Thanks to NWUK Instructor and physiotherapist Heather Watson (pictured) for sharing this excellent, comprehensive case study of how Nordic walking was used to rehabilitate a 48 year Woman who suffered from back and leg pain. First presented at our National Conference in 2011, this study is a useful resource for all those involved in rehabilitation exercise.

We have outlined the key points of the case study below and attached the full paper as a PDF (see below).

The patient presented with the following medical history: chronic low back and leg pain on the left side which was recently aggravated by a fall from her horse. Clinical findings on examination included:

• Limited lumbar movements
• Occasional left foot pins and needles and numbness
• Normal reflexes
• Painful resisted muscle tests with left leg
• Rounded trunk posture when standing
• Poor weight bearing on left leg
• Reduced arm swing on the left
• Reduced body rotation when walking

Compensation on the right side of the body with right arm and trunk pulling down when walking caused by overactivity of the latissimus dorsi muscles.

The treatment given to the patient previously in the clinic included manual therapy, soft tissue release, and a remedial exercise programme based on the JEMS Movement approach (Elphintson 2008). Nordic Walking was introduced after an initial activity focusing on foot movements, posture and weight bearing to help activate the stabilisers and prepare for walking. The Nordic Walking poles helped the patient to equalise weight bearing, enabling achievement of a more balanced posture by allowing the left side of her body and her left leg to take more weight, thereby releasing some of the compensation from the right side. A relative lack of trunk stability had resulted in compensatory stabilising strategies on the right side with the latissimus dorsi becoming overactive in response to a weak gluteus maximus muscle on the left (Elphinston 2008), therefore restoration of trunk stability was an initial priority to prevent this issue from recurring. Single poling, with a pole in the left hand only, was used for part of the session to increase the patient’s awareness of her left arm and trunk, and to enable the right arm to start relaxing. Once increased activation of the stabilisers had been achieved with better posture and improved weight bearing, allowing improved stride length and hip motion, better activity in the gluteus maximus, a reduction of over activity in the right latissimus dorsi was possible. This enabled the right arm to release and swing more freely which was necessary prior to working on body rotation.

Loss of counter body rotation results in loss of elastic energy created by the myofascial sling (Figure 2) since it is thought that the sling acts like an elastic band – when the body rotates energy is stored as it contracts and released when it relaxes, helping propel the body forward and allowing the transfer of forces across the body and through the limbs.

Improved body rotation, where the arms are allowed to swing freely, results in a larger range of motion with the elasticity creating momentum. Rotation increases the tension through the myofascial sling which can help to stimulate activation of the gluteal muscles on opposite sides of the body (Elphinston 2008, 2013). In turn, they are then able to generate more power for the propulsion required for walking, resulting in a lengthened stride with improved hip motion. The movement inherent in rotation reduces tension in the spinal muscles that can be a contributing factor in pain and discomfort. In the patient’s case, she had been walking slowly due to back and leg pain, which in turn reduced her arm swing, and consequently her body’s counter-rotation. With the pain having already compromised efficiency in her gluteal muscles, and trunk and pelvic stabilisers, this lack of rotation further reduced her ability to access these muscles and walk more effectively.

The patient was able to practice and improve her arm swing technique using Nordic Walking poles to give extra momentum to the swing.

This case considers the interventions made in a single 1 hour session with the patient which enabled her to achieve an improved posture when walking along with improved dynamic control of the trunk. On observation her weight bearing appeared to became more symmetrical and she had better acceptance of weight through the left leg, and increased awareness of her left arm and leg. Body rotation was also improved with the consequent immediate results of increased walking speed and fluidity of movement.

Conclusion
In this case study Nordic walking enabled the therapist to progress rehabilitation into functional outdoor walking using the principles of Nordic walking technique applied with a professional understanding of the underlying condition, and drawing on techniques to improve movement efficiency and fluency.

Nordic walking, delivered by an appropriately qualified instructor who is also a physiotherapist can be a useful adjunct to standard physical rehabilitation for progressing function outside of the clinic, and can support a patient to take up regular independent walking exercise by increasing confidence that it is safe and effective.

In summary, Nordic Walking is an accessible exercise technique which may help to reduce back pain and tension, enabling the individual to move more freely and feel the benefits of regular physical activity. As the individual progresses, stamina and fitness is likely to increase, which may help reduce the risk of longer term health problems and the risk of recurrent or persistent back pain and health issues associated with an inactive lifestyle.

Tips for Nordic Walking Instructors working with people with existing back and/ or leg pain:

• Aim to achieve some improvement in walking posture in the first session as this will increase activation of the deep trunk stabilisers and help establish equal weight bearing.
• Any side-to-side trunk movement observed is likely to be associated with loss of body rotation and/ or poor use of one arm.
• Practice arm swings while walking, and if necessary standing still, to regain the feeling of rotation and progress into body rotation while walking.
• Avoid steep or long hills in the early stages until a good basic technique has been established as these can aggravate pain if there is insufficient muscle power for effective propulsion.

Note:
The case study described here is based on a case presented at the Nordic Walking UK Instructor Conference 2011 by Heather Watson, a Chartered Physiotherapist with a special interest in movement and exercise. Heather is a qualified Nordic Walking Instructor and combines her knowledge and expertise as a Specialist Musculoskeletal Physiotherapist, and her educational experience as a national Tutor for the Joanne Elphinston Movement Systems (JEMS) with her skills as a Nordic Walking Instructor.

Nordic Walking technique instruction should only be conducted under the guidance of a fully qualified Nordic Walking Instructor: For more information about Nordic walking and to find a qualified instructor please visit www.nordicwalking.co.uk . For clients with significant health issues Nordic walking Instructors should also hold an Exercise Referral qualification or be a qualified health professional. See HERE for details.

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Attachments: (PDF)
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