Tag Archives: balance

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.

Knowing When to Do Nothing

art_628465There is a concept in Taoism known as Wu Wei – literally ‘no action’, and often interpreted as ‘do nothing’. It goes hand-in-hand with another concept, Wu Bu Wei – ‘not no action’, or ‘do everything’ [1.] Those who study Taoist philosophy seek to achieve harmony in their lives by doing nothing and doing everything. The idea of doing everything is one that’s probably familiar to all of us: from the moment we wake up we attend to the tasks, chores, and activities of our day right up to the point we close our eyes to sleep again. Doing nothing, however, is a stranger concept. It does not mean being slothful, lazy, or apathetic. Instead, it is about recognising the times when there is nothing you can, or should do – that the right course of action is to not act.

It is a challenging concept to get one’s head around, so let me try to illustrate with an example. Think about the last time you had an argument with someone. It may have been over something of significance to one or both of you, or it may have been – in hindsight – over nothing. If you go back and think about it, you can probably see that it all started from something that was said or done that induced an emotional response in one of you. That response got expressed, which led to an emotional response in the other person, and back and forth it went. Like many arguments it probably heated up as it continued on, perhaps it even got out control and one or both of you were yelling at the other. Chances are at least one of you got their feelings hurt. (If so, hopefully you’ve resolved that by the time you’re reading this!)

Think of that argument as a timeline, like a scene from a movie. You can probably see how the argument started from nothing, and then developed into a full-blown argument. You can probably also see that it took two people to have that argument. Even if it was just one person berating the other, it still took the interaction of both for the argument to happen. Now imagine you can edit that scene. You can move along that timeline and pick a point and edit what happened at that moment. What might have happened if, at some point in the timeline, one of you had stopped arguing? It may have been as simple as saying, “stop, I don’t want to argue anymore”, or perhaps it needed one of you to walk away. If one of you had simply stopped, could there even have been an argument? And if there was no argument, could the problem have been solved faster, easier, or better?

This is where doing nothing becomes important. Using this example, you can think of the argument as doing everything. In fact, you probably are doing everything while arguing – yelling, shouting, trying to put forward, or impose, or defend, your view, and getting emotional. You’re trying to ‘win’, and you will do everything to ‘win’ – and sometimes, ‘winning’ leads to some very undesirable outcomes. If you’ve ever ‘won’ an argument but didn’t feel better for it, you’ll understand what I mean.

To not argue, or cease arguing, is to do nothing. It does not mean turning your back and walking away (though in some instances that might be what it takes). Rather, it is about recognising that continued action is not going to make the situation any better, nor achieve the outcome you really want. In that case it is better to cease your actions – to do nothing – and in doing so, avoid creating a new problem through arguing. As my Tai Chi master says, “you can’t resolve a problem while ever someone is trying to fight you. It is only when they stop fighting you can sit and have tea and work out what the problem is.”

Makes sense, doesn’t it? Of course it’s easy to say, yet much more difficult to put into practice. I’m going through a process now which, for the moment, is out of my control, and all I can do is nothing. And yet, for my life to go forward in the way I want it to, this process must happen, and quickly. I have people who need me and who are relying on me to get this done. I have opportunities that are dependent on this happening. And for my own well-being, I need this resolved. The fact that it is taking time is very oppressive and hard to deal with – it’s causing unnecessary strain on me and those I love. I feel responsible and I feel I need to do something to change it – I am trying to do everything, because I’m afraid if I don’t I will lose what it is I’m striving for. Yet the reality is that there is simply no more I can do until it is put back into my hands. I need to do nothing. I know this, and I know that in doing nothing I will be better off, but knowing and doing are often different things, aren’t they? So I am trying to do nothing, however I will be the first to admit it’s not easy.

We can all reflect on our lives and find instances where it seemed that no matter what we did, not matter how hard we tried, no matter how much effort we put into something, we didn’t get to where we wanted to be. We often think that if we stop, everything stops; that inactivity is somehow detrimental to achieving. Nothing could be further from the truth. It is like sailing: you can hoist your sails and work your lines and rigging all you want, however if you’re sailing against the wind, you won’t get very far. But if you stop, and just let the wind fill your sails, you’ll find it takes you to where you need to be.

The trick is not to just do nothing, but to know when to do nothing. And as the Taoists say, in doing nothing, leave nothing undone.

  1. Zhao, Qiguang. (2010). Do nothing and do everything: an illustrated new Taosim. Minnesota: Paragon House