Evidence that Matters for Function: Hip Extension in the Elderly
by Dr. David Tiberio
Kerrigan DC, Todd MK, Della Croce U, Lipsitz LA, Collins JJ. Biomechanical gait alterations independent of speed in healthy elderly: evidence for specific limiting impairments. Arch Phys Med Rehabil 199879:317-322.
The purpose of this study was to look deeper into the established fact that walking speed decreases in the elderly. Walking speed is the distance traveled in a minute. The authors wanted to determine which of the following factors produced this decrease in walking speed: a slower cadence, a shorted stride length, or both. They confirmed that even healthy elderly subject demonstrated decreased walking speed compared to younger adults. The reduction in distance covered was a result of decreased step stride length rather than a slower walking cadence. One of the two principal findings was decreased hip extension. When the authors had the elderly subjects try to walk faster, they increased both the cadence and the stride length. However, the increase in stride length was not from increased hip extension. That deficit remained the same.
From this and other studies we know that hip extension is a critical resource for the function of walking. Our sedentary life style, combined with less functional activity as we age, makes the elderly population particularly prone to the loss of this critical body resource. The traditional approach might be to put the client in the prone position and stretch the anterior hip tissues to create hip extension. This may increase the hip motion, but is there a better way (based on the Principles of Human Movement) to help patients / clients gain, maintain, and use functional hip extension?
Practitioners of Applied Functional Science® (AFS) would first assess hip extension in an upright position using the Anterior Chain Reaction® (movement) of 3DMAPS® (3D Movement Analysis and Performance System). If the elderly patient / client was not comfortable performing a lunge with a simultaneous bilateral hand (arm) swing, the movement could be tweaked. Using a lunge and hold position creates hip extension in the non-lunging hip. With both feet on the ground, the “Bilateral Hands, Posterior at Overhead” (arms) swing would assess the availability of additional hip extension.
Assuming we find a deficit, what would a Principle-based Strategy to restore extension look like? Using components of the Performance System of 3DMAPS®, we might start by giving the patient / client four points of support (two hands and two feet). The elderly patient / client will feel stable, and a pelvis driver will be used to create hip motion. To get extension we would drive the pelvis forward / anterior. But this would be attacking his / her plane of least success. The principle of 3D would suggest driving the pelvis in the frontal and transverse planes to create more sagittal plane motion. With increased hip extension, the patient / client would be repositioned with the hip more extended and the frontal and transverse plane Strategy would be repeated.
The next progression might be to use the arms as the drivers of hip motion. Using a “Fixed Trunk” Strategy of positioning the trunk close to the extension limit, the arms would drive motion down into the hip using the frontal and transverse planes again. As hip extension improves, a new trunk position is assumed and the arm drivers repeated. Both this movement sequence and the one outlined above do not drive the hands in the sagittal plane. Instead motion in the more successful planes facilitates the improvement in the sagittal plane extension.
Now it might be time to go after the hip extension directly by driving the arms posterior overhead. But is there a way to use the tweaks of AFS to increase the chances of success? One possible Strategy would be to assess if the hip extension limitation is better with the feet toed-in or toed-out. Let’s assume that there was more hip extension in the toed-out position. With the patient / client positioned in the anterior lunge position, we would have him / her position the back foot toed-out. The arms would drive overhead. As the hip extension increases, the amount of toe-out would gradually be decreased while continuing to drive the arms posteriorly overhead. With success, the external rotation produced by the toe-out would gradually be progressed to hip internal rotation with a toe-in position. The hip extension would improve in all three positions, neutral, externally rotated, and internally rotated – thus providing the patient / client with improved function for many different activities!