In today’s episode of the PT on ICE Daily Show, join Modern Management of the Older Adult lead faculty Alex Germano to find out which lateral stepping strategy is associated with more strength and less falls during today’s episode.
She discusses how to assess this stepping strategy, which is preferable, and how to intervene!
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Good morning, everybody. All right. Good morning and welcome to the PT on Ice daily show brought to you by the Institute of Clinical Excellence. My name’s Alex Germano. I’m a member of the older adult division, and I’m really excited to be talking to you all today about something that comes up in our live course. We’re going to be talking about reactive steps, particularly in the lateral plane. This may sound a bit specific, but picking up on our patients’ tendencies to step a certain way when recovering their balance laterally can actually tell us a lot about their strength and inform us about better treatment interventions and inform us about our patients’ fall risk. You may have noticed that we humans have a variety of stepping strategies available to us when we start to lose our balance. And you actually may be seeing this with patients in a formal way by doing maybe the mini best test. Or when you’re doing challenging balance activities, you’ll notice that different patients use a different stepping strategy, especially in the lateral direction. You may see a crossover step. So this is when the patient is standing, where if they start to fall, say, to the right, their left leg becomes unweighted. They take the left leg and they cross it. over the right leg. You may also see, we’ll call it a lateral step or a lateral withdrawal step, where the, say they’re again, falling to the right, and instead of moving their left foot, instead they kind of quickly push the weight back to the left foot and then step out big with the right leg to recover balance. So we’ve got two different strategies, crossover step or a lateral withdrawal step. Now on the mini best test, if you’re doing this in a formal manner and you’re running that assessment on folks, When you get to that reactive balance component, or that reactive balance section, you’ll notice that you can get a full two points, you mean pass that part of the test, if you do either the lateral withdrawal step or the crossover step.
WHAT’S “BETTER”: LATERAL OR CROSSOVER STEPPING?
Now, my question, and what I’ve been thinking about for a while here, is actually one strategy better than the other. Should they really be equal in our mind? Should I be satisfied with the crossover step? Let’s talk anecdotally first, like my own clinical practice. I will say that I don’t see the lateral withdrawal step chosen as often in my older patients. I see that If my patient is going to perform that lateral withdrawal step, they tend to be stronger, faster patients. I will say that the unloaded crossover step is seen in my weaker patients. And so I was trying to dig into the evidence to figure out, does this make sense with what’s in the evidence? Can looking at this different type of step tell me more about the human in front of me? So I’ll be talking about three different studies. I’ll link them on Instagram after this. The first one was kind of diving into the crossover step. This first study pitted older adults versus younger adults. They saw that the older adults tended to select that crossover step more frequently. They also noted and described the crossover step as being passive in nature. It’s a passive approach to maintaining your balance in that direction. They also noticed that when the crossover step was selected, that older adults tended to use more steps to recover their balance. and there was heightened inner limb collisions. That makes sense, right? We’re crossing one leg over the other. The legs naturally may hit each other if they didn’t take a far enough step forward or back. We also see that these crossover steps come, they take longer and they come with more alterations in trunk movement. None of these things sound great to me, but these were just observations of the step themselves. Then there was a systematic review of hip muscle strength activation in both balance and mobility tasks. This one confused me a little bit, but I’ll walk us through it. There was a study within the systematic review that suggested that hip abduction torque couldn’t distinguish who was going to take the lateral step versus the crossover step. But then another study in the review reported that older adults with greater hip abduction torque had a higher incidence of lateral steps. So maybe it’s hard to say like, is lateral stepping predictive of strength? If my patient took a lateral step, does that mean they’re stronger? I don’t know if we can say that, but strength is looking to be more predictive of the lateral step. Like if the patient is stronger, they’re more likely to choose the lateral step. Um, what the study did say, quote, is in this present systematic review, we identified overall during predictable and unpredictable induced balance perturbations, a lateral step requires greater hip abductor neuromuscular activation compared with other step types across the age group. So in order to take this lateral step, you do have to have better hip abductor activation.
STEPPING STRATEGIES & FALL RISK
Okay. Lastly, let’s dive into maybe a patient-specific population. This will talk about patients with Parkinson’s disease. Surprisingly, I was surprised, that they didn’t see a huge difference in step selection in people with Parkinson’s disease and without. However, they did find that people who use the lateral step had the least amount of falls. This suggests that maybe there’s a more optimal stepping strategy. To put this all together, here’s what the evidence maybe is leading us in the direction of, not just my anecdotal experience. Lateral steps are safer. I would prefer my patient use a lateral stepping strategy. I’m happy if they select any stepping strategy. Honestly, at this point, if you’ve done enough mini best assessments, you see a lot of people use no strategy at all. I’m okay with a crossover or lateral. If I start seeing the crossover, I know in my mind, I want to start training the lateral step. I would prefer my patient use them. They are safer because those crossover steps are a passive strategy. All right, the crossover step is a passive strategy. It’s a strategy that has a risk of interlimb collision. It’s going to take longer to facilitate the steps. It’s going to cause more alterations in trunk movement. Now, we don’t want to assume anyone is weak when they take the crossover step. Let’s not assume that they’re weak. but we know that you have to have pretty strong hip abductors in order to take the lateral step. Okay. You’ve got to have strong hip abductors. Older adults tend to take longer to activate hip abductors. So we need to work on increasing speed in loaded conditions with this group. So this makes me really reflect on this, like, uh, makes me really reflect on how much lateral power work am I doing? in my sessions with older adults. I think this is where we really could have a game-changing, more game-changing interventions for our older folks.
IMPROVING LATERAL STEPPING STRENGTH & POWER
So here’s some simple ways, let’s think of some simple ways to layer up lateral hip power exercises, okay? Think about all the ways that you can get your patient to move in the lateral direction quickly, right? And we wanna maybe do this first in unloaded conditions, where a patient maybe does a big step out to a target, and we ask them to stomp and step quickly. Maybe we give them a cue or a target to step to. We then want to start practicing this lateral step out. Because if you think about the mechanics of the step out, right? Like if they’re falling to the right, they’re going to have to take a leg, their right leg, that has all the weight on it. They’re going to have to shift the weight back to the left leg quickly, then send the right leg out to the side. We can practice that. We can practice lean to the right, all right? Quick step left, right. Right. We can practice these kind of weight shifts onto a leg, then quickly weight shift off and then lateral step out to the side. Okay. Those are things we can practice. So you probably first want to start with unloaded limbs, working on the speed of an unloaded limb, then layer up the difficulty on the loaded side. All right. You can absolutely train the person’s crossover step. I think about, I use grapevine stepping or karaoke, whatever you want to call it. all the time. I think that’s a great intervention, but maybe you’re training the crossover step to reduce inner limb like collisions, okay, reducing inner limb collisions. I also see the utility of the clock yourself app, right, you can use if you want to work on that that crossover step maybe you have the clock yourself app set up on one side of the patient and then you have the opposite leg reaching for numbers so they’re having to work on some coordination of the crossover step. And then obviously we want to take all of this lateral hip power that we’re going to start working on with patients, you want to move them to more reactive situations and scenarios. So reactivity could include using the big resistance band over the patient, pulling them in different directions so they’re having to react quickly. You can do this while standing, while moving, ideally while moving and walking. In conclusion, we can learn a lot about our patient based off of what stepping strategy they use in the lateral plane. Are they using a lateral withdrawal step or are they using that crossover step? We know that we probably don’t love the crossover step. It’s not an ideal stepping strategy. It’s not as safe It is associated with more falls. It is associated with inner limb collisions. We know that you need strong hip abductors to perform that lateral step. So we need to start training speed in the hip abductors under loaded and unloaded conditions during our interventions for older adults, during our interventions. So let’s start seeing some really cool lateral hip power interventions here going forward.
Now, we hope to see you at a live course. We actually get to practice this mini best test at our live course. We get to get hands on, we get to work on our guarding technique, and we talk a little bit about these strategies that are used. And we would love to see you at some of our live courses this year. We’ve got quite a few on the radar. I’m going to highlight some of our options in March and April. Just if you’re a planner like me, I know you’re probably not thinking about coming to a course this weekend, but if you’re looking forward to an early spring course, we’ve got a couple on the radar. We are in Glencoe, Maryland, March 2nd and 3rd. We’re in Rome, Georgia, that same weekend. Madison, Wisconsin, at the end of the month, the 23rd and 24th of March. We’ll be in Urbana, Illinois, on the 6th of April, as well as Raleigh, North Carolina, on the 6th. So those are just five of many courses. Please head to the ptonice.com website to check out where MMOA is going to be. All right, I hope you all have a great rest of your Wednesday. Get stepping.
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