August 2, 2017
The staff at the Virginia Cartilage Center have created a novel exercise program, the object of which is to optimize joint mechanics and reduce stress concentrations by understanding and controlling stress vectors. The program is designed for patients with cartilage damage and osteoarthritis of the knee and incorporates weight-bearing exercises focused on tri-planar control of the foot and hip to promote proper alignment of the knee. Proper alignment is continually stressed in standing, walking, occasionally running as well as transfers from sitting to standing and stair climbing. Emphasis is placed on motor control in the performance of the exercises rather than high repetition endurance training or overload strength training. Exercises are performed without footwear and in view of mirrors for visual feedback. Kinesthetic awareness is promoted by verbal cuing and manual correction in activity performance. Concurrent clinical research using this novel exercise approach has generated outcomes of improved knee joint alignment in stance, walking, and on stairs in as little as six weeks of training. Patients report “awareness of how to use the knee” as well as decreased symptoms of pain and improved function.
Motion Analysis
Vector analysis is the key to the development of the Richmond Vector Training Program. Understanding vector patterns and their control is the core of the program. It is through this neuromuscular training that we believe cartilage stress concentration is minimized and cartilage preservation is maximized.
The labs at Biomotion offer three-dimensional computerized Motion Analysis to evaluate forces that move through the body. In addition to being used in academic kinesiology labs, computerized motion capture systems are used to create video-games and motion pictures. With this technology, very refined determinations of normal and abnormal motion patterns can be ascertained. Combining state-of-the-art equipment, software, and clinical expertise, our lab provides precise measurements and descriptions of an individual’s walking, running and movement patterns.
The 2 primary variables that we objectively measure are:
- Kinematics: motion of each joint in the sagittal, frontal and transverse planes.
- Kinetics: forces of the individual muscles acting at each joint in the sagittal, frontal and transverse planes. Kinetics are comprised of ground reaction forces, center of pressures, joint moments and joint powers.
As part of the Virginia Cartilage Center, the motion analysis lab is able to provide individuals with pre and post treatment data about their biomechanical alignment during functional activities such as walking and ascending and descending stairs. We are able to measure changes in hip and knee alignment, changes in speed of motion, and alterations in forces that are generated at each individual joint. Shear forces are a focus of research at our lab.
The Richmond Vector Training Program is a series of exercise-like movements that the therapists, kinesiologists and engineers have developed as part of a program to minimize cartilage stress at the knee. Our data suggests that by altering the biomechanical alignment and improving core motor control, individuals can have a reduction in knee pain and increased functional improvement in their quality of life.
Richmond Vector Training Program
Training principles incorporated into the training program involve control of force vectors acting on the knee creating compression, tension and particularly shear.
Control of forces acting on the knee can be influenced by local contraction of muscles crossing the knee joint, but also influenced by the support and alignment afforded by the hip and foot/ankle complex in the kinetic chain. Instruction is given in control of force vector direction and magnitude through balance and lower quarter neuro-muscular retraining in three planes of motion. Lower quarter alignment strategies are a focus of training in sit-to-stand transfers, gait, stair climbing as well as sport. Training optimizes the elasticity and potential energy stored in biologic tissues that can be directed toward more efficient human movement.
“Coaching points” promoted in the Richmond Vector Training Program include the following:
Weight distribution through the foot should occur through a “tripod” formed from the balls of the big and little toes to the heel
- Alignment of the kneecap should be held over the second toe with the shin aligned vertically
- Pelvis and shoulders should be held parallel to the ground with back vertical
- Activate more proximal or “core” muscles before attempting a movement sequence to facilitate better control of your center of mass
- Activate the large posterior hip muscles before squatting, arising from sitting, climbing a step
- When squatting attempt to “stick your hips back as far as possible” to activate hip muscles and minimize loads on the knees
- Hand support or counter-weight held anteriorly will assist hips to be “stuck out backwards” accomplishing this squatting movement
- Maintain “kneecap over second toe” relationship when landing on your next stride, from a step, and from a jump
- Attempt to walk faster rather than slower to take advantage of the power created in triple extension of the ankle, knee, hip
- Attempt to walk or run faster by focusing on forward body lean rather than longer strides
- Curl your toes into the ground to achieve greater power in pushing off while walking
- Attempt to land in a “foot flat” position rather than striking your heel while walking or running as foot flat positioning will aid in propulsion forward rather than braking forward momentum
- Squatting is an activity that allows force distribution over a greater knee joint surface area when properly performed and should be practiced
The grid is a training aid used by patients in the Richmond Vector Training Program to better visualize movement patterns performed in three planes of motion.
The central solid blue circle serves as an alignment point to begin varied movement patterns as well as an axis of motion for movement in the transverse plane. Parallel “vertical” bars serve as the “railroad tracks” for movement in the sagittal plane. The single horizontal line allows patients to track motion through the frontal plane. Multi-colored concentric circles function as targets for multi-plane reaching patterns for both upper and lower extremities. These circles also offer quick patient recognition for improvement in controlled displacement in defined vectors. The triangles along the outer green circle are visualized as numbers on a clock face situated at “12-6”, “10-4”, “8-2 o’clock” and the intersection of the horizontal line at “3-9 o’clock”. The identification of these clock face numbers serves as a method of communication between patient and instructor for initiation of movement in cardinal planes as well as diagonal vectors from a stationary central starting point.
Five Functional Screening Tests
Functional screening tests serve to assess participants’ range of motion, flexibility, strength, balance, endurance, motor control, and tolerance to impact loading. Participants are evaluated in performance of functional screening tests on their initial visit and re-evaluated after six weeks of exercise. Grading of functional screen performance serves as a measure to evaluate improvement as well as to define deficiencies that serve as a basis for follow-up exercise training.
The Five Functional Screening Tests include single leg stance, warrior II, hip hinge, full squat, and bench skip. The screening tests are preceded by an easy warm-up for the lower extremities such as stationary bicycling. Each exercise is performed bare-foot and four of the five screens utilize a weighted bar (4 lbs.) to counter-balance and facilitate erect trunk posture.
Single Leg Stance
Purpose: Control center of mass three-dimensionally over a narrowed base of support with attention to alignment of trunk, hip, knee, ankle and foot
Instructions:
- While standing in stride barefoot with the right foot behind the left; engage the core muscles by tightening the trunk and hip muscles as though preparing to “take a punch in the stomach”.
- Drag the right foot forward with pressure on the ball of the right foot; when the right foot parallels the left foot lift the right knee to the front to a height creating a 90 degree angle at the right hip and knee.
- Hold the position for 30 seconds attempting to make the trunk “as tall as possible” slightly elevating the bar held across the back of the shoulders.
- Return to double leg stance and repeat the sequence with the left foot in stride behind the right.
Warrior II
Purpose: Control sagittal plane flexion/extension of the knee with a hip external rotation bias emphasizing kneecap over second toe alignment of the knee
Instructions:
- From a foot parallel stance, step out to the left at a distance wider than shoulder width turning the left foot 90 degrees to the left.
- Maintain the hips and shoulders directed forward as in the original parallel stance while engaging the trunk and hip muscles as if “taking a punch”.
- With the left kneecap directed over and not exceeding the second toe of the left foot, slowly bent the left knee “covering the left toes from sight”.
- Hold the position for 30 seconds and/or alternately bend and straighten the left knee, if holding the posture is uncomfortable.
- Return to parallel stance and repeat to the right turning the right foot out to 90 degrees beyond shoulder width.
Hip Hinge
Purpose: Control alignment of the stance lower extremity through muscle contractions emphasizing the hip abductors, extensors, and lateral rotators of the stance extremity
Instructions:
- Standing in a parallel stance with a bar at arm’s length across your thighs facing “12 o’clock” on an imaginary clockface where “6 o’clock” is directly behind; engage the trunk and hip muscles as though “taking a punch”.
- Balance of the left foot while bending forward lowering the bar toward the floor raising the right foot toward “6 o’clock” behind.
- Reach with the right foot toward “4 o’clock, up to 6 o’clock, and behind the left leg to 8 o’clock”.
- Return the right foot to “6 o’clock” then back to the floor while returning to an upright parallel stance.
- Repeat 10 times on each leg.
Full Squat
Purpose: Develop control of sagittal plane knee flexion and extension using a hip extensor muscle strategy
Instructions:
- Standing in parallel stance with a bar at arms length across the thighs; engage the trunk and hip muscles as though “taking a punch”.
- Extend the bar as far forward as possible while extending the hips as far back as possible over the heels as though attempting to sit in a chair.
- Continue the descent as far as can be controlled without knee pain, hold the bottom position for 2 seconds, return to standing while maintaining a “hips as far back as possible” posture.
- Repeat 10 times.
Bench Skip
Purpose: Control eccentric-to-concentric muscle contractions of the extensors the lumbar spine, hip, knee, and ankle developing the elastic recoil of the myotatic, or stretch reflexes in each of those muscle groups
Instructions:
- Standing with the left foot atop a 4” step and the right foot on the floor; engage the trunk and hip muscles as though preparing to “take a punch”.
- Jump vertically into the air pushing off both feet changing foot positions in the air so as to land softly with the right foot atop the 4” step and the left foot on the floor.
- Immediately repeat the vertical jump off both feet while alternating foot positions as though “landing on hot coals”.
- Repeat the jump cycles until the left foot lands atop the step for 10 repetitions.
Conclusions from the Vector Training Program
- Malalignment of the knee is known to speed deterioration of the early osteoarthritic knee
- Vector training incorporates a philosophy of motor control using hip and ankle strategies to maintain proper alignment of the knee in 3 planes of motion
- Five functional screening tests are used to demonstrate deficiencies in lower extremity motor control that direct the focus of a rehabilitation program
- Preliminary findings demonstrate improved function in ascending/descending stairs as well as reduction in symptoms after 6 weeks of exercise in patients with early osteoarthritis of the knee
- The Vector Training Program uses minimal training equipment with minimal training time enhancing patient compliance for program use in home exercise.