Category Archives: Physical Therapy

Applying Tai Chi to Physical Therapy – Part 2: Gait Training

Walking is a skill that many of us take for granted – let’s face it, when was the last time you actually thought about the way you walk? Yet it is still a skill, and when your ability to walk is suddenly impeded, or lost altogether, you realise just how important it is to your life. Even with disease or injury, many of us find a way to maintain our ability to walk, however any deviation from ‘normal’ gait (the medical term for walking) can often result in the development or compounding of other problems: pain, muscle imbalance, and arthritis being some of the more common, not to mention the difficulty in attending to day-to-day activities.

What is ‘Normal’ Gait and Why is it Important?

I often explain gait as a “controlled fall”. In order to walk, we shift our center of mass (CoM – see Part 1 for an understanding of the importance of CoM) forwards so that our body starts to move forwards. If we allowed this shift in CoM to continue unchecked, we would fall flat on our face. To avoid this, we use a complex pattern of movements to support ourselves on one leg while we place the other one in front of us to arrest our fall. If we keep our CoM moving forward, we have to repeat the pattern again: the leg in front now becomes the supporting leg, and the leg that was supporting us must now swing forward to save us. Repeat over and over again and you are walking.

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The way our limbs and body produce this – not just the movements themselves, but the way they are coordinated – is referred to biomechanically as a ‘gait pattern’. A ‘normal’ gait pattern is a complex, ideal version of these coordinated movements that result in a stable and efficient means of locomotion which has minimal impact on our musculoskeletal system. It is defined by a number of different factors, including joint angles, distribution of mass (ie: the location of CoM), forces applied to the body, and synergy of movements. For a more in-depth explanation of normal gait, check out this article on Physiopedia.

Anything that doesn’t comply to a ‘normal’ gait pattern is considered to be an ‘abnormal’ gait pattern. This is not to say that it is wrong as such, merely that it does not conform to the ideal that is normal gait. Physical Therapists strive to teach people to walk with a normal gait pattern, or as close to a normal pattern as is achievable. For some people this might not be possible, for example, due to anatomical differences, muscle weakness, imbalances, or tightness, neurological changes or deficits, pain and/or injury, disease, aging, or some combination of these factors. However, while the ‘perfect’ gait pattern might not always be achievable, many people who experience problems with walking can be assisted through Physical Therapy to improve their gait pattern, and in doing so their overall functional capacity.

How Can Tai Chi Help?

Tai Chi

Photo courtesy of Gold Coast Tai Chi Academy

Students of Tai Chi spend a lot of time learning to walk correctly. One main example of this is the technique known as mao xing, or ‘cat walking’. In mao xing, the Tai Chi practitioner shifts weight into one leg while stepping forward with the other. The stepping leg has no weight in it right up to the point the heel makes contact with the ground. The practitioner completes the step by gradually transferring weight from the supporting leg to the stepping leg, involving a shift from side-to-side and back-to-front. As the stepping leg is loaded it becomes the supporting leg, eventually freeing up the other leg to take another step forward.

This sounds very similar to normal gait, however a key difference is the location of the person’s CoM. As already described, normal gait requires the CoM to be displaced forwards outside the person’s base of support BoS), providing momentum. In mao xing, however, the CoM is maintained within the BoS while weight is shifted from one limb into the other, effectively eliminating the “falling” part of walking. To do this successfully, the Tai Chi student must develop a deeper understanding and awareness of how their body moves, in terms of coordination, weight shift, loading and unloading of the limbs, and placement of the feet. As a Physical Therapist, if I could have all my patients mao xing I wouldn’t have to worry about any of them having falls!

Applying Tai Chi to Physical Therapy: Recovery from Joint Replacement Surgery

Recently I’ve been applying the principles of mao xing in retraining normal gait patterns in patients who’ve undergone total hip or knee replacements. In the first weeks after surgery, many joint replacement patients demonstrate a very “stiff-legged” gait pattern: they tend to hold the operated leg very stiff when attempting to mobilise, and limit the amount of time they bear weight through the limb. In some cases the patient will circumduct or swing their leg around rather than bend their hip and knee in order to take a step forwards. Some patients may also have been walking like this for sometime prior to their surgery due to the nature of the condition that required joint replacement.

It can be quite challenging to retrain patients to walk with a normal gait pattern again, and often requires very precise practice. This has been particularly true in patients who have had bilateral joint replacements, who don’t have a ‘good’ leg to support themselves on and so are very guarded with attempting to walk.Though I haven’t been trying to teach my patients mao xing as such (though I often think I would like to), I’ve found that incorporating a number of the principles of mao xing – stepping onto the heel, rolling through the foot to come up onto the toes and push-off – as well as instructing the patient in a similar manner to how I would teach the technique to a Tai Chi student, provides a much more correct and consistent result than other methods I’ve tried. I’ve also found in practice that focusing on the principles related to the foot (heel strike, weight shift, stance, toe off) produce a subsequent improvement in the pattern of movement at the knee and hip – that is, an increase in the amount of flexion at the hip and knee during swing phase – and tolerance to weight-bearing during stance phase. When I apply these principles to gait training, I seldom have to draw attention to or correct movements at the hip, knee, or lumbo-pelvic area as these seem to correct themselves when the patient is applying the principles to their feet.

Lastly, and in some ways the most exciting part, is that I’ve found that patients are more likely to practice this “creeping” (as several patients have referred to it) way of walking as part of their home exercise program than they are other techniques or exercises designed to improve their gait. The exact reason why is unclear, however I would suggest it is because it is easier for the patient to conceptualise, understand, and apply, than other techniques that are more detailed and require a higher level of cognitive processing. In practice this apparent increase in compliance and attendance to exercises between therapy sessions does appear to translate – in general – into a more timely improvement in gait and physical function.

Again, this is at best observational evidence of a specific application of Tai Chi principles to physical therapy. However, it does support the increasing body of evidence-based research advocating  Tai Chi as a means of improving balance and mobility, and in my opinion, is worth further investigation as an adjunct to physical therapy.

Applying Tai Chi to Physical Therapy – Part 1: Weight Shift

I have been an advocate for Tai Chi (taiji quan) for at least as long as I’ve been a Physical Therapist, and have previously written about the benefits Tai Chi can bring to physical therapists and physical therapy. In this series, I aim to share some of the ways I’ve been able to apply the principles and practice of Tai Chi to my therapy skills, an in doing so enhance my patients’ care.

What is ‘Weight Shift’ and Why is it Important?

In basic terms, weight shift is our ability to move our center of mass (CoM) – our ‘weight’ – around our body in order to maintain – or disrupt – our balance. Think of your CoM like a pendulum or a plumb-bob; when you stand with perfect balance, your CoM sits right in the middle of your base of support (ie: the area around your feet). Once you start moving, your ‘pendulum’ moves as well, generally in the direction you are moving. We do this all the time  – in fact, if we couldn’t move our CoM, we couldn’t move at all.

An easy way to understand weight shift is to attempt to stand on one leg. To do this, you have to move your CoM – or ‘swing your pendulum’ – over your supporting leg so you can lift the other leg off the ground. If you don’t, you won’t be able to lift your leg, or if you do, you body will want to fall over to that side. You can try this for yourself to see how it feels (just make sure you do it by a table or counter top so you’ve got something to grab onto if you need it!).

20131110232510-fall-menBeing able to weight shift not only facilitates movement, it can help prevent unwanted or undesirable movement, for example, falling. Falling is a major contributor to injury and death amongst many populations: in the US, falling is considered to be leading cause of both fatal and non-fatal injuries. Physical therapists spend a great deal of time trying to both prevent falls in patients, and help patients recover from falls. Teaching patients to understand both how their CoM affects their balance, and how to shift their weight appropriately for safe movement, is critical to achieving functional movement and stability. However, in many patients the ability to weight shift is impaired either because of disease (eg: neuropathy, arthritis, vertigo) and injury (eg: stroke, spinal and nerve injuries), and regaining the ability to control weight shift can be very difficult.

How Can Tai Chi Help?

Weight shift is one of a number of fundamental skills Tai Chi training can improve or enhance. Almost every movement in any form from start to finish involves a gradual, controlled transfer of weight in coronal, sagittal, and transverse planes of movement. In order to perform the forms correctly, Tai Chi practitioners control the displacement of their CoM in all planes through slow, precise movements. In most instances, the CoM remains ideally located within the practitioner’s base of support, making it easy to maintain balance. This is evident even when the practitioner is performing ‘unbalanced’ movements, such as standing on one leg.

A classic example of this is the technique known as mao xing, or ‘cat walking’. In mao xing, the Tai Chi practitioner shifts weight into one leg while stepping forward with the other. The stepping leg has no weight in it right up to the point the heel makes contact with the ground. The practitioner completes the step by gradually transferring weight from the supporting leg to the stepping leg, involving a shift from side-to-side and back-to-front. As the stepping leg is loaded it becomes the supporting leg, eventually freeing up the other leg to take another step forward. (Note: this is a very simplistic description of mao xing and there is a lot more involved in it, however this illustrates the basic concept. I recommend trying Tai Chi to better understand mao xing)

One main difference between mao xing and regular walking is the way weight shift is controlled. In regular walking, the CoM is displaced forward of the body, and the body’s reaction is to shift weight to one leg while stepping through with the other. Keeping the CoM displaced forwards and alternately repeating the sequence facilitates movement while preventing a fall forwards. In effect, walking is a repeatedly controlled fall. (Note: again, this is an overly simple description of walking, however is biomechanically accurate) Mao xing on the other hand, keeps the CoM positioned ideally within a person’s base of support at all times, even when one leg is not supported on the ground. Consider this in terms of a person who has an impaired ability to weight shift, such as someone who has a dense hemiplegia following a stroke. Which method of walking would you consider safest to have them perform?

Applying Tai Chi to Physical Therapy: Stroke and Femoral Nerve Injury Examples

Recently I was able to apply the principles of mao xing to improve the mobility of two patients who had difficultly with weight shift: a middle-aged male with a dense left hemiplegia following a stroke, and an elderly female with the inability to maintain knee extension following an injury to her femoral nerve. Neither patient was able to support weight on their affected side and both were consequently such a high risk of falling they could only mobilize in a wheelchair. Therapy included exercises to encourage weight shift and improve the ability to bear weight over the affected side, however in both instances progress was slow and their was little retention between therapy sessions.

Using the principles of mao xing, I had both patients practice stepping into a lunge stance with their affected side, then returning to a neutral standing position. Patients practiced the gradual loading and unloading of the affected side, first supported and then with standby assistance as their skill improved. In both cases, within the completion of 2 sets of 10 repetitions there was an observed improvement in the patient’s understanding and ability to shift weight to the affected side, and in maintaining standing balance. With successive therapy sessions and in conjunction with other exercises, both patients advanced their ability to weight shift to the point where they were able to stand and mobilize with an appropriate aid. The male with the hemiplegia was ultimately able to mobilize with a cane independently. The female with the femoral nerve injury has so far progressed to be able to mobilize with a standard frame under supervision.

This is, at best, observational evidence of a specific application of Tai Chi principles to physical therapy, and weight shift is only one aspect of maintaining balance. However, it does support the increasing body of evidence-based research advocating  Tai Chi as a means of improving balance and mobility, and in my opinion, is worth further investigation as an adjunct to physical therapy.

5 Tips for Surviving the NPTE

keep-calm-and-pass-the-npte-2After eighteen months of preparation, perspiration, and palpitations, I have finally passed the National Physical Therapy Exam (NPTE), administered by the United States of America’s Federation of State Boards of Physical Therapy (FSBPT). The NPTE is the means by which all candidates for physical therapy licensure, whether domestic graduates or foreign trained applicants, are assessed for basic entry-level competency for the profession. It is not the only requirement for licensure, however it is the one standarised requirement in all fifty States, and if you want to work as a physical therapist in the USA, you must sit and pass it.

You might think for someone like myself who has been a physical therapist for the past eleven years this would be little more than a formality. Think again. The NPTE is one of – if not THE – toughest exams I’ve ever taken. Unfortunately, those who have taken the exam are prohibited from disclosing any information about the exam itself, so I cannot reveal the anything about its content or structure. I can, however, give some more general advice based on my experience in preparing for and undertaking the exam – advice I would have found invaluable in my own lead-up to the exam date.

Here are my five tips for surviving the NPTE:

  1. Allow plenty of time to prepare

A five-hour 250 question exam requires ample preparation time. The exams generally run every three months, so depending on where you are in the schedule should guide you as to which exam you should take. Don’t be in a rush to sit the first available exam. It may be in your best interest to give yourself additional time to ensure you are able to cover all the required material, get a feel for the exam with some practice exams (see below), and build your confidence in your ability to do well.

  1. Study everything

The NPTE potentially covers the entire scope of practice of physical therapy, from musculoskeletal to neurology, cardiac and respiratory to lifespan, and principles of general practice and research. Chances are you don’t remember everything there is to know about physical therapy, even if you are a new graduate. If you are currently working as a physical therapist, you probably know the area you work in quite well, but haven’t even thought about other areas in a long time. You need to study everything about physical therapy, and feel confident that you can apply that knowledge. It is a big ask, and it is probably the last time you will ever need to know everything about the profession, however it is essential if you want to get through the NPTE.

Didn’t keep all your old textbooks? Fear not, there are some very useful resources to help you revise and prepare for the exam. Two that I used are BenchPrep, an online prepatory course for the NPTE, and PT Exam: The Complete Study Guide by Scott Giles, a reference text which is a thorough summary of all the areas of physical therapy, set out in a way that is specific to the content of the NPTE. BenchPrep is particularly useful as it gives you a study guide, which tells you how much material you need to cover in a given timeframe in order to be ready for the exam, and enables you to connect to other students preparing for the exam to ask questions or form study groups. The PT Exam text I used was a little dated (2011), however the material is still relevant and the practice exams that come with it are very useful indicators of how you’re doing. The resources available are not limited to these and you should search for some that you feel are most appropriate to your needs.

  1. Do the practice exams

Find and complete as many practice exams as you possibly can. Not only is it useful to familiarise yourself with the exam situation, it will give you clear feedback as to where your strengths and weaknesses are, and enable you to adjust your study plan accordingly. Both BenchPrep and the PT Exam book have quizzes and practice exams, and FSBPT provides (for a fee) an online practice and assessment tool (PEAT) which very closely mirrors what you can expect from the actual exam. Practice exams enable you to get a feel for how questions will be worded, and practice interpreting the possible answers. Often, the answer that’s required is not a matter of separating right from wrong, but understanding which answer is the MOST correct based on the information you’re presented with. It takes practice to be able to understand this, particularly if you’re a current practitioner, as chances are you have developed your own ways of addressing the needs of patients, and this may not match to what the examiner is expecting.

  1. Seek support

Having good support structures in place is invaluable, both in terms of supporting your study and maintaining your sanity. Having family members, friends, loved ones who can support you during this incredibly stressful time can make all the difference to your mental and emotional health. A little understanding goes a long way, and it’s likely you will need plenty in the lead in to the exam.

Support from other people undertaking the exam is very useful as well. Being able to find discussion forums or study groups can greatly assist your preparation. This gives you the chance to check your understanding about different things, develop your judgement and reasoning, and ensure you are covering everything you need to know. In most groups you will find someone who knows the answer you’re looking for, or who will ask a question you haven’t thought of. It can also be useful to be able to relate to others who are going through the same experience you are.

  1. Find ‘you’ time

It can be very easy to narrow your focus to preparing for the exam, and let all other aspects of your life fall by the wayside in the process. Do this, and not only do you risk severely over-stressing yourself, you may cause damage to your health, your relationships, and other things that are important to you. This is where allowing ample time (see 1. above) becomes critical. You need to be able to step away from your study and preparation, if only to give yourself a chance to recharge and recuperate. Take a walk, go to the gym, play with the kids or catch a movie you’ve been wanting to see. There are no bonus points for spending all your time on studying – in fact, chances are by taking some ‘you’ time, you will return to your studies with a clearer mind and sharper focus.

According to FSBPT, only about 88% of US graduates, and 30% of non-US graduates, pass the NPTE the first time. Incorporating these tips into your study plan might just give you the edge on ensuring you are one of those who pass.

If you are preparing to take the NPTE, I wish you the best of luck for a successful outcome, and for your future career as a physical therapist.

Got some other tips for taking the NPTE? Please feel free to share in the comments section below.