Author: Maite Tubía Tejada
Cross pattern movement means using the opposite arm and leg at the same time. Sensory and motor neurons on both sides of the brain are activated, requiring them to work in coordination to move the opposite arm and leg. There is an exchange of information between the left hemisphere and the right hemisphere so that both brain hemispheres work as a well-integrated whole.
Integrating is making a whole with the parts. In the cross percussion gait, the two diagonals of opposite hand-leg coordination are integrated in a movement of set unity, alternating one and the other coordination. Learning it requires cognitive work, a mental effort to master the body that improves body awareness.
The first practice of cross pattern movement will be to touch with the hand the medial face of the opposite knee, alternating one and another diagonal coordination.
Before starting to teach the patient the walking with crossed percussions, he shall practice and pass the following cross lateral exercise:
1st Position: seated
Movement: lifting each leg alternately and simultaneously touching the inside of the knee being lifted with the hand on the opposite side (right hand → left knee; left hand → right knee) and add a slight twist of the trunk towards the leg being lifted.
2nd Position: perform the same exercise standing
This exercise requires coordination of movement on both sides of the body and familiarises the patient with the criss-crossing of movement from one side of the body to the other, crossing the midline in two diagonals that intersect and alternate in the action.
WALKING WITH CROSSED PERCUSSIONS
The next cross pattern movement practice will be the walking with crossed percussions. Here, we will use long cardboard cylinders of 3-4.5 cm in diameter and length a little below the shoulders height, to be used as Nordic walking poles.
Nordic walking is a sporting activity in which cross-over coordinations are performed by sticking the poles (tipped) into the ground. In cross-country skiing, this cross-over pattern is also performed by sticking the poles (tipped) into the snow. Its equivalent in the Musical Body Rhythmics will be the walking with crossed percussions, in which the cylinder hits the wooden floor with each step of the opposite leg. The exercise is practised on a wooden floor, which is pleasant to the ear. Both nailing the pole in the ground and hitting the cardboard cylinder on the floor are skills that the hemiparesis patient will have to develop.
Once it has been determined when the patient is ready to learn to walk with cross percussions, the difficulties that will be encountered in the affected arm-hand are as follows:
– The hand does not hold (it does not grip) the cylinder properly, so the patient drags it and soon falls to the ground.
– The arm does not extend forward.
– There is no action of hitting the ground with the cylinder (or nailing the tip of the walking nordic pole). The patient puts the cylinder on the floor, but the action is not clear.
Walking with crossed percussions is learned at an advanced stage of training in the Tubía rhythmics method to recover the movement. The patient must have passed walking exercises, walking exercises with rhythmic sequences and hand coordination, hand exercises, arm exercises, lateral displacements, percussions with 90 cm cardboard cylinders, the cross lateral exercise described above, etc.
Although the patient grasps objects or has improved elbow extension, when put into a complex movement pattern, where several actions need to be brought together in an ensemble response, he cannot make simultaneous synchronisations to coordinate.
Crossed percussions walking will test the improvements of certain movements practised in isolation in a complex movement situation, which will require a great effort of concentration, a cognitive work of mental mastery of the body.
GUIDELINES TO FOLLOW
In the crossed percussions walking with two cylinders, one hit is given at each step, with the coordination of these hits being hand-opposite leg that gives the step.
To start directly with two cylinders would be setting the bar too high, so what we are going to do is to decompose this march in order to learn it. In addition, it is essential to master the coordination of a single cylinder with the opposite leg, whether carried in the right or left hand.
The guidelines and steps to be followed for a patient with right-sided hemiparesis are described below. For a patient with left-sided hemiparesis, we will reverse everything.
1st STAGE
The first coordination that the patient will do will be with the healthy arm: cylinder in the left hand, coordinating the percussions with the steps of the right foot. With each step of the right foot, the left hand hit the floor with the cylinder at the level of the right foot (tendency to hit the cylinder forward).
People who walk in the countryside and in the mountain are very familiar with this practice, being most often using a dry branch found in the nature. We will check whether the patient has ever done this practice in his life. If not, we will teach him how to do it by standing next to him and we will take the cylinder movement to him. First he will feel the movement well done and then he will reproduce it by himself.
This march with cross percussion with a single cylinder will be practised on a wooden floor.
2nd STAGE
Once the patient has mastered the coordination between the healthy left arm and the paretic right leg, we will move on to put the paretic arm into action. The therapist is placed on the right side of the patient and with his right hand grips the cylinder below the level of the patient’s hand to mark the hits, and with his left arm takes the patient’s right arm from behind to mark the movements that this arm should do but it still does not. The movement in which we are going to feel the most opposition is going to be stretching the arm forward, because of the spasticity and because it does not move. But it does not matter. We are now at the stage where the patient feels the movement well done and also feels the repercussions it has on his posture and balance, which implies a work of adjustment of the center of gravity and with it an improvement of the balance. This fact requires him to make an effort of concentration.
We will use musical pieces at 60 steps/minute. As the patient becomes familiar with the exercise, we will ask him to join in the movement (because we are doing it to him).
The next step is for us to mark 4 co-ordinations and the next 4 he will do alone. Without the music, we will let the patient know that after the first hit, his arm stays behind and he forgets to bring it forward and he drags the cylinder. We will slowly mark on the arm the movement to be made. We will continue day by day doing what has been described so far until a moment comes when the patient starts to bring the cylinder into place for a few steps. From this point on, we continue to perfect and practise walking with cross percussion with each arm separately.
Complements:
During this stage the patient is learning to co-ordinate: on the one hand, the left arm with the right leg and on the other hand, the right arm with the left leg, these co-ordinations being executed separately. He will practise one coordination with a whole piece of music and then the other coordination with the same piece of music.
It will also be important to carry out complementary exercises every day, following the above, in order to begin to unify both co-ordinations in an alternating movement, combining both co-ordinations.
These exercises will consist of swinging the cylinders that we are using for walking, the classification, but not description, of which is detailed below:
Starting position: patient and therapist face each other, holding the cylinders horizontally, on the sides of the legs, to make swinging movements.
1. Swinging of the two cylinders in the same direction.
2. Swinging of each cylinder separately.
3. Reproduction of the swinging of the arms while walking: swinging with cylinders.
4. Coordinating footsteps on the site with the movement of the cylinders.
5. Arm retroversion.
6. Gait with horizontal cylinders.
3rd STAGE
Walking with crossed percussions with two cylinders
Materials: 2 long cardboard cylinders of length a little below the shoulders height and 3-4.5 cm in diameter, to be used as percussion instruments. Wooden floor. Sometimes it can be useful to put a path of thin carpet on the wooden floor to help fix the hit.
Starting position: weight distributed on both legs. One cylinder in each hand resting on the floor. The therapist stands in front of the patient to lead the movement of the cylinders, holding them below the level of the patient’s hands and moves backwards.
In order for the patient to assimilate this coordination, which will be very complex for him, we will start by leading him for 4 steps. We will then stop to recompose the starting position, the symmetry of the posture and we will lead him another 4 steps and so on. We are at the stage where he feels the movement well done. The first step will be taken with the affected leg and the percussion with the healthy hand. This is because the patient has to concentrate on the hand that is to be coordinated and start with the action of the hand he controls will facilitate the boot of the exercise. At each step we will stop rhythmically, so that the steps are not chained but stopped. Chained steps have pulse of crotchet (quarter note) and stopped steps have pulse of minim (half note).
A fact is going to occur concerning the posture. The patient is used to having the right hemitrunk backwards. It will happen that at the moment of the percussion of the cylinder of the right hand with the step of the left foot, the right hemitrunk has to turn, very slightly, in that direction. As we make this correction, the posture he takes is very strange for him, accustomed as he has been for a long time to having his hemitrunk backwards.
Tapping the cylinder at each step of the opposite foot makes the sensation of that coordination more concrete than if the hand is empty.
Detail: collisions of the affected foot with the cylinder. The collisions of the paretic foot with the cylinder will help the patient to correct the external rotation of the leg. They will be so many that they will make him more aware that he is having that leg a little abandoned and as it is annoying, heavy, the conscious correction will make the correct orientation of the leg and the foot automate.
With practice the number of steps without having to stop will increase. Then we will perform the exercise with music at 60 beats/minute and lead the patient throughout the whole piece of music. In subsequent weeks we will introduce faster pieces of music up to 70 beats/minute.
At the appropriate moment the patient will start to do the exercise by himself. We ask him to take 4 steps with the corresponding coordination. He stops, recomposes his posture and takes another 4 steps. And so on.
Cognitive difficulties:
The fact of having led the patient, marking the therapist the percussions so that he feels the coordination well done, has left its mark on the patient’s memory of sensations. This will allow him to compare what happens when he is led with what happens when he do the cross percussions alone.
The mistakes he will encounter and have to overcome are:
– He percuss the cylinder with the leg step on the same side.
– He percuss both cylinders simultaneously with one step.
In video 1 we can see how these difficulties occur.
– Once he manages the correct cross coordination he will have to correct the exact point of the hit (which is at the level of the stepping foot) because he Will have a tendency to percussing ahead of the foot that takes the step.
To correct these difficulties it is helpful to lead him through 4 steps and the next 4 steps are taken by himself without help, linking these transitions rhythmically and fluently and at the appropriate speed of assimilation.
This walking exercise with cross percussions is a test in itself and is considered passed when the patient remains constant in movement and rhythm for an entire piece of music. The patient will also pass this test without music (video 2).
When we see the patient doing the exercise alone without music, we will be able to appreciate the good influence that the music has had on the maintenance of a constant speed, not only in the steps but also in the thinking, in the motor planning of this cross-coordination. Also in the voice, in the words that he may repeat rhythmically: – another, another, another… step, step, step, step… Language, thought and movement come together in integration, in unison. Three functions have been launched in unison, to which we can add one more: the will, personal motivation, the pleasure of discovering a complex movement.
In the walking with cross percussions, we will observe how the patient’s posture improves in terms of the affected backwards hemitrunk, which will be more in its place. We will also observe that the dragging foot is not dragging during this exercise. The collisions of the foot with the cylinder make him more aware of lifting the foot and he corrects it himself. The patient also corrects the external rotation of the affected leg.
Walking with cross percussions is a very complete exercise that will make the patient with hemiparesis aware of the sensation of body symmetry that he has lost or never had if the hemiparesis is congenital.
Gait with cross-coordinations and free-hands
Once the patient has passed the two-cylinder cross-percussion gait, he will try the same cross-percussion coordination without cylinders, with free hands.
The right arm will go forward with each step of the left foot, but in addition the left arm simultaneously goes backwards and the trunk makes a gentle twist turning very slightly towards the foot it steps on (the left foot).
The left arm will go forward with each step of the right foot, but in addition the right arm simultaneously goes backwards and the trunk makes a gentle twist turning very slightly towards the foot it is stepping on (the right foot).
Moving behind the patient, we will correct the arm movements. If we take the example of the patient with right hemiparesis, the healthy left arm will not take the correct trajectory of retroversion but rather open, so we will be prepared to bring this arm into the correct position. Passing quickly behind him, we will take his right arm by the forearm and bring it backwards. As the patient is not ready to make a correct retroversion, a practical action for the parectic arm is, instead of attempting pure retroversion, to place the hand on top of the right buttock supported by the dorsum.
What matters is the cognitive work for correct coordination even if there are motor difficulties in the affected arm and leg.
In terms of how to proceed we will apply the 4 steps and stop action tactic → 4 steps and stop action…
Cognitive difficulties:
– The patient brings the arm forward with the step of the leg on the same side.
– Patient simultaneously brings both arms forward with each step.
In video 3 we can see how these difficulties occur.
This exercise is itself a test and is considered passed when the patient remains constant in movement and rhythm for an entire piece of music. The patient will also pass this test without music and will be able to reproduce this movement pattern at any time (Video 4).
When the patient passes the cross percussion gait exercises with cylinders (video 2) and the cross coordination gait with free hands (video 4), we will remind him how difficult it was for him to learn something so complicated and that he has managed it by taking it easy, with small progress little by little and with a few minutes of great mental concentration over many, many days. Overcoming a difficulty produces emotional well-being. The person realises that the effort, overcoming discouragement with an endeavour, has been worthwhile.
In video 2 of this article we will see a young man with right congenital hemiparesis and intellectual disability who has learned and practises walking with cross percussions. In video 1 we will see cognitive difficulties in the learning stage.
In video 4 of this article we will see the same young person performing the the cross coordinations gait with free hands. In video 3 we will see cognitive difficulties in the learning stage.
Finally, it should be noted that the procedure, the way of teaching and the stages described in the cross percussions gait with cilinders and in the cross coordinations gait with free hands, are the same for both congenital and acquired hemiparesis. They are also the same in intellectual disability and these cross movement patterns will contribute to motor and cognitive development. The final mastery of the walking with cross percussions will be with chained steps to pulse of crotchet (quarter note), at the natural walking speed of each person.
Onwards, it will be good for the patient to practise Nordic walking in outdoor environments in dirt ground and especially on a lawn, with metal-tipped poles to stick them into the ground. It is also practical to use rubber pads, which are very suitable for hard (asphalted) surfaces.
In the case of congenital hemiparesis we have to keep in mind that the patient is learning a large number of movements that he has never experienced before, which is not an obstacle. The movement therapist is a movement teacher for the patient. In hemiparesis due to acquired brain injury we will find variability in cognitive impairment, in the speed of progress in learning these cross-coordinations and in the recovery of movement on the affected side of the body. An advantage will be to have had experience of these co-ordinations prior to the brain damage.
With regard to motor and cognitive movement disorders, two circumstances should be taken into account:
1 Injuries to a mature brain, which has developed, acquired skills and abilities but has lost them as a result of injury or disease. This is the case for stroke, TBI, Parkinson’s, multiple sclerosis, tumours, etc.
2 Injuries to an immature brain, when it has not yet developed and therefore has not acquired skills and abilities of which the first group has experience. This is the case for all injuries that occur during gestation, birth and the first months of life.