Tricks of the trade: Backward walking

image credit: https://pixabay.com/vectors/slide-sliding-falling-stickman-151861/

image credit: https://pixabay.com/vectors/slide-sliding-falling-stickman-151861/

A single event can generate asynchronous sensory cues due to variable encoding, transmission, and processing delays. Robert Peterka talks about this, along with posture compensation and system apportionment when it comes to balance and coordination of the visual, vestibular and proprioceptive systems. We have talked about that here on the blog in the past.

We are often looking for ways to “highlight” pathology and make it more visible in the clinical exam. Having your patient/client walk backwards is one of those tools.

Walking and remaining upright in the gravitational plane requires 3 integrated systems to work in concert with one another: the visual, vestibular and proprioceptive systems. Backwards walking requires a more coordinated effort AND IF there is a “hiccup” or extra demand on the system (the proprioceptive in this case), neurological processing can take a little longer, efforts can be delayed and the end result is a greater compensation is needed; this often makes pathology more evident.

Try having your client walk backwards when you are doing your exam and see what we mean. We think you will be surprised with the results : )

Dr Ivo Waerlop, one of The Gait Guys

Peterka RJStatler KDWrisley DMHorak FB. Postural compensation for unilateral vestibular loss. Front Neurol. 2011 Sep 6;2:57. doi: 10.3389/fneur.2011.00057. eCollection 2011.

temporal Shayman CSSeo JHOh YLewis RFPeterka RJHullar TE.Relationship between vestibular sensitivity and multisensory temporal integration. J Neurophysiol. 2018 Oct 1;120(4):1572-1577. doi: 10.1152/jn.00379.2018. Epub 2018 Jul 18.

Hawkins KABalasubramanian CKVistamehr AConroy CRose DKClark DJFox EJ. Assessment of backward walking unmasks mobility impairments in post-stroke community ambulators. Top Stroke Rehabil. 2019 May 12:1-7. doi: 10.1080/10749357.2019.1609182. [Epub ahead of print]

#backwardwalking #clinicalexam #thegaitguys #gaitpathology #clinicaltricksofthetrade

More on Fatigue... When are you examining your patients?

You have probably read our posts from a day or so ago about fatigue and running. If not, see here and here.   In addition to the articles cited, it was based on this article here.

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So how many times do we se someone in the clinic who have a problem, but it is not apparent at the time of exam? You know the scenario "I get this low back pain at mile 10" or "My knee hurts on the bike at mile 50". Our questions are

"So, when are you examining your patient?".

  • Are they fresh out of the box 1st thing in the morning, before their work out because that  is when you had an opening?
  • Is it after a long day with a different workout under different circumstances?
  • Is it right about at the time they usually have the issue?

The correct answer is "C". We like to say "if we can reproduce the pain, we can most likely figure out what the problem is and can usually come up with a solution or a different compensation". 

See your people around the time of the injury. If they get pain at mile 19, then have them run 18 prior to their visit and have them finish up in the office. If the knee pain is at mile 50 on the bike, have them do the last 10 on the trainer under your supervision. People will often have great mechanics until they begin to crumple. Your job is to see them at their worst, or watch their function deteriorate real time and try and come up with a solution. 

This concept is used all the time in exercise and stress testing. Why don't we use it with other than cardiovascular evaluations? The question eludes us. We often call this "pre fatigue" and use its all the time. You should too. The factors that separate a good clinician from a great one is outcomes. Be all you can be...

 

The Gait Guys

 

Dores H, Mendes L, Ferreira A, Santos JF. Symptomatic Exercise-induced Intraventricular Gradient in Competitive Athlete. Arquivos Brasileiros de Cardiologia. 2017;109(1):87-89. doi:10.5935/abc.20170075. FREE FULL TEXT

Biffi AAmmirati FCaselli GFernando FCardinale MFaletra EMazzuca VVerdile LSantini M.Usefulness of transesophageal pacing during exercise for evaluating palpitations in top-level athletes. Am J Cardiol. 1993 Oct 15;72(12):922-6. FREE FULL TEXT: http://www.ajconline.org/article/0002-9149(93)91108-T/pdf

 

 

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OK Folks

Take a look at these pics for a moment, then come back and read.

Ready? Lets see how much you remember about torsions and versions. Take a look at this child that was brought in by their parent (legs were too short to drive themselves : )  ) They were wondering if the child needed orthotics. What do we see?

top left photo: legs are in a neutral position. note the position of the knee (more specifically the tibial tuberosity and patellae can sometimes fake you out. ( OK, maybe not you, but they can sometimes fake SOME people out). The plane of the 2nd metatarsal is LATERAL to the tibial tuberosity, This is EXTERNAL TIBIAL TORSION; it appears greater on the (patients) right (look also at the left lower leg in the center picture as well, it has less torsion). Note also the lower longitudinal arches bilaterally (they are typically higher in non-weightbearing but in children this young they are typically lower in the early stages).

top right photo: I am fully internally rotating the right lower leg and hip. Note the position of the knee; it does not rotate as much as you would expect (normally 40 degrees) when compared to the distance the foot seems to have travelled. This hip is RETRO-TORSIONED (remember we are born anteverted about 40 degrees, which decreases approximately 1.5 degrees per year to puberty, resulting in an 8-12 degree angle in the adult. If you need a review, go back and read the February 27th post). Go back and read our 5 part series on Versions and Torsions (“Are you Twisted ?”).

Center photo: I am fully externally rotating the right leg. Note that range of motion is much greater than internal rotation and exceeds 40 degrees. This supports the previous paragraph, retro-torsion.

Bottom left: I am fully internally rotating the left lower leg. It appears normal  with about 40 degrees (or more) of internal rotation. This femur is NORMAL or has NORMAL FEMORAL VERSION.

Bottom right: I am externally rotating the left leg. Motion appears to mimic internal rotation and is approximately equal. This supports the previous paragraph as NORMAL FEMORAL VERSION.                               

In summary:

  • External tibial torsion, R > L
  • flattened longitudinal arches
  • Right femoral retrotorsion
  • Left femoral version, NORMAL

Well, what do you think? Are orthotics going to help this kiddo? No, probably not, they may even make the problem worse, by slowing derotation of the talar head, forcing them into more permanent varus of the forefoot.                                                                                                           

How did you do? Can you see now why torsions and versions (the degree of “twistedness” of a limb is so important? They help you understand skeletal development and help you to make clearer decisions.

The Gait Guys. Twisted in a good way. Versioned but not torsioned.

all material copyright 2013 The Gait Guys/The Homunculus Group. all rights reserved. please don’t use our stuff without asking : )