the neck (which is probably one of the reasons they flex their neck). Breathing from here is shallow and inefficient. This action (shrugging the shoulders) activates the upper trap and deactivates the lats (which are the functional link between the upper and lower extremities)

at 05: they begin to flex the lumbar spine

at :06 they flex at the waist as well as the neck. This rounds the spine and puts the glutes at a mechanical disadvantage for extending the hips and limiting some of the driving power. They then become hamstring dependent, which isn’t as efficient. Dropping the head defacilitates the extensor muscles neurologically, so they will have some power loss (as well as stiffness loss) as well. They keep their neck flexed till :07, where they really begin to pick up more speed. The torso remains flexed at the waist through most of the footage.

it appears at :07 that the left foot strikes the ground in eversion bottom of foot pointing away from camera) indicating some degree of forefoot pronation. A shot from behind would be helpful to confirm this

The arm swing appears asymmetrical from left to right, right being greater both forward and especially backward. I would wonder what they are hiding (biomechanically) there (so are they increased on the right or less on the left?. Here is where foot age from behind would be instructional).

Ok folks. Hope you enjoyed the ride!

we still are….The Gait Guys…..