House MD. : Is he using his cane on the correct side ?

House MD. : Is he using his cane on the correct side ? (hint: vascular infarct to the quadriceps muscle)

*disclaimer: Note to listeners…. there is controversy over the lyrics, there always has been and always will be …..but they are listed below at the end of the post.)

When can you ever go wrong with AC/DC ? Combine that with Hugh Laurie from HOUSE MD and you have a great mix.

So, watching this video, why is he using his cane incorrectly? We all know that House’s has a problem with the right hip and leg. “The Rules” state that with a hip problem the cane should always be used on the opposite side to change the D2 lever arm (great lesson on this:https://www.youtube.com/watch?v=FLFQOKVO6X4&feature=youtu.be). After watching this Gait Guys videos you will clearly understand (perhaps to a better level than most of your therapists and doctors who gave you the cane) why it is used on the opposite side.

So, why in the world is the brilliant Dr. House using it on the same side ? We have received this question more than once. And the answer is quite simple. His problem is likely extracapsular. In the pilot episode of House MD it was explained that he suffered a vascular infarct to the quadriceps muscle. Like bone infarcts, muscular infarcts can be painful. If he contracts the quadriceps when loading the leg there will be pain. Just like if the infarct were osseous, the loading of the cortical bone and stress on the trabecular infrastructure in that case, axial loading of the limb (muscular or osseous) will drive pain. So, to lessen the issue he uses the cane on the same side to literally share his body mass load over the length of the cane and splinting of his body mass through that right arm and the cane. He is essentially attempting to use the cane as his weight bearing limb, same as if using crutches. The cane use on the opposite side is best used when you are attempting to unload the muscular compressive forces across the hip (acetabulofemoral) joint. Contraction of the gluteus medius generates the greatest joint compressive loading of all of the hip muscles because of its orientation during gait. Thus, utilizing the cane on the opposite side acts as a hydraulic lift necessitating a shift in body mass closer to the joint and reducing the compressive demands on the gluteus medius muscle.

* Rule breaker: sure, you can still use the cane on the same side to reduce the gluteus medius forces, it is just a bit more awkward and arguably less efficient from a physics persective. But it can be done. Think about and elderly folk who had a weaker opposite arm, they would feel more comfortable using House’s strategy. The rules are not hard pressed.

* So, House is using the cane correctly for his condition. Of course, he is no dummy !

Rules are meant to be broken. When you are as smart as House you know when to break the rules.

Thanks for the reminder AC/DC ……lyrics

https://thegaitguys.tumblr.com/post/17823193087/house-md-is-he-using-his-cane-on-the-correct?fbclid=IwAR1pAHFxhByiSr1orgIKIkOqwj9W1F-dd-4jQ8BEPntlEztgrolwrT60mos

“Living easy, living free
Season ticket on a one-way ride
Hey Momma, look at me

Gait help: How and where to carry a cane, and why.

Screen Shot 2018-02-04 at 2.45.32 PM.png

Test Question from this photo:

This lady on the right is using her cane and purse correctly IF, she has a degenerative hip on the RIGHT or LEFT ?

Answer: LEFT hip

Why, because the cane in the right hand pressing down creates a ground reactive force back up through the cane, helping to tip her torso to the left, the passive cane-generated lean in effect reduces the left gluteus medius compressive load across a painful degenerative hip. Result, less painful gait.

But, she is also brilliant to use the purse in the left hand, to effectively PULL her torso over the left hip (again, limiting g.medius joint compressive forces through more passive means).
End result, less compressive pain loading across a degenerative joint.
*IF we were her daughter we would help by putting a 10 pound brick in the purse, just to help of course.

IF she however has a painful degenerative right hip, school her.

The smell of napalm in the morning: Your gait and trouser coughs, a clinical entity no one talks about.

Written by Dr. Shawn Allen


This is our very last gait guys blog post. Yes, all good things come to an end, even this trusted blog.
But, keeping in good faith, we will finish on a strong note ……. One of gardenia and lavender.  Thanks for the last 5 years gait brethren, is has been a great ride.  Shawn and Ivo
_______________________________
The technical title of this blog post should have been, “The reactive influence of non-normopressure bowel distention and spontaneous high vapor dissipation on bipedal locomotion.”  but no one but true gait nerds would have read it had we stuck with this pubmed-type title. Yes, we are talking about farts and gait here today folks, buckle up.

One biomechanical principle we will link to this entity of “off-gassing“ is that excessive or sustained ankle plantarflexion could inhibit dorsiflexion and certainly, at the very least, works against it. We have talked about this often here on the blog and how the lack of ample ankle dorsiflexion can impair many of the biomechanical events higher up into the human frame. So, how can someone’s bowel gas translate into gait problems ?

Think about this …  to squeeze out a right “cheek sneak” (fart) with optimal crowd pleasing pitch and peak vibrato, some elevation and relaxation of the lower and middle gluteus maximus divisions (coccygeal and sacral) seems imperative to optimally control off-gassing . Seemingly, to do this, a significant degree of right ankle plantarflexion may be necessary to lift the right hemipelvis driving a subsequent intentional clockwise pelvic distortion assisting in the relaxation of these gluteal divisions.  This consciously driven right side of the body “lift” via the right ankle plantarflexion can also be met and assisted via ipsitlateral abdominal and contralateral gluteus medius contraction to further enable the optimal right hemipelvis elevation. Go ahead, stand up and mimic the posture and note these biomechanical pieces. Recall our mantra, 

“when the foot is on the ground, the glutes are in charge, when the foot is in the air, the abdominals are in charge”.  

These coordinated motor patterns might be considered dual/multi tasking. This honed series of biomechanical events is one often perfected in frat houses and basement gaming rooms. But make no mistake, there is a biomechanical danger lurking here if this becomes a habitual compensation pattern, one common in large volume legume consumers (beware vegans). Habituation of this motor task, or demonstrating poor technique over time can render right quadratus lumborum shortening and weak lower abdominals rendering an anterior pelvic tilt. This tilt may lead to gluteal inhibition/weakness (because it is difficult to contract the gluteals in an anterior pelvic tilt, go ahead stand up again and try it) which over time can impair stance phase gait mechanics. However, relating to the off-gassing, this physical posturing might optimize low frequency gluteal vibrations that can optimize vibrato during gas dissipation if pressurization is in fact optimal for an “audible”.  It is important to note that conscious variable control of the tonus of the muscular anal sphincter complex plays a big part in the pitch and vibrato. There is always a drawback it seems, it does truly come down to motor control it seems, doesn’t it always ?


This is not to say that avoiding “audibles” through holding “one” in doesn’t have consequences. The exotic gas (nitrogen, carbon dioxide, hydrogen, methane, oxygen) induced gut distention that could only make your collage roommate proud can inhibit the abdominal wall and thus the lower thoracic canister and disable normal breathing mechanics. This could be a serious complication to the coupled events of respiration and thoracic mobility. So, holding that big one in for your friends rather than engaging the compensatory Trendeleburg-type off-gassing posture as described above is also fraught with problems. We know that functional disconnection of the thoracic canister from the pelvic core can disrupt the normal anti-phasic mechanics of the contralateral upper and lower limbs as well as possibly impair the normal spinal cord mediated central pattern generators.

Farts…..Call them what you want, those ear pleasing, nose hair curling, trouser coughs that only a teenage boy can truly relish and recognize as a function of boyhood success.  All joking aside, they truly should be your biggest concern in your gait analysis evaluation, bar none. Ask your patients about their bowels and off-gassing, it should be part of your clinical history intake. Maybe even consider taking out the discomfort of open dialogue, and put it on your intake forms. We found that a stick figure diagram in a good biomechanical squat posture with a mushroom cloud formation hanging overhead eases dialogue tension about this sensitive topic. We even give the young children crayons to they can color the cloud. What fun !


Dare us to write a part two on this topic. “Blue Angels” (unfamilar with this clinical phenomenon? look it up). Go ahead, dare us for a part 2. 

By now, if you haven’t realized that The Gait Guys just punked you, then you likely haven’t had your cup of morning coffee. Yes, we have no clue what we were talking about on this blog post, well, ok maybe, after all we do have that y-chromosome. Yes, we are NOT ending the blog either :) 

Are you now considering us juvenile ? Ok maybe we are a little, but don’t deny it, you thought about some unique and honest body biomechanics for a moment here and it is these mental gymnastics that will take your creative thinking about gait to the next level. If you are upset, so be it. There will be no apologies here in this growing PC world. Off-gassing is a human thing, we all do it. We have been writing serious stuff daily for 5 years here on The Gait Guys. It was time for us to write something a little lighter.  We can only hope that you will think of us and the complexities of the gait cycle the next time you sneak one out while having dinner at the in-laws.  Try not to giggle when you do, but for certain, think about your body mechanics when you do, we can’t be responsible for off-gassing injuries. Think of us.

Shawn Allen, remaining here, for the duration.

disclaimer: we cannot be responsible for injuries that might be sustained by improper off-gassing events. We also do not recommend attempts at performing Blue Angels, this is a potentially dangerous activity and could cause great bodily harm (seriously). :)

Video Gait Case: It is Neuromechanics Wednesday.

* Remember: you can always click on the YOUTUBE logo in the bottom right corner of the video to be hyperlinked to a blown up version of the video on youtube.  Just remember to read what we have written here as well. 

Here we present a video case of a client with advancing spinal myelopathy with characteristics of Trendelenburg gait pathology. Be patient with the first few slides, we have to set up and teach about the important issues regarding the topic and case otherwise some folks will get lost.  There is much to this case. There is evidence of balance issues (dorsal column disease), limb circumduction, 5 point turning strategy (abnormal), pathologic arm swing changes and a few other issues to observe. If you are looking for a great gait case that covers several layers, this is a good one. Be sure to check our our blog, youtube channel and website for other great videos and teaching cases.