Podcast 151: Gait and neurology of movement, including, Tightness? shortness? What’s the difference? It's the Neurology.

Truths about Stretching, a case of sesamoiditis, plus exercised induced muscle damage and impaired motor learning, central fatigue, POSE and Chi running and injuries. This is a good one gang, do not miss it !

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Other links for today's show:

http://traffic.libsyn.com/thegaitguys/pod_151final.mp3

http://thegaitguys.libsyn.com/gait-and-neurology-of-movement-including-tightness-shortness-whats-the-difference-its-the-neurology

http://directory.libsyn.com/episode/index/id/11168369

Show notes and links:

We lose muscular Strength as we age.
Changes in supra-spinal activation play a significant role in the age-related changes in strength.
This motor system impairment can be improved by heavy resistance training
https://www.ncbi.nlm.nih.gov/pubmed/25940749

Age (Dordr). 2015 Jun;37(3):9784. doi: 10.1007/s11357-015-9784-y. Epub 2015 May 5.
Strength training-induced responses in older adults: attenuation of descending neural drive with age. Unhjem R1, Lundestad R, Fimland MS, Mosti MP, Wang E.

Osteoarthritis and running
https://journals.lww.com/acsm-csmr/Abstract/2019/06000/Running_Dose_and_Risk_of_Developing.5.aspx
Recent literature adds to a growing body of evidence suggesting that lower-dose running may be protective against the development of osteoarthritis, whereas higher-dose running may increase one's risk of developing lower-extremity osteoarthritis. However, running dose remains challenging to define, leading to difficulty in providing firm recommendations to patients regarding the degree of running which may be safe.

Can even experienced orthopaedic surgeons predict who will benefit from surgery when patients present with degenerative meniscal tears? A survey of 194 orthopaedic surgeons who made 3880 predictions
Non-surgical management is appropriate as first-line therapy in middle-aged patients with symptomatic non-obstructive meniscal tears.
https://bjsm.bmj.com/content/early/2019/08/12/bjsports-2019-100567

Sports Biomech. 2019 Jul 31:1-16. doi: 10.1080/14763141.2019.1624812. [Epub ahead of print]
Running biomechanics before and after Pose® method gait retraining in distance runners.
Wei RX1, Au IPH1, Lau FOY1, Zhang JH1, Chan ZYS1, MacPhail AJC1, Mangubat AL1, Pun G1, Cheung RTH1.

Does Manual Therapy help with OA?

Footnotes 7 - Black and Red.jpg

The answer is yes, at least according to this lit review.

The “data crunching” found that manual therapy, defined as any hands on treatment rendered, with (and without) exercise therapy resulted in reducing pain, improving function, ROM and physical performance in patients with knee OA, at least in the short term. 

Anwer et al., Effects of orthopaedic manual therapy in knee osteoarthritis: a systematic review and meta-analysis. J Physiother 104 (2018) 264-276.

Is there a need for "Gait Retraining'?...We think so

photo source: https://commons.wikimedia.org/wiki/File:Severe_(Tönnis_grade_3)_osteoarthritis_of_the_hip.jpg

photo source: https://commons.wikimedia.org/wiki/File:Severe_(Tönnis_grade_3)_osteoarthritis_of_the_hip.jpg

There seems to be some controversy with regards to gait retraining. Some folks seem to believe that it should be “left to itself” and they are fully compensated already (1). Perhaps this is true…or not. We have not seen any studies that compare gait retraining vs non gait retraining as a whole, but there seems to be plenty for specific conditions (2). We all see folks AFTER THE FACT and seek to correct the problems and reverse, halt or slow the progression of further pathology. That seems to be what many of us do.

This recent study (3) looks ate altered loads and muscle recruitment patterns in patients with osteoarthritis. they conclude:

“This study documents alterations in hip kinematics and kinetics resulting in decreased hip loading in patients with hip OA. The results suggested that patients altered their gait to increase medio-lateral stability, thereby decreasing demand on the hip abductors. These findings support discharge of abductor muscles that may bear clinical relevance of tailored rehabilitation targeting hip abductor muscles strengthening and gait retraining.”

There is substantial evidence that hip pathomechanics lead to osteoarthritis (4, 5). Wouldn’t it make sense to assist in altering motor patterns and correct those biomechanical faults before it becomes a problem? Lets change our focus (if we haven’t already) and concentrate on skill, endurance and strength, in that order for the betterment of ourselves, our patients and humanity.

  1. Nigg BM, Baltich J, Hoerzer S, Enders H. Running shoes and running injuries: mythbusting and a proposal for two new paradigms: “preferred movement path” and “comfort filter” Br J Sports Med. 2015 Jul; doi: 10.1136/bjsports-2015-095054. bjsports - 2015-095054. 

  2. Davis IS, Futrell E. Gait Retraining: Altering the Fingerprint of Gait. Physical medicine and rehabilitation clinics of North America. 2016;27(1):339-355. doi:10.1016/j.pmr.2015.09.002. FREE FULL TEXT

  3. Meyer CAG, Wesseling M, Corten K, Nieuwenhuys A, Monari D5, Simon JP, Jonkers I, Desloovere K. Hip movement pathomechanics of patients with hip osteoarthritis aim at reducing hip joint loading on the osteoarthritic side. Gait Posture. 2018 Jan;59:11-17. doi: 10.1016/j.gaitpost.2017.09.020. Epub 2017 Sep 22.

  4. Christian Egloff, Thomas Hügle, Victor Valderrabano: Biomechanics and pathomechanisms of osteoarthritis Swiss Med Wkly. 2012;142:w13583 FREE FULL TEXT

  5. https://www.the-rheumatologist.org/article/get-out-of-your-oa-box/?singlepage=1&theme=print-friendly

The buck DOES NOT stop here...

The buck doesn't stop here..

image from: http://www.aofas.org/footcaremd/treatments/pages/triple-arthrodesis.aspx

image from: http://www.aofas.org/footcaremd/treatments/pages/triple-arthrodesis.aspx

One of the most pervasive problems following a ankle arthrodesis, particularly a triple arthrodesis which involves fusing the subtalar (talocalcaneal), calcaneocuboid , and talonavicular joints results in a loss of ankle rocker. The "buck" needs to be passed somewhere and this usually will mean proximally in the lower kinetic chain.

Seeing adjacent joints with osteoarthritic changes following hypomobility have another joint is nothing new; you probably see it all the time in practice. Remember that it is not always have to be a "fusion". Simple longstanding pathomechanics or longstanding hypomobility will often cause the same problems.

A nice, full text referenced review 1 of her favorite journals. Some nice side discussions as well. Enjoy : )

"Altered biomechanics after ankle arthro­desis often increase stress on the adjacent joints in the foot, which can cause or exacerbate osteoarthritic degeneration in those joints. Clinicians and researchers are working to better understand this process and how to minimize patients’ risk."

http://lermagazine.com/…/adjacent-joint-arthritis-after-ank…
#anklemobility #anklerocker #triplearthrodesis #hypomobility

 

So here is somewhat of a controversial subject.     Perhaps, though not discussed in this article, activating more axial extensors (vestbulospinal pathways, things like your erector spinae) could be somewhat protective, in that it could, at least theoretically, help to normalize flexor/extensor ratios in the lower extremity.   We see flexor dominance (increased corticospinal activity) in many cases of lower extremity problems causing an imbalance. Perhaps activating extensors the lower extremity (tibialis interior, extensor digitorum longest, etc.) could explain, in part, some of these (controversial) results.    We’re not recommending or condoning taking up smoking to preserve your knees. This is merely food for thought in the ever-changing landscape of clinical application.      http://lermagazine.com/cover_story/smoking-knee-oa-from-clinical-controversy-to-therapeutic-possibility

So here is somewhat of a controversial subject.

Perhaps, though not discussed in this article, activating more axial extensors (vestbulospinal pathways, things like your erector spinae) could be somewhat protective, in that it could, at least theoretically, help to normalize flexor/extensor ratios in the lower extremity. 

We see flexor dominance (increased corticospinal activity) in many cases of lower extremity problems causing an imbalance. Perhaps activating extensors the lower extremity (tibialis interior, extensor digitorum longest, etc.) could explain, in part, some of these (controversial) results.

We’re not recommending or condoning taking up smoking to preserve your knees. This is merely food for thought in the ever-changing landscape of clinical application.


http://lermagazine.com/cover_story/smoking-knee-oa-from-clinical-controversy-to-therapeutic-possibility

Just because it looks good, doesn’t mean that it is.  We have all had patients with seemingly negative knee x rays and pain, only to develop arthritic changes at a later date. Find and treat the cause!  “Our analysis found that incident radiographic knee osteoarthritis is preceded by prodromal symptoms lasting at least 2-3 years. This has potential implications for understanding phasic development and progression of osteoarthritis and for early recognition and management.”  Case R, Thomas E, Clarke E, Peat G. Prodromal symptoms in knee osteoarthritis: a nested case-control study using data from the Osteoarthritis Initiative. Osteoarthritis Cartilage 2015 Apr 2. [Epub ahead of print]  picture from:  http://whyfiles.org/…/chronic-pain-understanding-the-roots…/

Just because it looks good, doesn’t mean that it is.

We have all had patients with seemingly negative knee x rays and pain, only to develop arthritic changes at a later date. Find and treat the cause!

“Our analysis found that incident radiographic knee osteoarthritis is preceded by prodromal symptoms lasting at least 2-3 years. This has potential implications for understanding phasic development and progression of osteoarthritis and for early recognition and management.”

Case R, Thomas E, Clarke E, Peat G. Prodromal symptoms in knee osteoarthritis: a nested case-control study using data from the Osteoarthritis Initiative. Osteoarthritis Cartilage 2015 Apr 2. [Epub ahead of print]

picture from: http://whyfiles.org/…/chronic-pain-understanding-the-roots…/

Podcast 81: Gait, critical, pure and essential principles

This week’s show sponsors: 

www.newbalancechicago.com

www.lemsshoes.com

A. Link to our server: 

http://traffic.libsyn.com/thegaitguys/pod_81f.mp3

Direct Download: 

http://thegaitguys.libsyn.com/podcast-81-gait-critical-pure-and-essential-principles

B. iTunes link:

https://itunes.apple.com/us/podcast/the-gait-guys-podcast/id559864138

C. Gait Guys online /download store (National Shoe Fit Certification and more !) :

http://store.payloadz.com/results/results.aspx?m=80204

D. other web based Gait Guys lectures:

www.onlinece.com   type in Dr. Waerlop or Dr. Allen,  ”Biomechanics”

______________

Today’s Show notes:

Show Sponsors:
 

* Gait Guys online /download store (National Shoe Fit Certification and more !) :

http://store.payloadz.com/results/results.aspx?m=80204

* Other web based Gait Guys lectures:

www.onlinece.com   type in Dr. Waerlop or Dr. Allen,  ”Biomechanics”

 
Show Notes and links:
 
Forget Cheetah Blades. This Prosthetic Socket Is a Real Breakthrough
http://www.wired.com/2014/10/forget-cheetah-blades-prosthetic-socket-real-breakthrough
 
Rebuilding and Regenerating Damaged Knees: The Future Has Arrived!
http://www.huffingtonpost.com/nicholas-dinubile-md/rebuilding-and-regenerati_b_6043374.html
 
the foot gym:
 
From a reader:
Thanks for sharing all the great information over the years. I would like to pose to you some simple questions. How do you decide what area/s are relevant to the issue a patient presents? How do you decide what is “normal” given anatomical variations, history of injuries, torsion’s, etc., and if pain is present, why would you address biomechanics, since pain is a neurological phenomenon not a biomechanical phenomenon?
This may not be that simple but would like to hear what you have to say on these topics.
Thank you,
Joe 
 
COMPARISON OF ISOMETRIC ANKLE STRENGTH BETWEEN FEMALES WITH AND WITHOUT PATELLOFEMORAL PAIN SYNDROME
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4196327/
 
the drawbacks of technology
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Whoa!  It is amazing what the human frame can withstand…

This 300 pound individual is retired from working with tow trucks from a towing company as well as a service station.   He believes working with the tow trucks, particularly jumping out of them contributed to the O.A. of the ankles.

He has osteoarthritic ankles, a rear foot varus of 15 degrees left side, 5 degrees right.  He is currently in the New Balance 1040 shoe.  He would like some new orthotics built. He Fowler tests positive on his current orthotic set up (with the foot on the ground, dorsiflex the foot at the 1st metatarsal phalangeal joint (ie big toe joint), simulating terminal stance; the orthotic should hug the arch through the range of motion; ie about 45-60 degress of great toe dorsiflexion, which he incredibly has). He is unable to one leg stand because of the O.A. on the ankles and pain.

He has bi-lat. internal tibial torsion, Left > Right and moderate tibial varum, L > R. He has very little internal rotation of the hips bi-lat. Ankle dorsiflexion is about 5 degrees bilaterally.

He is currently in an older New Balance motion control shoe. You can see how he has worn the shoes into varus. More neutral shoes hurt his feet; attempts to put his rear foot into valgus causes increased ankle pain. Exercise compliance is minimal.

WHAT WOULD YOU DO?

The Gait Guys. Teaching and educating with each post.

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You evidently can’t have your cake and eat it too…

Here is more research to show that running in shoes give you a mechanical advantage in force generation,  but at the cost of increased stress on the knees.

“The results imply higher mechanical stress in shod running for the knee joint structures during midstance but also indicate an improved mechanical advantage in force generation for the ankle extensors during the push-off phase.”

No surprise really. You could swing a broomstick with little effort and a baseball bat with more effort, but which will hit the ball farther? Which may tax your shoulder more?

Whenever we take a foot, that SHOULD supinate, effectively decrease its mobility (making it stiffer)  and MAKE IT supinate, we will have more power. Remember P = W/t? P is power, W is work and t is time.  W is also F X s, where F is force and s is displacement; so we have P= Force X displacement/time. We are increasing displacement here: with force and time remaining unchanged, we have more power.

But…all things wear out in time with use; including your joint cartilage. Hmmm, maybe we reduce the force and allow the joints (like the ankle) to displace (we see increased displacement in unshod running) and we run into our 100’s.

The choice is yours.

The Gait Guys: 2 docs, making a difference, one step at a time.


J Biomech. 2010 Aug 10;43(11):2120-5. Epub 2010 May 11. Footwear affects the gearing at the ankle and knee joints during running. Braunstein B, Arampatzis A, Eysel P, Brüggemann GP. Source

Institute of Biomechanics and Orthopaedics, German Sport University Cologne, Germany. braunstein@dshs-koeln.de

Abstract

The objective of the study was to investigate the adjustment of running mechanics by wearing five different types of running shoes on tartan compared to barefoot running on grass focusing on the gearing at the ankle and knee joints. The gear ratio, defined as the ratio of the moment arm of the ground reaction force (GRF) to the moment arm of the counteracting muscle tendon unit, is considered to be an indicator of joint loading and mechanical efficiency. Lower extremity kinematics and kinetics of 14 healthy volunteers were quantified three dimensionally and compared between running in shoes on tartan and barefoot on grass. Results showed no differences for the gear ratios and resultant joint moments for the ankle and knee joints across the five different shoes, but showed that wearing running shoes affects the gearing at the ankle and knee joints due to changes in the moment arm of the GRF. During barefoot running the ankle joint showed a higher gear ratio in early stance and a lower ratio in the late stance, while the gear ratio at the knee joint was lower during midstance compared to shod running. Because the moment arms of the counteracting muscle tendon units did not change, the determinants of the gear ratios were the moment arms of the GRF’s. The results imply higher mechanical stress in shod running for the knee joint structures during midstance but also indicate an improved mechanical advantage in force generation for the ankle extensors during the push-off phase.

http://www.ncbi.nlm.nih.gov/pubmed/20462583

Now here is something a little different. Check out this PhD Thesis submission. What you do DOES make a difference! as we have been saying: it is a cortical phenomenon. 
    http://www.graduate.technion.ac.il/heb/StudentsLec/amir%20haim/abstract.htm    
   Plasticity of Locomotor Patterns & Gait Conditioning via      Controlled    
   Biomechanical intervention       
  Amir Haim, MD (Ph.D candidate  )    
  Supervisor: Dr. Alon Wolf  
  Biorobotics and Biomechanics Lab,  Faculty of Mechanical Engineering  
     
  Overall, the task of walking is attained by a proper kinematic trajectory command conveyed by the nervous system to its skeleto-muscular instruments which generate the appropriate kinetics. Extensive evidence indicates that motor program adaptations can compensate for losses in mechanical integrity through altered movement and muscle activation patterns. Further more, non surgical biomechanical manipulations, have been shown influence kinetic and kinematic parameters and to generate “active”-neuromuscular re-education.    
  In  the present study we  hypothesized that specific biomechanical challenges will stimulate matching biomechanical responses trough out the musculoskeletal kinematic chain. We further hypothesized that repetitive exposure to a biomechanical stimulus would generate  a process of motor learning thus conveying  plasticity of existing  locomotor patterns and gait strategies.   
  To test our hypothesis ; we  examined two cohorts - healthy young male adults and subjects suffering from knee Osteoarthritis (OA). All participants underwent gait analysis comprising kinematic kinetic and ellcetromygragic patterns during gait. We modeled the direct locomotor response to controlled footwear-generated biomechanical manipulations utilizing a novel biomechanical apparatus   comprising four modular elements . Further more we prospectively examined (via gait analysis and valid questioners) patients with abnormal gait patterns (due to knee osteoarthritis) who were subjected to extended biomechanical intervention.   
    Study results confirmed our hypothesis; A direct association was found between specific biomechnical challenges and  direct kinetic and kinematic response in both healthy and OA subjects. Like wise, OA participants who where exposed to long term biomechanical interventions exhibited normalization of cartelistic gait patterns and had a favorable subjective outcome.      
  http://www.oandp.org/jpo/library/1993_02_039.asp  
  http://emedicine.medscape.com/article/320160-overview  
  http://books.google.com/books?id=S2YVKbu77uQC&pg=PA123&lpg=PA123&dq=altered+motor+patterns+and+gait&source=bl&ots=xY7jGQDXA4&sig=6HmLZRimLVjoc_iFjuWaWTjZdUo&hl=en&ei=iFqWS6yrB4vysgOx1LzCAQ&sa=X&oi=book_result&ct=result&resnum=6&ved=0CCMQ6AEwBTgK#v=onepage&q=altered%20motor%20patterns%20and%20gait&f=false  
  http://jn.physiology.org/cgi/content/full/80/4/1868  
  http://uppercervicaldr.com/wordpress/?p=58

Now here is something a little different. Check out this PhD Thesis submission. What you do DOES make a difference! as we have been saying: it is a cortical phenomenon.

http://www.graduate.technion.ac.il/heb/StudentsLec/amir%20haim/abstract.htm

Plasticity of Locomotor Patterns & Gait Conditioning via Controlled

Biomechanical intervention  

Amir Haim, MD (Ph.D candidate)

Supervisor: Dr. Alon Wolf

Biorobotics and Biomechanics Lab,  Faculty of Mechanical Engineering

 

Overall, the task of walking is attained by a proper kinematic trajectory command conveyed by the nervous system to its skeleto-muscular instruments which generate the appropriate kinetics. Extensive evidence indicates that motor program adaptations can compensate for losses in mechanical integrity through altered movement and muscle activation patterns. Further more, non surgical biomechanical manipulations, have been shown influence kinetic and kinematic parameters and to generate “active”-neuromuscular re-education. 

In the present study we hypothesized that specific biomechanical challenges will stimulate matching biomechanical responses trough out the musculoskeletal kinematic chain. We further hypothesized that repetitive exposure to a biomechanical stimulus would generate  a process of motor learning thus conveying  plasticity of existing  locomotor patterns and gait strategies.

To test our hypothesis; we examined two cohorts - healthy young male adults and subjects suffering from knee Osteoarthritis (OA). All participants underwent gait analysis comprising kinematic kinetic and ellcetromygragic patterns during gait. We modeled the direct locomotor response to controlled footwear-generated biomechanical manipulations utilizing a novel biomechanical apparatus comprising four modular elements . Further more we prospectively examined (via gait analysis and valid questioners) patients with abnormal gait patterns (due to knee osteoarthritis) who were subjected to extended biomechanical intervention.

Study results confirmed our hypothesis; A direct association was found between specific biomechnical challenges and  direct kinetic and kinematic response in both healthy and OA subjects. Like wise, OA participants who where exposed to long term biomechanical interventions exhibited normalization of cartelistic gait patterns and had a favorable subjective outcome. 

http://www.oandp.org/jpo/library/1993_02_039.asp

http://emedicine.medscape.com/article/320160-overview

http://books.google.com/books?id=S2YVKbu77uQC&pg=PA123&lpg=PA123&dq=altered+motor+patterns+and+gait&source=bl&ots=xY7jGQDXA4&sig=6HmLZRimLVjoc_iFjuWaWTjZdUo&hl=en&ei=iFqWS6yrB4vysgOx1LzCAQ&sa=X&oi=book_result&ct=result&resnum=6&ved=0CCMQ6AEwBTgK#v=onepage&q=altered%20motor%20patterns%20and%20gait&f=false

http://jn.physiology.org/cgi/content/full/80/4/1868

http://uppercervicaldr.com/wordpress/?p=58