Podcast 88: interpreting Shoe Wear patterns & Running Surface Effects

Show sponsors:
www.newbalancechicago.com

Plus: Biometrics in Pro Sports, Epigenetics and How Exercise changes our DNA, Hip Dysplasia,, Pavlik harnesses.

We hope you find today’s show helpful. Remember, we don’t know everything, and we do not expect everyone else to know everything either. We are just bringing our logic and knowledge and hopefully truth to the web … . . Please, Correct us when we are sharing inaccuracies, as we try to do the same. There is alot of misguided info on the web and in the wrong hands, people can get hurt … . we feel we are doing our part to carve a safe path. But, when we go astray, please our dear brethren……call us out on it ! We insist. -Shawn and Ivo

Other Gait Guys stuff

Download links:

A. http://traffic.libsyn.com/thegaitguys/pod_88_solid.mp3

B. http://thegaitguys.libsyn.com/podcast-88

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

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:
Monthly lectures at : www.onlinece.com   type in Dr. Waerlop or Dr. Allen,  ”Biomechanics”

Show notes:

New biometric tests invade the NBA
http://espn.go.com/nba/story/_/id/11629773/new-nba-biometric-testing-less-michael-lewis-more-george-orwell

How Exercise Changes Our DNA
http://well.blogs.nytimes.com/2014/12/17/how-exercise-changes-our-dna/

An integrative analysis reveals coordinated reprogramming of the epigenome and the transcriptome in human skeletal muscle after training. Lindholm ME
Epigenetics. 2014 Dec 7:0. [Epub ahead of print]

Hip Dysplasia
http://journals.lww.com/pedorthopaedics/Abstract/2015/01000/Back_carrying_Infants_to_Prevent_Developmental_Hip.11.aspx

Journal of Pediatric Orthopaedics:
January 2015 - Volume 35 - Issue 1 - p 57-61
Back-carrying Infants to Prevent Developmental Hip Dysplasia and its Sequelae: Is a New Public Health Initiative Needed? Graham, Simon M.

Plus: Pavlik harness
https://www.google.com/webhp?sourceid=chrome-instant&ion=1&espv=2&ie=UTF-8#q=pavlik%20harness

Does Correct Head Positioning Make You Run Faster?http://runnersconnect.net/running-injury-prevention/running-form-proper-head-position/

Running surfaces
http://www.slowtwitch.com/Training/Running/Concrete_or_Asphalt__4793.html

How to Read and Interpret the Wear Pattern on Your Running Shoes
http://runnersconnect.net/running-tips/read-wear-pattern-running-shoes/

Do you know your stuff? Would you correct this child’s gait ? Give them orthotics, exercises, force correction, leave them alone ? 

Is he Internal Tibial torsioned ? Is he “pigeon toed” ,if that is the only lingo one knows, :(  Does he have femoral torsion ?  A pronation problem locally at the foot or an internal spin problem through the entire limb ? Or a combination of the above ? 

What’s your solution?

It MUST be based on the knowledge necessary to fix it, not the limits of YOUR knowledge. You can never know what to do for this lad from his gait evaluation, no matter how expensive your digital, multi-sensor, 3D multi-angle, heat sensor, joint angle measuring, beer can opening, gait analysis set up is. You can never know what to do for this lad if you do not know normal gait, normal neuro-developmental windows, normal biomechanics, know about torsions (femoral, tibial, talar etc), foot types etc.  It is a long list.  You cannot know what to do for this kid if you do not know how to accurately and logically examine them. 


Rule number 1. First do no harm.

If your knowledge base is not broad enough, then rule number one can be easily broken ! Hell, if you do not know all of the parameters to check off and evaluate, you might not even know you are breaking rule number one !  If everything looks like a weak muscle, every solution will be to “activate” and strengthen and not look to find the source of that weakness.  Muscles do not “shut down” or become inhibited because it is 10 minutes before practice or because it is the 3rd Monday of the month. You are doing your client a huge disservice if you think  you are smarter than their brain and activate muscles that their brain has inhibited for a reason. What if it were to prevent joint loading because of a deeper problem ?  If every foot looks flat and hyper pronated, and all you know is orthotics or surgery or shoe fit, guess what that client is prescribed ? If all you see is torsions, that is all you will look to treat. If all you see is sloppy “running form” and all you know is “proper running form” forcing your client into that “round peg-square hole” can also lead to injury and stacking of compensation patterns.  

One’s lack of awareness and knowledge, are one’s greatest enemies. If you don’t know something exists, because you’ve never studied or learned it, how can you be aware of it ? If you’re not spending enough time examining a client, you might not be aware of an issue even though you may be knowledgeable about the issue.
One must have both awareness and knowledge. One must also be aware that compensations are the way of the body. What you see is not your client’s problem. It is their strategy to cope.

Are you helping your client ? Hurting them ?  Adding risk to their activity ? Are you stepping beyond your skill set ?  

Rule Number 1: First do no harm. 

Shawn and Ivo

PS: we will get to this case another time, we just wanted to make a point today about the bigger problems out in the world.

the gait guys

Podcast 87: Podcast 87: The Kenyan's Running Brain & "The" Anterior Compartment.

Plus, Some unknown facts about going minimalism and barefoot. We POUND anterior compartment strength today gang ! Hope you enjoy !

Show sponsors:
www.newbalancechicago.com

A. Link to our server: 
http://traffic.libsyn.com/thegaitguys/pod_87final.mp3

Direct Download: 
http://thegaitguys.libsyn.com/podcast-87

Other Gait Guys stuff

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:
Monthly lectures at : www.onlinece.com   type in Dr. Waerlop or Dr. Allen,  ”Biomechanics”

Show notes:


On high heels and short muscles: A multiscale model for sarcomere loss in the gastrocnemius muscle

http://www.sciencedirect.com/science/article/pii/S0022519314006262

The Brain Needs Oxygen

Maintained cerebral oxygenation during maximal self-paced exercise in elite Kenyan runners.

http://www.runnersworld.com/racing/the-brain-needs-oxygen
http://www.ncbi.nlm.nih.gov/pubmed/25414248
J Appl Physiol (1985). 2014 Nov 20:jap.00909.2014. doi: 10.1152/japplphysiol.00909.2014. [Epub ahead of print]

The texting lane in China
http://www.theguardian.com/world/shortcuts/2014/sep/15/china-mobile-phone-lane-distracted-walking-pedestrians

Dialogue on endurance training,
NeuroRehabilitation. 2006;21(1):43-50. 
http://www.ncbi.nlm.nih.gov/pubmed/16720937

Effects of dorsiflexor endurance exercises on foot drop secondary to multiple sclerosis.  Mount J1, Dacko S.

APOS Therapy
we were asked out opinion on this
http://apostherapy.com/

Foot instrinsic dialogue
Motor Control. 2014 Jul 15. [Epub ahead of print]

Quantifying the Contributions of a Flexor Digitorum Brevis Muscle on Postural Stability.
Okai LA1, Kohn AF.

There are many factors in adults that impair gait. It is not all biomechanical. This is part of our ongoing dialogue on the aging population and why gait impairments and falls are so prevalent.
Acta Bioeng Biomech. 2014;16(1):3-9.
Differences in gait pattern between the elderly and the young during level walking under low illumination.
Choi JS, Kang DW, Shin YH, Tack GR.


Podcast 86: The Best of The Gait Guys Podcast: Part 1

Show sponsors:

www.newbalancechicago.com

A. Link to our server: 

http://traffic.libsyn.com/thegaitguys/pod_87_Best_of_Part_1.mp3

Direct Download: 

http://thegaitguys.libsyn.com/podcast-87-the-best-of-the-gait-guys-part-1

Other Gait Guys stuff

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:

Monthly lectures at : www.onlinece.com   type in Dr. Waerlop or Dr. Allen,  ”Biomechanics”

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Test your Mental Clinical Thinking Skills with this pedograph case. 

A few months ago, we discussed this case in great detail. There is likely little chance you will see our thinking progression with these final conclusions without sitting down with a warm cup of coffee and going over these 2 prior blog posts on this case (part 1 and part 2).  Besides, it will be a good review for you and it is great mental gymnastics.  This kind of analysis gets easier each time you do it but we have to through out our standard warning. This is the kind of stuff one needs to be able to go through on the fly in one’s practice, it is something to aspire to.

First of all, caveats:

  • Our discussions on this case were all theoretical.  What we went through was an exercise in static assessment and clinical thinking
  • One cannot, and must not, make clinical decisions from a static assessment. 
  • As in all assessments, information is taken in, digested and then MUST be confirmed, denied and/or at the very least, folded into a functional and clinically relevant assessment of the client before the findings are accepted, dismissed and acted upon. 
  • Gait analysis or pedograph-type assessment are helpful tools, but not the final answer.

Our static exam proposal on this case came up with the following theories (please stand up and mimic as we discuss, trust us, it will help you). *Remember: the foot on YOUR LEFT is the RIGHT foot for the purposes of this discussion. And remember, this is all theoretical, this is an exercise in biomechanical and clinical thinking, nothing more.

  • Suspect Counter-clockwise pelvis distortion pattern (causes relative internal rotation on LEFT and external rotation on RIGHT), this will drive Left knee hyperextension and Right knee flexion (hence foot plantar pressures as we discussed in previous 2 blog posts linked above). This of course cannot be seen, but we are extrapolating from our clinical experiences.
  • poor pronation and internal limb spin control on the left (hence longer foot and toe hammering). Obviously, we would see a dramatic shift of the pressures to the medial foot if this were truly the case.  Perhaps this is because of the greater lateral left pelvis drift forcing the glute and foot pronatory controls to have to work harder and longer, and maybe even quicker, to control the internal spin and pronation. Over time, they fatigue and fail rendering a flatter, more pronated and longer heel:toe ball length ratio. This would also give credence to the left toe hammering/gripping response.
  • static increased left limb weight bearing (left hip drift)
  • abrupt right foot loading pattern (more mid-forefoot strike), perhaps as reflected by the static forefoot loading. Again, supposition.
  • with all of the above, it is suspect that this client will appear to have a subtle limp, coming off the left quickly or prematurely as they speed through uncontrolled pronation and resulting in an abrupt right limb loading response that mostly skips through heel strike and results in a more aggressive mid-forefoot loading response.  This, sort of, creates a catching of the loading response by the quadriceps more than the gluteals. This can cause medial knee drift (valgus loading) if the medial knee stabilizers are not up to task, this also creates a sudden patellofemoral compresson event and unappreciated sudden tension on the extensor mechanism (the quad-patella-patellar tendon complex).  Can you say generic anterior knee pain ?

Just some thoughts. Please go back to the prior 2 blog posts to delve deeper into the conclusions we have brought about here, we have other good reasoning to suspect the above as the scenario. But remember, what you see is not the problem, we see people’s compensations, their strategies. This was just an exercise in “what ifs”, nothing more. But you will see it in your clinic, just substantiate it with an exam, not what you necessarily see in your clients gait or static assessment. Static assessments are for fools, don’t be a fooled fool.  What  you see is not the problem.

Remember this critical fact.  After an injury or a long standing problem, the job of muscles and motor patterns is to stabilize and manage loads (stability and mobility) for adequate and necessary movement. Injuries often leave a mark on the system as a whole because adaptation was necessary during the initial healing phase. This usually spills over during the early movement re-introduction phase, particularly if movement is reintroduced too early or too aggressively.  Plasticity is often a culprit. Just because the injury has come and gone does not mean that new patterns of skill, endurance, strength (S.E.S -our favorite mnemonic), stability and mobility were not subsequently built onto the apparently trivial remnants of the injury. There is nothing trivial if it is abnormal. The forces must, and will, play out somewhere in the body and this is often where pain or injury occurs but it is rarely where the underlying problem lives. Is the compensation top down, bottom up, or both ?

Don;t be a fooled fool. Get the facts.

Shawn and Ivo, the gait guys

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The case of the dropped (plantarflexed) metatarsal head. Or, “How metatarsalgia can happen”.

This gentleman came in with fore foot pain (3rd metatarsal head specifically), worse in the AM upon awakening, with first weight bearing that would improve somewhat during the day, but would again get worse at the end of the day and with increased activity. The began insidiously a few months ago (like so many problems do) and is getting progressively worse.

Rest and ice offer mild respite, as does ibuprofen. You can see his foot above. please note the “dropped” 3rd metatarsal head (or as we prefer to more accurately say, “plantarflexed 3rd metatarsal head”) and puffiness and prominence in that area on the plantar surface of the foot. 

To fully appreciate what is going on, we need to look at the anatomy of the short flexors of the foot. 

The flexor digitorum brevis (FDB) is innervated by the medial plantar nerve and arises from the medial aspect of the calcaneal tuberosity, the plantar aponeurosis (ie: plantar fascia) and the areas bewteen the plantar muscles. It travels distally, splitting at the metatarsal phalangeal articulation (this allows the long flexors to travel forward and insert on the distal phalanges); the ends come together to divide yet another time (see detail in picture above, yes, we are aware it is the hand, but the tendon structure in the foot is remarkably similar)) and each of the 2 portions of that tendon insert onto the middle of the middle phalanyx (1) 

As a result, in conjunction with the lumbricals, the FDB is a flexor of the metatarsal phalangeal joint, and proximal interphalangeal joint (although this second action is difficult to isolate. try it and you will see what we mean). In addition, it moves the axis of rotation of the metatasal phalangeal joint dorsally, to counter act the function of the long flexors, which, when tight or overactive, have a tendency to drive this articulation anteriorly (much like the function of the extensor hallucis brevis above in the drawing from Dr Michauds book, yes, we are aware this is a picture of the 1st MTP).

Can you see the subtle extension of the metatarsal phalangeal joint and flexion of the proximal interphalangeal joint in the picture?

We know that the FDB contracts faster than the other intrinsic muscles (2), playing a tole in postural stability (3) and that the flexors temporally should contract earlier than the extensors (4), assumedly to move this joint axis posteriorly and allow proper joint centration. When this DOES NOT occur, especially if there is a concomitant loss of ankle rocker, the metatarsal heads are driven into the ground (plantarflexion), causing irritation and pain. Metatarsalgia is born….

So what is the fix? Getting the FDB back on line for one. 

  • How about the toe waving exercise? 
  • How about the lift spread reach exercise? 
  • How about retraining ankle rocker and improving hip extension?
  • How about an orthotic with a metatarsal pad in the short term? 
  • How about some inflammation reducing modalities, like ice and pulsed ultrasound. Maybe some herbal or enzymatic anti inflammatories?

The Gait Guys. Increasing your gait and foot literacy with each and every post. 

1. http://en.wikipedia.org/wiki/Flexor_digitorum_brevis_muscle

2. Tosovic D1, Ghebremedhin E, Glen C, Gorelick M, Mark Brown J.The architecture and contraction time of intrinsic foot muscles.J Electromyogr Kinesiol. 2012 Dec;22(6):930-8. doi: 10.1016/j.jelekin.2012.05.002. Epub 2012 Jun 27.

3.Okai LA1, Kohn AF. Quantifying the Contributions of a Flexor Digitorum Brevis Muscle on Postural Stability.Motor Control. 2014 Jul 15. [Epub ahead of print]

4. Zelik KE1, La Scaleia V, Ivanenko YP, Lacquaniti F.Coordination of intrinsic and extrinsic foot muscles during walking.Eur J Appl Physiol. 2014 Nov 25. [Epub ahead of print]

Learning and being humbled.

There is a quote out there by someone that suggests that in the moments of talking and teaching one will learn nothing, for one is merely spouting off the limits of what one already knows, some of which is likely outdated or incorrect. One cannot teach that which one has not previously heard, experienced and mastered.
*Learning is about listening, and evaluating our prior beliefs against the current wisdom. It is about unlearning the false and relearning the latest truths that have come to light. Learning is not about talking.

Dear Gait brethren: Ivo and I do not have all the answers, but we seek and share what we know daily in this realm of The Gait Guys. Through challenging old and current theories, principles and research, one’s insight and wisdom can only grow. We will get things wrong, and we will admit when we do, and thank those who teach us the present truths. We have no single guru we follow, nor should you. No one person or method has all the answers to all of your client’s woes. The day you only trust one guru and one theory and the day you stop seeking, learning, unlearning, and being humbled to the mistakes one has made and been taught, is the day one begins a journey to being left behind and possibly insignificant in time. Thanks to all of you who correct us, teach us, humble us and trust us. It has been a great year here on TGG, thanks for hanging out with us ! 
“The illiterate of the 21st century will not be those who cannot read and write, but those who cannot learn, unlearn, and relearn.” ~Alvin Toffler.
Enjoy the funny cartoon, it is sort of related to the words above. It is a huge comment on communication, communication in relationships and possibly stuff that gets communicated in seminars. Things get lost in translation everyday, sadly. But perhaps that is a good thing, perhaps that is why theories and principles morph into greater wisdom. Not all change is bad.

Podcast 85: Texting & Walking, 2015 Shoe talk

Plus: Endurance training and the immune system, hamstring endurance, Ampla Fly shoe, 

Show sponsors:

www.newbalancechicago.com

A. Link to our server: 

http://traffic.libsyn.com/thegaitguys/pod_85f.mp3

Direct Download: 

http://thegaitguys.libsyn.com/podcast-85-texting-walking-2015-shoe-talk

Other Gait Guys stuff

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:

Monthly lectures at : www.onlinece.com   type in Dr. Waerlop or Dr. Allen,  ”Biomechanics”

Show notes:

Exercising Too Long Can Hurt Your Immune System
http://www.outsideonline.com/news-from-the-field/Exercising-for-Too-Long-Can-Hurt-Your-Immune-System.html

Future Shoe: New Ampla Fly Shoe Breaks The Mold
http://running.competitor.com/2014/11/video/nov-30-future-shoe-new-ampla-fly-shoe-breaks-mold_118688

How We Test Shoes
http://www.runnersworld.com/running-shoes/how-we-test-shoes?adbid=10152448718631987&adbpl=fb&adbpr=9815486986&cid=socSG_20141203_36589687

Three minutes of all-out intermittent exercise per week increases skeletal muscle oxidative capacity and improves cardiometabolic health
https://www.readbyqxmd.com/read/25365337/three-minutes-of-all-out-intermittent-exercise-per-week-increases-skeletal-muscle-oxidative-capacity-and-improves-cardiometabolic-health

 

The Gait Guys talk about Cerebellar Afferents

http://youtu.be/tP-PvzB-fYM

Texting and Walking

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2535903/

 
 

Texting and Walking.  Your gait will change when you are texting on your phone.

You are going to want to put away your cell phone after you read this, or at least hide your parent’s phones. *(the video link attached here has likely been blocked by ABC News, you should see a forwarded link to their youtube feed. If not,

here it is

.  So you think you are a multi-tasker do you ?  Do you know how much cerebral cortex real estate is necessary to walk or drive and text ? Just try texting while walking for 5 seconds in an unfamiliar environment and see what happens.  Dual tasking is difficult especially when one task is cognitive and the other is spacial and motor. At some point something has to give, especially if you are on the edge of tapping out the executive function centers in the brain because of early disease or age related mental decline.  This has never been more prevalent than in the elderly and the number of mounting studies proving that dual attention tasks lead to a dramatic increase in age related fall injuries.  If you look into the literature the fall rate increases from anywhere from 11 to 50%, these are strong numbers correlating falls and dual attention tasking in the elderly.  Certainly the numbers are worse in the frail and gait challenged and fewer in healthier elderly folks, but the correlation seems to be strong particularly when there are even early signs of frontal cortex demise. We have talked about this on several recent podcasts

(check out podcasts 80-85)

and this has been rooted even further from one of our neurology mentors, Dr. Ted Carrick.   Recently in the Journal of Applied Biomechanics, Parr and associated took 30 young able bodied healthy individuals with experience texting on cellular phones. The study used an 11-camera optical motion capture system on a 8m obstacle-free floor. 

The study showed a reduction in gait velocity in addition to significant changes in spatial and temporal parameters, notably, step width, while the double support phase of the gait cycle increased.  Furthermore, and equally disturbing, toe clearance decreased but luckily step length and cadence decreased. 

Thus, it appears that the attention draining texting task generally forced the brain to slow the gait, reduce step length while improving stability via increasing step width and double support phase of gait, keep in mind that these are young healthy experienced individuals with no early cognitive challenges. 

This is not the case in aging adults, or in adults with factors that have either challenged gait stability (degrees of impaired balance, vision, vestibular, proprioception etc) or challenged frontal cortex function where that functionality of the brain is already nearing its tipping point for adequate function.  Sadly, these are all factors in the aging adult and they are why falls are increased and riskier for the elderly. Essentially, what the studies are showing is that dual tasking creates a distraction that can amplify any sensory-motor challenges in the system.  Mind you, there are studies that show that if the dual task is remedial such as talking while walking the effects are more muted, however in those who are at the tipping point capacity of mental executive function, mere talking (cognitive linguistic engagement), can also tip the system into deciding whether to focus on the gait or the talk but not both adequately.  Something will have to give in these folks, safe competent dual tasking is beyond the ability of their system.  As we have eluded to here, there are many factors and variables that can challenge the system. Visual challenges such as low light vision problems or depth perception challenges can act similarly on the system to dual tasking attempts and thus magnify fall risk. What about sensory challenges from a spinal stenosis or peripheral neuropathy such as in advancing diabetes?  Balance and vestibular challenges, let alone factors such as unfamiliar environments (perhaps magnified by vision challenges) as precursors are a foregone conclusion to increase fall risk in anyone let alone the elderly. By this point in this article it should be a given that texting while doing anything else is a dual tasking brain challenge that could lead to a fall, an embarrassing spill into the public pool or into a fountain at the mall let alone driving off a cliff or into a crowd of people.  But are all of these unfortunate people showing signs of frontal cortex/executive function impairment? Perhaps not, especially if they are healthy.  One has to keep in mind that texting is a high demanding cognitive attention task, even though we think nothing of it as a healthy adult. Think about it, one has to engage a separate screen other than the environment they are trying to walk through. Additionally, one has to think about what they are trying to text, engage a seperate motor program to type, then there is spelling, choosing text recipients, sending the message, watching and listening for a response, and the list goes on meanwhile the person is still trying to run the gait subprograms.  We take it for granted but texting is highly engaging and adding walking can tip the system into a challenge or failure if we are in a crowd, unfamiliar environment, low light etc.   So if you have ever wondered why elderly people trip and fall in even the most benign environments, it is likely a compounded result of challenges to situation and spatial awareness and working memory with many possible factor challenges. Again, things like poor lighting, vision limitations, unfamiliar environment, vestibular limitations, numbness in the feet, talking or even if they are simply carrying the afternoon tea to the sun room these things all are dual tasking and some require higher demands from the executive function brain centers.   Any factor(s) which tax the already-reducing executive function centers in the elderly subtract from the most basic elements required for upright posture and gait.  If dual-tasking can impair healthy young individuals, the elderly are a forgone conclusion to have magnified risks.   There can be a plus to all of this however. If the goal were to only reduce falls and fall risks in the elderly, an astute clinician can work this to their favor and do gait challenges and retraining in the office environment while safely stacking dual task challenges to expand and restore some executive function capabilities.  We are never too old to learn and lay down improved motor and cognitive patterns. So, use this information to your advantage to improve function instead of delivering it as a dark cloud to hang over your clients, whether they are elderly or neurologically challenged.  In summary, put down the darn phone, trust us, that text can wait.  Rather, enjoy the sunshine, the smiling faces, the trees.  If you are driving or walking, dump the phone and pay attention to traffic and your environment. Stop and wave to a friend. Teach your kids about this texting problem, they are likely already oblivious to many risks in the world, and this one likely hasn’t crossed their mind either. At the very least, help the elderly lady or man cross the street. By now you should understand all that they are consciously and subconsciously trying to calculate to negotiate the street crossing. Their declining executive function is often a mental feat all on its own, but having to actually add the physical act of walking (which is likely already showing aspects of age related biomechanical decline) might just be their tipping point leading to a fall.  So offer your arm, a warm smile, and think everything of it, because someday it will be you at that street corner with sweaty palms and great fear.  

Dr. Shawn Allen, one of the gait guys

References : 1. 

Eur J Neurol.

 2009 Jul;16(7):786-95. doi: 10.1111/j.1468-1331.2009.02612.x. Epub 2009 Mar 31. Stops walking when talking: a predictor of falls in older adults?

Beauchet O

1, 

Annweiler C

Dubost V

Allali G

Kressig RW

Bridenbaugh S

Berrut G

Assal F

Herrmann FR

. 2. 

J Appl Biomech.

 2014 Dec;30(6):685-8. doi: 10.1123/jab.2014-0017. Epub 2014 Jul 9. Cellular Phone Texting Impairs Gait in Able-bodied Young Adults. 

Parr ND

1, 

Hass CJ

Tillman MD

. 3. 

Gait Posture.

 2014 Aug 20. pii: S0966-6362(14)00671-7. doi: 10.1016/j.gaitpost.2014.08.007. [Epub ahead of print]  Texting and walking: effects of environmental setting and task prioritization on dual task interference in healthy young adults. Plumer, Apple, Dowd, Keith. 4. 

Gait Posture.

 2012 Apr;35(4):688-90. doi: 10.1016/j.gaitpost.2011.12.005. Epub 2012 Jan 5.  Cell Phones change the way we walk.  Lamberg, Muratori 5. 

Int J Speech Lang Pathol.

 2010 Oct;12(5):455-9. doi: 10.3109/17549507.2010.486446.  Talking while walking: Cognitive loading and injurious falls in Parkinson;s disease. 

LaPointe LL

1, 

Stierwalt JA

Maitland CG

.

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What would you do? This is what we did.

History:

This 7 year old girl is brought in by her mother because of knee misalignment while skiing, L > R. No history of trauma; normal term birth with no complications. No knee pain. Of incidental note, she is deaf in the left ear.

Exam findings:

She has bi-lat. external tibial torsion, left much worse than right (40 degrees transmallolear angle vs 22 degrees. for info on measuring torsions, click here). remember, you should be able to draw a line from the tibial tuberosity down through the 2nd metatarsal head. 

She has a 5mm anatomical leg length deficiency on the right (see top above left).

She has femoral antetorsion right side with very little external rotation, approximately 10 degrees,  internal rotation is in excess of 50.  Left side has normal femoral versions (for a review of femoral versions and torsions, click here).  See last 2 pictures which are full internal and external rotation respectively.

She has a mild uncompensated forefoot varus (cannot really see from the pictures, you will need to take our word for it) with a relatively cavus arch to her foot(see center and last picture on right.

Neurologically, she appeared to have integrity with respect to sensation, motor strength and deep tendon reflexes in the lower extremities.

Assessment:

Pathomechanical alignment as described.  Severe left external tibial torsion. MIld to moderate right. Femoral antetorsion right.

Plan:

We are going to build her a medium heel cup full length modified UCB orthotic inverting the cast bi-lat. left greater than right.  We gave her  balance and coordination exercises, heel walking, lift/spread/reach and one leg balancing. She will follow up for a dispense.  Her mother will try to get a better fitting ski boot as the one she has currently is two sizes too big. She will return for a dispense. She should consider wearing the orthotics in everyday footwear as well. We will do a follow up post in a few weeks. 

The Gait Guys. Teaching you something new in each and every post. Like this post? Tell and share it with a friend. Don’t like this post? Let us know!

Human Gait Changes following mastectomy.  We first wrote about this a year ago after the news of Angelina Jolie’s double mastectomy decision. Research has confirmed that following a mastectomy there are limitations in the efficiency of the upper limb and even changes in the posture of the torso. (1,2,3)  Following mastectomy, whether unilateral or bilateral, restorative measures are necessary, and not just for cosmetic effects either. From a biomechanical perspective, obviously depending on breast size, removing a considerable mass of tissue is going to change the symmetry of the torso particularly if we are dealing with a unilateral mastectomy.  Not only is it going to change symmetry from a static postural perspective (bulk, weight, fascial plane changes, strength etc) but it will change dynamic postural control, mobility and stability as well as dynamic spinal kinematics.  The literature has even shown that post-mastectomy clients display changes in spatiotemporal gait parameter such as step length and gait velocity. Breast tissue moves. It oscillates a various cycles depending on speed of walking or running.  There is a rhythmic cycle that eventually sets up during walking and running and the cycle is intimately and ultimately tied to arm swing.  Thus, it would make sense that removing a sizable mass of tissue, particularly when done unilaterally, will change the tissue and joint rhythmicity. And if you have been here with The Gait Guys for more than a year you will know that impairing an arm swing will show altered biomechanics in the opposite lower limb (and furthermore, if you alter one lower limb, you begin a process of altering the biomechanical function and rhythmicity of the opposite leg as well.)  Here are 2 links for more on these topics,Arm Swing: Part 1 and Arm Swing: Part 2, When Phase is Lost. Plus here from our blog search archives, everything we have talked about on Arm Swing.  Arm swing impairment is a real issue and it is one that is typically far overlooked and misrepresented. The intrinsic effects of altering the body through subtraction of tissue are not all that dissimilar to extrinsic changes into the system from things like  walking with a handbag/briefcase, walking with a shoulder bag, walking and running with an ipod or water bottle in one hand.  And do not forget other intrinsic problems that affect spinal symmetry, for example consider the changes on the system from scoliosis that can either consciously or unconsciously alter arm swing and thus global body kinematics.  (Also, do not forget any changes in opposite leg function secondary to a frozen shoulder (adhesive capsulitis) and the like which can impair arm swing. The bottom line is that because of the neurologically embedded reflexes and reflexive motions and motor patterns, which are things that permeate all human locomotion, anything that changes one of the limbs directly or indirectly can impair and change locomotion, motor pattern choices and programming.  Obviously the degree to which intervention is taken depends on the amount and location of breast tissue removed and intervention will be determined by physical placement of the prosthesis (whether it be external or internal) as well as the prosthesis weight, shape and possibly several other independent factors such as comparative support to the chest wall in comparison to the opposite breast. (There is a plethora of research out that addresses other methods of intervention such as latissimus dorsi relocation to reform the breast mass. This deserves a blog article all on its own because modifying a major shoulder, scapular and spinal stabilizer and prime mover has never made sense to us clinically or biomechanically.) In Hojan’s study (below) they found significant differences in the gait parameters in the younger age groups with and without breast prosthesis however there appeared to be no significant differences in the women of the older study group.  However, it appeared that their study did not take into account all of the intimate issues we talk about in gait here on The Gait Guys blog. None the less, in the younger and likely more active study group, the use of a breast prosthesis brought the gait parameters closer to the healthy control group, as we suspected.  Bottom line, every external and internal parameter that changes affects the human organism and thus affects their gait. Again, here are those links to our other blog writings on arm swing that are paramount to understanding what we are discussing here today. Arm Swing Part 1: The Basics   http://thegaitguys.tumblr.com/post/13869907052/arm-swing-in-gait-and-running-part-1-there-is Arm Swing Part 2: When Phase is Lost   http://thegaitguys.tumblr.com/post/13920283712/arm-swing-part-2-when-phase-is-lost From our blog search   http://thegaitguys.tumblr.com/search/arm+swing Shawn and Ivo, The Gait Guys References: 1.Blomqvist L, Stark B, Engler N, et al. Evaluation of arm and shoulder mobility and strength after modified radical mastectomy and radiother- apy. Acta Oncol. 2004;43(3):280Y283. 2. Rostkowska E, Bak M, Samborski W. Body posture in women after mastectomy and its changes as a result of rehabilitation. Adv Med Sci. 2006;51:287Y297. 3. Crosbie J, Kilbreath SL, Dylke E, et al. Effects of mastectomy on shoulder and spinal kinematics during bilateral upper-limb movement. Phys Ther. 2010;90(5):679Y692. 4. Hojan K, Manikowska F, Molinska-Glura M, Chen PJ, Jozwiak M. Cancer Nurs. 2013 Apr 29. [Epub ahead of print] The Impact of an External Breast Prosthesis on the Gait Parameters of Women After Mastectomy.

Human Gait Changes following mastectomy. 

We first wrote about this a year ago after the news of Angelina Jolie’s double mastectomy decision.

Research has confirmed that following a mastectomy there are limitations in the efficiency of the upper limb and even changes in the posture of the torso. (1,2,3) 

Following mastectomy, whether unilateral or bilateral, restorative measures are necessary, and not just for cosmetic effects either. From a biomechanical perspective, obviously depending on breast size, removing a considerable mass of tissue is going to change the symmetry of the torso particularly if we are dealing with a unilateral mastectomy.  Not only is it going to change symmetry from a static postural perspective (bulk, weight, fascial plane changes, strength etc) but it will change dynamic postural control, mobility and stability as well as dynamic spinal kinematics.  The literature has even shown that post-mastectomy clients display changes in spatiotemporal gait parameter such as step length and gait velocity.

Breast tissue moves. It oscillates a various cycles depending on speed of walking or running.  There is a rhythmic cycle that eventually sets up during walking and running and the cycle is intimately and ultimately tied to arm swing.  Thus, it would make sense that removing a sizable mass of tissue, particularly when done unilaterally, will change the tissue and joint rhythmicity. And if you have been here with The Gait Guys for more than a year you will know that impairing an arm swing will show altered biomechanics in the opposite lower limb (and furthermore, if you alter one lower limb, you begin a process of altering the biomechanical function and rhythmicity of the opposite leg as well.)  Here are 2 links for more on these topics,Arm Swing: Part 1 and Arm Swing: Part 2, When Phase is Lost. Plus here from our blog search archives, everything we have talked about on Arm Swing. 

Arm swing impairment is a real issue and it is one that is typically far overlooked and misrepresented. The intrinsic effects of altering the body through subtraction of tissue are not all that dissimilar to extrinsic changes into the system from things like  walking with a handbag/briefcase, walking with a shoulder bag, walking and running with an ipod or water bottle in one hand.  And do not forget other intrinsic problems that affect spinal symmetry, for example consider the changes on the system from scoliosis that can either consciously or unconsciously alter arm swing and thus global body kinematics.  (Also, do not forget any changes in opposite leg function secondary to a frozen shoulder (adhesive capsulitis) and the like which can impair arm swing.

The bottom line is that because of the neurologically embedded reflexes and reflexive motions and motor patterns, which are things that permeate all human locomotion, anything that changes one of the limbs directly or indirectly can impair and change locomotion, motor pattern choices and programming. 

Obviously the degree to which intervention is taken depends on the amount and location of breast tissue removed and intervention will be determined by physical placement of the prosthesis (whether it be external or internal) as well as the prosthesis weight, shape and possibly several other independent factors such as comparative support to the chest wall in comparison to the opposite breast. (There is a plethora of research out that addresses other methods of intervention such as latissimus dorsi relocation to reform the breast mass. This deserves a blog article all on its own because modifying a major shoulder, scapular and spinal stabilizer and prime mover has never made sense to us clinically or biomechanically.)

In Hojan’s study (below) they found significant differences in the gait parameters in the younger age groups with and without breast prosthesis however there appeared to be no significant differences in the women of the older study group.  However, it appeared that their study did not take into account all of the intimate issues we talk about in gait here on The Gait Guys blog. None the less, in the younger and likely more active study group, the use of a breast prosthesis brought the gait parameters closer to the healthy control group, as we suspected. 

Bottom line, every external and internal parameter that changes affects the human organism and thus affects their gait.

Again, here are those links to our other blog writings on arm swing that are paramount to understanding what we are discussing here today.

Arm Swing Part 1: The Basics   http://thegaitguys.tumblr.com/post/13869907052/arm-swing-in-gait-and-running-part-1-there-is

Arm Swing Part 2: When Phase is Lost   http://thegaitguys.tumblr.com/post/13920283712/arm-swing-part-2-when-phase-is-lost

From our blog search   http://thegaitguys.tumblr.com/search/arm+swing

Shawn and Ivo, The Gait Guys

References:
1.Blomqvist L, Stark B, Engler N, et al. Evaluation of arm and shoulder mobility and strength after modified radical mastectomy and radiother- apy. Acta Oncol. 2004;43(3):280Y283.

2. Rostkowska E, Bak M, Samborski W. Body posture in women after mastectomy and its changes as a result of rehabilitation. Adv Med Sci. 2006;51:287Y297.

3. Crosbie J, Kilbreath SL, Dylke E, et al. Effects of mastectomy on shoulder and spinal kinematics during bilateral upper-limb movement. Phys Ther. 2010;90(5):679Y692.

4. Hojan K, Manikowska F, Molinska-Glura M, Chen PJ, Jozwiak M. Cancer Nurs. 2013 Apr 29. [Epub ahead of print] The Impact of an External Breast Prosthesis on the Gait Parameters of Women After Mastectomy.

Human gait is cyclical. For the most part, when one limb is engaged on the ground (stance phase), the other is in swing phase. Before we continue, you should recall that there is a brief double limb support phase in walking gait, that which is absent in running gait. Also, we wish to remind you of our time hammered principle that when the foot is on the ground the glutes are heavily in charge, and when the foot is in the air, the abdominals are heavily in charge.   For us to move cleanly and efficiently one would assume that the best way to do that would be to ensure that the lower 2 limbs are capable of doing the exact same things, with the same timing, same skill, same endurance and same strength. This goes for the upper 2 limbs as well, and then of course the synchronizing of the 4 in a cohesive effort. For this clean seamless motor function to occur, one must assume that there would be no injuries that had left a remnant mark on one limb thus encouraging a necessary compensation pattern in that limb (and one that would then have to be negotiated with the opposite limb as well as the contralateral upper or lower limb).  For example, when right ankle rocker (dorsiflexion) is impaired, early heel departure will occur and hip extension will be limited. An alteration in right glute function will most likely follow.  One could theorize that the left step length (the length of measure from right heel strike through to left heel strike) would thus be shortened. This would cause a premature load onto the left limb, and could very well force the left frontal plane to be more engaged than is desirable. This could lead to left core and hip frontal plane weakness and compensation patterns to be generated (ie. right arm abduction. One can see all of these components in the photo above, and in this case here). It could also lead to a pelvic distortion pattern which would further throw off the anti-phasic nature of symmetrical and efficient gait.  To complicate the cyclical scenario, the time usually used to move sagittally will be partially used to move into, and back out of, the left frontal plane. This will necessitate some abbreviations in the left stance phase timely mechanical events. Some biomechanical events will have to be abbreviated or sped through and then the right limb will have to adapt to those changes. These are simple gait problems we have talked about over and over again here on the gait guys blog. (Search “arm swing” on our blog and you will find 45 articles around this topic.) These compensation patterns will include expressed weaknesses in various parts of the human frame as part of the pattern, and merely fixing those weaknesses does not address the right ankle rocker problem. Fixing said weaknesses merely encourages the brain to possibly continue to perpetuate necessary tightnesses in other muscles and engrain the compensations (challenges to mobility and stability) further or more complexly.  It is easy to find something weak, it takes a sharp brain to find the sometimes silent sparking event. Are you able to find the problem in this never ending loop of compensations and find a way to unwrinkle the system one logical piece at a time, or will you just chose to strengthen the wrinkled system and hope that the new strength on top of the compensations is adequate for you our your client ? One should not be forever sentenced to daily or weekly rehabilitative sessions/ homework to negate and alleviate symptoms, this is a far more durable machine than that. Fix the problem. Now, lets add another wrinkle to the system.  What if there were problems before any injuries ?  Meaning, what if there were problems during the timely maturation and suppression of the primitive reflexes ? Or problems in the timely appearance or maturation of postural reflexes? A problem in these areas may very well result in a central or peripheral nervous system malfunction and a representation of such in one’s movement and gait.  That is a larger discussion for another time. There is a reason that in our practices we often assess and treat contralateral upper and lower limbs as well as to address remnants from old injuries whether they are symptomatic or not. This is a really tough puzzle and game you are playing. For example, when there is insufficient hip internal rotation unilaterally you can regain some of the loss through increased foot pronation unilaterally, but at a consequence to both the local and global pictures.  Remember, most of the time you are trying to walk in a straight line from A to B and if the parts are not symmetrical you have many options to compensate. It is not as simple as telling your athlete to swing one arm more, or to stop pulling it across their body; they need to do those things, it is called a “compensation”. It is often not as simple as finding an impaired Rolling Pattern and driving it back to symmetry, in doing so, you may have just added strength and skill to a compensation.  Merely addressing things locally can be a crime.  If you are seeing an arm swing change, you would be foolish not to look at the opposite lower limb and foot at the very least, and of course assess spinal rotation, lateral flexion and hinging as well as core mobility and stability.  For your neuro nerds, remember the receptors from the central spine and core fire into the midline vermis of the cerebellum (one of the oldest parts of our brain, called the paleo cerebellum); and these pathways, along with other cerebellar efferents, fire our axial extensor muscles that keep us upright in the gravitational plane and provide balance or homeostasis.  So, those need assessed and addressed as well.   Or, if this is too much thinking for you, … you can just train harder and get stronger . .  . in all your compensation patterns, after all, it is easier than figuring out why and how that right ankle started the whole mess, if in fact that is even the first piece of the puzzle. Welcome to the matrix. shawn and ivo, the gait guys

Human gait is cyclical. For the most part, when one limb is engaged on the ground (stance phase), the other is in swing phase. Before we continue, you should recall that there is a brief double limb support phase in walking gait, that which is absent in running gait. Also, we wish to remind you of our time hammered principle that when the foot is on the ground the glutes are heavily in charge, and when the foot is in the air, the abdominals are heavily in charge.  

For us to move cleanly and efficiently one would assume that the best way to do that would be to ensure that the lower 2 limbs are capable of doing the exact same things, with the same timing, same skill, same endurance and same strength. This goes for the upper 2 limbs as well, and then of course the synchronizing of the 4 in a cohesive effort. For this clean seamless motor function to occur, one must assume that there would be no injuries that had left a remnant mark on one limb thus encouraging a necessary compensation pattern in that limb (and one that would then have to be negotiated with the opposite limb as well as the contralateral upper or lower limb).  For example, when right ankle rocker (dorsiflexion) is impaired, early heel departure will occur and hip extension will be limited. An alteration in right glute function will most likely follow.  One could theorize that the left step length (the length of measure from right heel strike through to left heel strike) would thus be shortened. This would cause a premature load onto the left limb, and could very well force the left frontal plane to be more engaged than is desirable. This could lead to left core and hip frontal plane weakness and compensation patterns to be generated (ie. right arm abduction. One can see all of these components in the photo above, and in this case here). It could also lead to a pelvic distortion pattern which would further throw off the anti-phasic nature of symmetrical and efficient gait.  To complicate the cyclical scenario, the time usually used to move sagittally will be partially used to move into, and back out of, the left frontal plane. This will necessitate some abbreviations in the left stance phase timely mechanical events. Some biomechanical events will have to be abbreviated or sped through and then the right limb will have to adapt to those changes. These are simple gait problems we have talked about over and over again here on the gait guys blog. (Search “arm swing” on our blog and you will find 45 articles around this topic.) These compensation patterns will include expressed weaknesses in various parts of the human frame as part of the pattern, and merely fixing those weaknesses does not address the right ankle rocker problem. Fixing said weaknesses merely encourages the brain to possibly continue to perpetuate necessary tightnesses in other muscles and engrain the compensations (challenges to mobility and stability) further or more complexly.  It is easy to find something weak, it takes a sharp brain to find the sometimes silent sparking event. Are you able to find the problem in this never ending loop of compensations and find a way to unwrinkle the system one logical piece at a time, or will you just chose to strengthen the wrinkled system and hope that the new strength on top of the compensations is adequate for you our your client ? One should not be forever sentenced to daily or weekly rehabilitative sessions/ homework to negate and alleviate symptoms, this is a far more durable machine than that. Fix the problem.

Now, lets add another wrinkle to the system.  What if there were problems before any injuries ?  Meaning, what if there were problems during the timely maturation and suppression of the primitive reflexes ? Or problems in the timely appearance or maturation of postural reflexes? A problem in these areas may very well result in a central or peripheral nervous system malfunction and a representation of such in one’s movement and gait.  That is a larger discussion for another time.

There is a reason that in our practices we often assess and treat contralateral upper and lower limbs as well as to address remnants from old injuries whether they are symptomatic or not. This is a really tough puzzle and game you are playing. For example, when there is insufficient hip internal rotation unilaterally you can regain some of the loss through increased foot pronation unilaterally, but at a consequence to both the local and global pictures.  Remember, most of the time you are trying to walk in a straight line from A to B and if the parts are not symmetrical you have many options to compensate. It is not as simple as telling your athlete to swing one arm more, or to stop pulling it across their body; they need to do those things, it is called a “compensation”. It is often not as simple as finding an impaired Rolling Pattern and driving it back to symmetry, in doing so, you may have just added strength and skill to a compensation.  Merely addressing things locally can be a crime.  If you are seeing an arm swing change, you would be foolish not to look at the opposite lower limb and foot at the very least, and of course assess spinal rotation, lateral flexion and hinging as well as core mobility and stability.  For your neuro nerds, remember the receptors from the central spine and core fire into the midline vermis of the cerebellum (one of the oldest parts of our brain, called the paleo cerebellum); and these pathways, along with other cerebellar efferents, fire our axial extensor muscles that keep us upright in the gravitational plane and provide balance or homeostasis.  So, those need assessed and addressed as well.  

Or, if this is too much thinking for you, … you can just train harder and get stronger . .  . in all your compensation patterns, after all, it is easier than figuring out why and how that right ankle started the whole mess, if in fact that is even the first piece of the puzzle.

Welcome to the matrix.

shawn and ivo, the gait guys

tumblr_nfw1xxi7Yt1qhko2so1_250.jpg
tumblr_nfw1xxi7Yt1qhko2so2_540.png

More on Stretching? Enough already, eh?

The last few weeks , we have been talking about techniques to improve your (or your clients) stretching experience. 1st, we talked about reciprocal inhibition here. Next we talked about post isometric inhibition here. The we spoke about the symmetrical tonic neck reflex (response) here. If there is a symmetrical tonic neck reflex, then there must be an asymmetrical one as well, eh? That is the topic of todays discussion

The asymmetrical tonic neck reflex was 1st described by Magnus and de Kleyn in 1912 (1). Like in the pictures above, when the head is rotated to one side, there is ipsilateral extension of the upper and lower extremity on that side, and flexion of the contralateral (the side AWAY from where you are rotating) upper and lower extremity. Take a few minutes to see the subtleness of the reflex in the pictures above. Now think about how this occurs in your clients/patients.  The reflex is everywhere!

The reflex persists into adulthood (2) and is modulated by both eye movement and muscular activity (3). When there is neurological compromise, the reflex can be more prevalent, and it seems to arise from the joint mechanoreceptors in the neck and its connection to the reticular formation of the brainstem (4). It may modulate blood flow and cardiovascular activity as well (5). 

So, how can we take advantage of this? We could follow in the footsteps of Berta Bobath (6) and incorporate these into our rehabilitation programs, which we have done, quite successfully. But rather than read a whole book, lets talk about how you could incorporate this into your stretching program. 

Let’s say you want to stretch the right hamstring:

  • actively rotating the head to the right (see reference 3) facilitates the right tricep and right quadricep AND facilitates the left bicep and left hamstring
  • through reciprocal inhibition, this would inhibit the right bicep and hamstring AND left tricep and left quadricep
  • To get a little more out of the stretch, you could actively contract the right tricep and quadricep (MORE reciprocal inhibition), amplifying the effect

We encourage you to try this, both on yourself and your clients. It really works!

Wow, isn’t neurology cool? And you thought it was only for geeks!

The Gait Guys. Giving you info you can use in a practical manner, each and every post. Be a geek. Spread the word. 

  1. http://www.worldneurologyonline.com/article/arthur-simons-tonic-neck-reflexes-hemiplegic-persons/#sthash.6QS3Eat3.dpuf 
  2. Bruijn SM1, Massaad F, Maclellan MJ, Van Gestel L, Ivanenko YP, Duysens J. Are effects of the symmetric and asymmetric tonic neck reflexes still visible in healthy adults?Neurosci Lett. 2013 Nov 27;556:89-92. doi: 10.1016/j.neulet.2013.10.028. Epub 2013 Oct

  3. Le Pellec A1, Maton B. Influence of tonic neck reflexes on the upper limb stretch reflex in man. J Electromyogr Kinesiol. 1996 Jun;6(2):73-82.

  4. Michael D. Ellis, Justin Drogos, Carolina Carmona, Thierry Keller, Julius P. A. Dewal Neck rotation modulates flexion synergy torques, indicating an ipsilateral reticulospinal source for impairment in stroke Journal of NeurophysiologyDec 2012,108(11)3096-3104;DOI: 10.1152/jn.01030.2011

  5. Hervé Normand, Olivier Etard and Pierre Denise Otolithic and tonic neck receptors control of limb blood flow in humans J Appl Physiol  82:1734-1738, 1997.

  6. Berta Bobath, Chartered Society of Physiotherapy (Great Britain)  Abnormal postural reflex activity caused by brain lesions Aspen Systems Corp. Rockville, MD, 1985 -

Podcast 84: Toe Walkers, Hip Impingment & Olympic Lifting Shoes

Plus: pulmonary edema syndrome in Triathlete swimmers, truths about olympic lifting shoes and more !

Show sponsors:

www.newbalancechicago.com

A. Link to our server: 

http://traffic.libsyn.com/thegaitguys/pod_84f.mp3

Direct Download: 

http://thegaitguys.libsyn.com/podcast-84

Other Gait Guys stuff

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:

Monthly lectures at : www.onlinece.com   type in Dr. Waerlop or Dr. Allen,  ”Biomechanics”

Show notes:

Are Triathletes Really Dying of Heart Attacks?

 
We had some stuff on FB last week about head positioning during running.  Alot of people tried to simplify it.  There is more to it. Here is another perspective.
 
Toe Walking children
 
Olympic lifting shoes ? or Converse Chuck Tailors ?
 
Journal of Foot and Ankle Research | Abstract | The associations of leg lean mass with foot pain, posture and function in the Framingham foot study
http://www.jfootankleres.com/content/7/1/46/abstract
 
Hip Impingements
 
Achilles oddity: Heeled shoes may boost load during gait | Lower Extremity Review Magazine
http://lermagazine.com/news/in-the-moment-rehabilitation/achilles-oddity-heeled-shoes-may-boost-load-during-gait
 
Toe Walking in Children. Do you know what you are dealing with ? Part 2 So you have now ruled out possible Autism-spectrum, possible CMT (Charcot-Marie Tooth Disease), CP (Cerebral Palsy), MD (Muscular Dystrophy) in your young toe walking individual.  Now you have been left with the aftermath foggy diagnosis of “Idiopathy Toe Walking”, that doesn’t leave you as a parent or clinician with much to work with or likely to be confident about. Let us try to help make things clearer and give you some other cognitive options to entertain. New research in recent years has brought new light onto the issue and we wanted to use today’s blog post as a platform to share it with you.  In a previous week’s “Part 1” blog post & video (link) you can see in the gait on the video that nothing appears to be terribly abnormal in the foot structure (from what we can tell), the client is merely remaining in the plantarflexed posture and forefoot weight bearing.  This is highly ineffective gait and can be very fatiguing let alone to mention the sustained loading into the posterior compartment and plantarflexor mechanism (gastrosoleus-achilles) not to mention the sustained forefoot loading response on the foot bones and joints. Remember, the tibialis posterior and long toe flexors are close neighbors with capabilities of plantarflexion moments, so there are possible clinical manifestations there as well not to mention the obvious (especially to long-time Gait Guys readers) deficits that will be found in functional ankle dorsiflexion, ankle rocker and S.E.S. (skill, endurance, strength) of the anterior compartment mechanism (tibialis anterior, long toe extensors, peroneus tertius).  Even if this client were to go into normal heel strike and stance phases right now, they would have lots of work to do to restore the anterior-posterior compartment balance, the 3 foot rockers (heel, ankle and forefoot) abd posterior compartment length to avoid functional pathology not to mention the timely coordination of all these events.  Idiopathic toe walking is suggested to be as prevalent as 12%. Toe walking is categorized when there is an absence, or at least a limitation, of heel strike during initial walking gait contact phase. We are not referring to, at all, forefoot running principles. Neuromotor maturation comes about via the suppression of the primitive reflexes/windows and appearance of the postural reflexes and responses. Delays or subtractions of these windows/reflexes may cause challenges in the normal development and maturation of the central and/or peripheral nervous systems.  With toe walking, the clinical window most studies suggest is to begin investigation after 3 years of age when the primitive motor patterns should have solidified and the gait and postural patterns have begun to layer on top of those primitive reflexes.  Remember though, the primitive patterns are not sequentially fixed, meaning that infants move in and out of these reflexes until they become skilled and permanent.  It is not until they are fixed that the postural patterns, which are volitional, can be gradually built. This should bring some deeper thoughts to your mind right now.  Is toe walking behavior a missed primitive window or a non-volitional postural window? These kids are not doing this by choice, anyone who has worked with these types of cases knows this very well, and we have seen our share.  In the literature and clinics a plethora of things have been tried and discussed (ie. serial casting, botulinum toxin, surgical tendon lengthening, gait retraining, orthoses/orthotics, night splints, day splints and the like). Keep in mind that only one of the above is addressing a functional change via cognitive and higher brain center demand, “gait retraining”. The others are passive forced attempts.  But is gait training enough ? And how far back into primitive and postural gait pattern training do you have to go? Gait training certainly does something as eluded to by two research papers we posted on our Facebook page in previous weeks. See those references below. “For both feet, contact time of the heel was increased after the training period, whereas contact time of the forefeet decrease. Also positive changes in the active range of joint motion of the ankle (dorsal extension) were observed in both feet. These positive effects were visible also in the follow–up assessment.” -Pelykh study “Daily intensive gait training may influence the elastic properties of ankle joint muscles and facilitate toe lift and heel strike in children with CP. Intensive gait training may be beneficial in preventing contractures and maintain gait ability in children with CP.” - Willerslev-Olsen study So what else could be going on here ? Is this neurodevelopmental ? Yes, for sure.  But where did things go awry ?  And how do we fix it ? Remember, the development of primitive and postural reflexes is supposed to occur proximal to distal (ie. from core to hand/foot). In a recent study in the Journal of Child Neurology,   “for the first time, motor and sensory challenges presenting in healthy children with an idopathic toe walking gait have been identified.These challenges imply an immaturity or mild impairment at the cerebellum or motor cortex level.” As the article suggested, the research did not render direct cause(s) for the gait pattern, rather some very viable theories on the topic. They found that only the areas of balance, upper body coordination and bilateral coordination were areas found to be problematic in the toe walkers. These 3 components require the integration of the tactile, vestibular and proprioceptive systems as a team. Diving deeper into how these 3 outputs are linked, there is a required “mix of occulomotor control and cues together with subtle and gross postural adjustments” (3). As Williams et al (3) suggested, “they are skills requiring the coordination of movements in which each side of the body moves simultaneously or in sequence”.  Kind of sounds like some topics on Arm Swing/Leg swing and also on the topic of phasic/antiphasic gait we have discussed over and over again here on TGG and in recent podcasts (82) doesn’t it ?  It was proposed that perhaps idiopathic toe walkers negotiate their sensory challenges by unconsciously engaging toe walking behavior to change or challenge these inputs.  Here were some of the proposed thoughts from the Williams study. “The tactile receptors of the skin may be stimulated through pressure at the ball of the foot or lessened by a reduction of surface contact by raising the heel off the ground. Proprioceptive input may be changed at the knee, ankle and even toe joints by unconsciously repositioning of the foot posture.  The vestibular input may be increased by the vertical stimulation of the bouncy type gait that results from toe walking.”(3) Williams It seems clear from the Williams study that these children demonstrate a number of sensory needs that motivate toe walking to alter (increase or decrease) or improve sensory input.  The study also suggests that the toe walking gait is an attempt to modify input on postural stimuli during gait to serve diminished postural and position awareness. The findings of this study are important.  Our most recent blog posts and podcasts (Nov 2014) have discussed some of the components to build, control and coordinate gait on a higher neurologic level. The Williams article seems to support these discussions, that some pathologic gaits are initiated on a neurologic level as opposed to biomechanical at the foot and ankle level.  This sounds like the work offered by “the functional neurologist”, graduates of the Carrick Institute for Graduate Studies ! (carrickinstitute.com) Have a great day gait brethren ! Shawn and Ivo, The Gait Guys References: 1. Eur J Phys Rehabil Med. 2014 Oct 9. [Epub ahead of print] Treatment outcome of visual feedback training in an adult patient with habitual toe walking. Pelykh O1, Klein AM, Feist-Pagenstert I, Schlick C, Ilmberger J. NeuroRehabilitation. 2014 Oct 15. [Epub ahead of print] 2. Gait training reduces ankle joint stiffness and facilitates heel strike in children with Cerebral Palsy. Willerslev-Olsen M1, Lorentzen J1, Nielsen JB2. 3. Is idiopathic toe walking really idiopathic ? The motor skills and sensory processing abilities associated with idiopathic toe walking gait.  J Child Neurol 2014, 29:71 Williams, C. , Curtin, Wakefield and Nielsen

Toe Walking in Children. Do you know what you are dealing with ? Part 2

So you have now ruled out possible Autism-spectrum, possible CMT (Charcot-Marie Tooth Disease), CP (Cerebral Palsy), MD (Muscular Dystrophy) in your young toe walking individual.  Now you have been left with the aftermath foggy diagnosis of “Idiopathy Toe Walking”, that doesn’t leave you as a parent or clinician with much to work with or likely to be confident about. Let us try to help make things clearer and give you some other cognitive options to entertain. New research in recent years has brought new light onto the issue and we wanted to use today’s blog post as a platform to share it with you. 

In a previous week’s “Part 1” blog post & video (link) you can see in the gait on the video that nothing appears to be terribly abnormal in the foot structure (from what we can tell), the client is merely remaining in the plantarflexed posture and forefoot weight bearing.  This is highly ineffective gait and can be very fatiguing let alone to mention the sustained loading into the posterior compartment and plantarflexor mechanism (gastrosoleus-achilles) not to mention the sustained forefoot loading response on the foot bones and joints. Remember, the tibialis posterior and long toe flexors are close neighbors with capabilities of plantarflexion moments, so there are possible clinical manifestations there as well not to mention the obvious (especially to long-time Gait Guys readers) deficits that will be found in functional ankle dorsiflexion, ankle rocker and S.E.S. (skill, endurance, strength) of the anterior compartment mechanism (tibialis anterior, long toe extensors, peroneus tertius).  Even if this client were to go into normal heel strike and stance phases right now, they would have lots of work to do to restore the anterior-posterior compartment balance, the 3 foot rockers (heel, ankle and forefoot) abd posterior compartment length to avoid functional pathology not to mention the timely coordination of all these events. 

Idiopathic toe walking is suggested to be as prevalent as 12%. Toe walking is categorized when there is an absence, or at least a limitation, of heel strike during initial walking gait contact phase. We are not referring to, at all, forefoot running principles. Neuromotor maturation comes about via the suppression of the primitive reflexes/windows and appearance of the postural reflexes and responses. Delays or subtractions of these windows/reflexes may cause challenges in the normal development and maturation of the central and/or peripheral nervous systems.  With toe walking, the clinical window most studies suggest is to begin investigation after 3 years of age when the primitive motor patterns should have solidified and the gait and postural patterns have begun to layer on top of those primitive reflexes.  Remember though, the primitive patterns are not sequentially fixed, meaning that infants move in and out of these reflexes until they become skilled and permanent.  It is not until they are fixed that the postural patterns, which are volitional, can be gradually built. This should bring some deeper thoughts to your mind right now.  Is toe walking behavior a missed primitive window or a non-volitional postural window? These kids are not doing this by choice, anyone who has worked with these types of cases knows this very well, and we have seen our share. 

In the literature and clinics a plethora of things have been tried and discussed (ie. serial casting, botulinum toxin, surgical tendon lengthening, gait retraining, orthoses/orthotics, night splints, day splints and the like). Keep in mind that only one of the above is addressing a functional change via cognitive and higher brain center demand, “gait retraining”. The others are passive forced attempts.  But is gait training enough ? And how far back into primitive and postural gait pattern training do you have to go? Gait training certainly does something as eluded to by two research papers we posted on our Facebook page in previous weeks. See those references below.

“For both feet, contact time of the heel was increased after the training period, whereas contact time of the forefeet decrease. Also positive changes in the active range of joint motion of the ankle (dorsal extension) were observed in both feet. These positive effects were visible also in the follow–up assessment.” -Pelykh study

Daily intensive gait training may influence the elastic properties of ankle joint muscles and facilitate toe lift and heel strike in children with CP. Intensive gait training may be beneficial in preventing contractures and maintain gait ability in children with CP.” - Willerslev-Olsen study

So what else could be going on here ? Is this neurodevelopmental ? Yes, for sure.  But where did things go awry ?  And how do we fix it ? Remember, the development of primitive and postural reflexes is supposed to occur proximal to distal (ie. from core to hand/foot).

In a recent study in the Journal of Child Neurology,  

“for the first time, motor and sensory challenges presenting in healthy children with an idopathic toe walking gait have been identified.These challenges imply an immaturity or mild impairment at the cerebellum or motor cortex level.”

As the article suggested, the research did not render direct cause(s) for the gait pattern, rather some very viable theories on the topic. They found that only the areas of balance, upper body coordination and bilateral coordination were areas found to be problematic in the toe walkers. These 3 components require the integration of the tactile, vestibular and proprioceptive systems as a team. Diving deeper into how these 3 outputs are linked, there is a required “mix of occulomotor control and cues together with subtle and gross postural adjustments” (3). As Williams et al (3) suggested, “they are skills requiring the coordination of movements in which each side of the body moves simultaneously or in sequence”.  Kind of sounds like some topics on Arm Swing/Leg swing and also on the topic of phasic/antiphasic gait we have discussed over and over again here on TGG and in recent podcasts (82) doesn’t it ?  It was proposed that perhaps idiopathic toe walkers negotiate their sensory challenges by unconsciously engaging toe walking behavior to change or challenge these inputs.  Here were some of the proposed thoughts from the Williams study.

“The tactile receptors of the skin may be stimulated through pressure at the ball of the foot or lessened by a reduction of surface contact by raising the heel off the ground. Proprioceptive input may be changed at the knee, ankle and even toe joints by unconsciously repositioning of the foot posture.  The vestibular input may be increased by the vertical stimulation of the bouncy type gait that results from toe walking.”(3) Williams

It seems clear from the Williams study that these children demonstrate a number of sensory needs that motivate toe walking to alter (increase or decrease) or improve sensory input.  The study also suggests that the toe walking gait is an attempt to modify input on postural stimuli during gait to serve diminished postural and position awareness.

The findings of this study are important.  Our most recent blog posts and podcasts (Nov 2014) have discussed some of the components to build, control and coordinate gait on a higher neurologic level. The Williams article seems to support these discussions, that some pathologic gaits are initiated on a neurologic level as opposed to biomechanical at the foot and ankle level.  This sounds like the work offered by “the functional neurologist”, graduates of the Carrick Institute for Graduate Studies ! (carrickinstitute.com)

Have a great day gait brethren !

Shawn and Ivo, The Gait Guys

References:

1. Eur J Phys Rehabil Med. 2014 Oct 9. [Epub ahead of print]

Treatment outcome of visual feedback training in an adult patient with habitual toe walking.

NeuroRehabilitation. 2014 Oct 15. [Epub ahead of print]

2. Gait training reduces ankle joint stiffness and facilitates heel strike in children with Cerebral Palsy.

3. Is idiopathic toe walking really idiopathic ? The motor skills and sensory processing abilities associated with idiopathic toe walking gait.  J Child Neurol 2014, 29:71 Williams, C. , Curtin, Wakefield and Nielsen
More Tricks for stretching, part 3 We have been talking about ways to enhance stretching, talking about taking avvantage of reciprocal inhibition (please see part 1 here) and autogenic  (or post isometric) inhibition (please see part 2 here).  Before we talk about this next one, we need to give you a little background (neurologically speaking).  Take a look at the picture above and note the posturing of the baby in the 2 positions. These neurological reflexes (or postures) are called symmetrical tonic neck reflexes or responses (STNR’s for short) and were described in animals and men by Magnus and de Kleyn in 1912 (1). This work was later studied and reported by by Arthur Simons in 1916  (2) and later by Francis Walshe in 1923 (3). These were later made popular by Berta and Karl Bobath in the 70’s (who studied Walshes work), whom they are often attributed to (4).  You next question is “Do these persist into healthy adulthood”? and the answer is a resounding YES (5). Take a look at the picture above again and note the following:  When the neck is flexed, the fore limbs flex (and the muscles facilitating that, bicep, brachialis, anterior deltoid are contracting) and the hind limbs are extending (relatively), with the glutes maximus, quadriceps, foot dorsiflexors contracting. Note that when the head is extended, the forelimbs are extended and the hind limbs flexed. Think about the muscles involved. Upper extremity tricep, anconeus, posterior deltoid, lower back extensors, hamstrings and foot plantar flexors facilitated. The reflex is based on the mechanoreceptors in the neck articulations and muscles and are frequently used by us and many others in the rehabilitation field. Generally speaking, looking up facilitates things which make you extend above T12, and flex below T12. Looking down facilitates flexion above T12 and extension below.  We would encourage you at this point to “assume” these positions and feel the muscles which are active and at rest. So, how can we take advantage of these while stretching?  Think about your head position:  If you are standing up and hinging at the hips to stretch your hamstrings (notice we did not say “bent at the waist”; there is a BIG difference in shear forces applied to your lumbar spine) you would probably want your neck bent forward, as this would fire your quads which would in turn ALSO inhibit your hamstrings, in addition to the STNR inhibiting the hamstring.  If you were in a hip flexor stretch position, you would want you head up, looking at the ceiling to take advantage of the reflex.  We are confident you can think of many more applications of this reflex and trust that you will, as it can apply to both upper and lower extremity stretches. Just remember that this reflex is symmetrical and will affect BOTH sides. Of course, there are reflexes that only effect things unilaterally, but that is the subject of another post.  The Gait Guys. Helping make you better at what you do for yourself and others and assisting you on using the neurology that God gave you.  http://www.worldneurologyonline.com/article/arthur-simons-tonic-neck-reflexes-hemiplegic-persons/#sthash.6QS3Eat3.dpuf  Simons A (1923) Kopfhaltung and Muskeltonus. Ges.Z. Neurol.Psychiatr. 80: 499-549. Walshe FMR (1923) On certain or postural reflexes in hemiplegia, with special reference to the so-called “associated movements.” Brain 46: 1-37.  Janet M. Howle . Symmetrical Tonic Neck Reflex in Neuro-developmental Treatment Approach: Theoretical Foundations and Principles of Clinical Practice.   NeuroDevelopmental Treatment, 2002  p 341 ISBN 0972461507, 9780972461504 Bruijn SM1, Massaad F, Maclellan MJ, Van Gestel L, Ivanenko YP, Duysens J. Are effects of the symmetric and asymmetric tonic neck reflexes still visible in healthy adults?Neurosci Lett. 2013 Nov 27;556:89-92. doi: 10.1016/j.neulet.2013.10.028. Epub 2013 Oct 21.

More Tricks for stretching, part 3

We have been talking about ways to enhance stretching, talking about taking avvantage of reciprocal inhibition (please see part 1 here) and autogenic  (or post isometric) inhibition (please see part 2 here). 

Before we talk about this next one, we need to give you a little background (neurologically speaking). 

Take a look at the picture above and note the posturing of the baby in the 2 positions. These neurological reflexes (or postures) are called symmetrical tonic neck reflexes or responses (STNR’s for short) and were described in animals and men by Magnus and de Kleyn in 1912 (1). This work was later studied and reported by by Arthur Simons in 1916  (2) and later by Francis Walshe in 1923 (3). These were later made popular by Berta and Karl Bobath in the 70’s (who studied Walshes work), whom they are often attributed to (4). 

You next question is “Do these persist into healthy adulthood”? and the answer is a resounding YES (5).

Take a look at the picture above again and note the following: 

  • When the neck is flexed, the fore limbs flex (and the muscles facilitating that, bicep, brachialis, anterior deltoid are contracting) and the hind limbs are extending (relatively), with the glutes maximus, quadriceps, foot dorsiflexors contracting.

  • Note that when the head is extended, the forelimbs are extended and the hind limbs flexed. Think about the muscles involved. Upper extremity tricep, anconeus, posterior deltoid, lower back extensors, hamstrings and foot plantar flexors facilitated.

The reflex is based on the mechanoreceptors in the neck articulations and muscles and are frequently used by us and many others in the rehabilitation field. Generally speaking, looking up facilitates things which make you extend above T12, and flex below T12. Looking down facilitates flexion above T12 and extension below. 

We would encourage you at this point to “assume” these positions and feel the muscles which are active and at rest.

So, how can we take advantage of these while stretching? 

Think about your head position:

  •  If you are standing up and hinging at the hips to stretch your hamstrings (notice we did not say “bent at the waist”; there is a BIG difference in shear forces applied to your lumbar spine) you would probably want your neck bent forward, as this would fire your quads which would in turn ALSO inhibit your hamstrings, in addition to the STNR inhibiting the hamstring. 

  • If you were in a hip flexor stretch position, you would want you head up, looking at the ceiling to take advantage of the reflex. 

We are confident you can think of many more applications of this reflex and trust that you will, as it can apply to both upper and lower extremity stretches. Just remember that this reflex is symmetrical and will affect BOTH sides. Of course, there are reflexes that only effect things unilaterally, but that is the subject of another post. 

The Gait Guys. Helping make you better at what you do for yourself and others and assisting you on using the neurology that God gave you. 

  1. http://www.worldneurologyonline.com/article/arthur-simons-tonic-neck-reflexes-hemiplegic-persons/#sthash.6QS3Eat3.dpuf 
  2. Simons A (1923) Kopfhaltung and Muskeltonus. Ges.Z. Neurol.Psychiatr. 80: 499-549.
  3. Walshe FMR (1923) On certain or postural reflexes in hemiplegia, with special reference to the so-called “associated movements.” Brain 46: 1-37. 
  4. Janet M. Howle . Symmetrical Tonic Neck Reflex in Neuro-developmental Treatment Approach: Theoretical Foundations and Principles of Clinical Practice.   NeuroDevelopmental Treatment, 2002  p 341 ISBN 0972461507, 9780972461504
  5. Bruijn SM1, Massaad F, Maclellan MJ, Van Gestel L, Ivanenko YP, Duysens J. Are effects of the symmetric and asymmetric tonic neck reflexes still visible in healthy adults?Neurosci Lett. 2013 Nov 27;556:89-92. doi: 10.1016/j.neulet.2013.10.028. Epub 2013 Oct 21.

Podcast 83: Gait & Brain Injury, and Compression Wraps Theories

Plus: Rocker Shoes, Knee Replacements, and Strong Ankles

Show sponsors:

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A. Link to our server: 

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

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D. other web based Gait Guys lectures:

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

Show notes:

Texting on the Loo

Hepatic encephalopathy: effect of liver failure on brain function.

http://www.nature.com/nrn/journal/v14/n12/fig_tab/nrn3587_F1.html

The Bouncy Gait: Premature heel rise gait. Taking another look.

This is a great video example of a premature heel rise during gait. You should be able to clearly see it on the left foot (and this was toned down after we brought it to his awareness!).  The heel rise occurs early in the stance phase of gait, instead of the late stance phase.

We have talked about this bouncy type vertically oriented gait many times in blog posts and in our podcasts.  This is a pretty prevalent problem in the world, mostly because so many people have impaired ankle rocker/dorsiflexion from weak anterior compartments and short/tight posterior compartments.  None the less, for the majority, this is a pathologic gait pattern and it will impart undue stress into the posterior mechanism (calf-achilles complex). Just think about it, this person is going vertical at or prior to the tibia achieving 90degrees (perpendicular to the ground) instead of continuing to progress the tibia to 110+ degrees to enable normal timely pronation and foot biomechanical events.  This is not a normal gait. Period. This will change the function of the entire posterior chain upward. 

If you want to see another great example  from the frontal plane, check out this cute video representation of a vertial/premature heel rise bouncy gait. 

This gait style is caused by a premature heel rise from joint range limitation and/or from premature engagement of the gastrosoleus (and sometimes even the long toe flexors, you will see them hammering and curled in many folks). It can be a learned habitual pattern and nothing more, we have even seen it even in child-parental gait modeling in our offices. These people will never get to NORMAL full late-midstance of gait (without biomechanical compromise) and thus never achieve full hip extension nor adequate ankle dorsiflexion / ankle rocker. The gait cycle is an orchestrated symphony of timely events and when one or several timely events are omitted or impaired the mechanics are passed into other areas for compensation. This vertical gait style is very inefficient in that the gluteals cannot adequately power into hip extension into a forward progression drive, because the calf is prematurely generating vertical movement through ankle plantarflexion.  This strategy is sometimes deployed because the person actually is significantly ankle dorsiflexion (ankle rocker) deficient.  Meaning, they hit the limitations of dorisflexion and in order to progress forward they first have to go vertical.  This vertical motion, because they are moving into ankle plantarflexion, re-buys more ankle dorsiflexion range which then can be used if they so choose. Obviously, the remedy is to find the functional deficit, remove it and retrain the pattern.  There are a whole host of other problems that go with this compensation pattern but we wanted our mission to stay focused today.  Remember, this is usually a subconscious motor pattern compensation. Is it like the toe walking issue we talked about last week (post link here) ? It is similar in some ways and can have primitive and postural motor pattern implications. We will follow up the “Idiopathy Toe Walking Gait: Part 2” shortly but we wanted to strategically put this blog post ahead of it, because there are similar characteristics and implications. Trust us, there is a method to our madness :)

Shawn and Ivo

The Gait Guys

More effective stretching, Part 2 Last week we looked at one (of many) methods to make stretching more effective, utilizing a neurological reflex called “reciprocal inhibition” If you missed that one, or need a review, click here.  Another way to get muscles to the end range of motion is to utilize a technique called “post isometric relaxation”. Notice I did not say to lengthen the muscle; to actually add sarcomeres to a muscle you would need to use a different technique. Click here to read that post. Contracting a muscle before stretching is believed to take advantage of a post isomteric inhibition (sometimes called autogenic inhibition), where the muscle is temporarily inhibited from contracting for a period immediately following a isometric contraction. This has been popularized by the PNF stretching techniques, such as “contract hold” or “contract relax” . EMG studies do  jot seem to support this and actually show muscle activation remains the same (1, 2) or increased after contraction (3-6). Perhaps it is due to an increased stretch tolerance (7,8).  The technique was 1st described by Mitchell, Morgan and Pruzzo in 1979 (9). These gents felt it was important to utilize a maximal contraction (using 75-100% of contractile force) to get to have the effect. It was later shown by Feland and Marin (10) that a more minimal, submaximal contraction of 20-60% accomplished the same thing.  Lewit felt that a less forceful contraction offers the same results, and combined respiratory assists (inspiration facilitates contraction, expiration facilitates relaxation) with this technique (11). Interestingly, there are bilateral increases in range of motion with this type of stretching, indicating a cross over effect (12). Regardless of the mechanism, the phenomenon happens and we can take advantage of it.  This is how you do it:  Bring the muscle to its end range (maximum length) without stretching, taking up the slack. This should be painless, as this will elicit a different neurological reflex that may actually increase muscle tone.  resist with a minimal isometric contraction (20-60%) and hold for 10 seconds.  You can inspire to enhance the effect. relax and exhale slowly. It is important to wait and feel the relaxation. Stretch through the entire period of the relaxation. You should feel a lengthening of the  muscle. repeat this 3-5 times This technique can also be used with the force of gravity offering isometric resistance. In a hamstring stretch, you could lean forward while maintaining the lumbar lordosis and allowing the weight of the upper body to provide the stretch.  Wasn’t that easy? Now you have another tool in your toolbox for yourself or your clients. The Gait Guys. Giving you useful information and explanations in each and every post. Magnusson SP, Simonsen EB, Aagaard P, Sorensen H, Kjaer M. A mechanism for altered flexibility in human skeletal muscle. J Physiol. Nov 15 1996;497 (Pt 1):291–298 Cornelius WL. Stretch evoked EMG activity by isometric coontraction and submaximal concentric contraction. Athletic Training. 1983;18:106–109 Condon SM, Hutton RS. Soleus muscle electromyographic activity and ankle dorsiflexion range of motion during four stretching procedures. Phys Ther. Jan 1987;67(1):24–30  Mitchell UH, Myrer JW, Hopkins JT, Hunter I, Feland JB, Hilton SC. Neurophysiological reflex mechanisms’ lack of contribution to the success of PNF stretches. J Sport Rehabil. 2009;18:343–357  Youdas JW, Haeflinger KM, Kreun MK, Holloway AM, Kramer CM, Hollman JH. The efficacy of two modified proprioceptive neuromuscular facilitation stretching techniques in subjects with reduced hamstring muscle length. Physiother Theory Pract. May 2010;26(4):240–250  Osternig LR, Robertson R, Troxel R, Hansen P. Muscle activation during proprioceptive neuromuscular facilitation (PNF) stretching techniques. American journal of physical medicine. Oct 1987;66(5):298–307 Mahieu NN, Cools A, De Wilde B, Boon M, Witvrouw E. Effect of proprioceptive neuromuscular facilitation stretching on the plantar flexor muscle-tendon tissue properties. Scandinavian journal of medicine & science in sports. Aug 2009;19(4):553–560  Mitchell UH, Myrer JW, Hopkins JT, Hunter I, Feland JB, Hilton SC. Acute stretch perception alteration contributes to the success of the PNF “contract-relax” stretch. J Sport Rehabil. May 2007;16(2):85–92 Mitchell F Jr., Moran PS, Pruzzo NA: An Evaluation of Osteopathic Muscle Energy Procedures. Pruzzo, Valley Park, 1979.   Feland JB, Marin HN. Effect of submaximal contraction intensity in contract-relax proprioceptive neuromuscular facilitation stretching. Br J Sports Med. Aug 2004;38(4):E18. Lewit K: Postisometric relaxation in combination with other methods of muscular facilitation and inhibition. Man Med, 1986, 2:101-104. Markos PD. Ipsilateral and contralateral effects of proprioceptive neuromuscular facilitation techniques on hip motion and electromyographic activity. Phys Ther. Nov 1979;59(11):1366–1373

More effective stretching, Part 2

Last week we looked at one (of many) methods to make stretching more effective, utilizing a neurological reflex called “reciprocal inhibition” If you missed that one, or need a review, click here

Another way to get muscles to the end range of motion is to utilize a technique called “post isometric relaxation”. Notice I did not say to lengthen the muscle; to actually add sarcomeres to a muscle you would need to use a different technique. Click here to read that post.

Contracting a muscle before stretching is believed to take advantage of a post isomteric inhibition (sometimes called autogenic inhibition), where the muscle is temporarily inhibited from contracting for a period immediately following a isometric contraction. This has been popularized by the PNF stretching techniques, such as “contract hold” or “contract relax” . EMG studies do  jot seem to support this and actually show muscle activation remains the same (1, 2) or increased after contraction (3-6). Perhaps it is due to an increased stretch tolerance (7,8). 

The technique was 1st described by Mitchell, Morgan and Pruzzo in 1979 (9). These gents felt it was important to utilize a maximal contraction (using 75-100% of contractile force) to get to have the effect. It was later shown by Feland and Marin (10) that a more minimal, submaximal contraction of 20-60% accomplished the same thing.  Lewit felt that a less forceful contraction offers the same results, and combined respiratory assists (inspiration facilitates contraction, expiration facilitates relaxation) with this technique (11). Interestingly, there are bilateral increases in range of motion with this type of stretching, indicating a cross over effect (12). Regardless of the mechanism, the phenomenon happens and we can take advantage of it. 

This is how you do it: 

  • Bring the muscle to its end range (maximum length) without stretching, taking up the slack. This should be painless, as this will elicit a different neurological reflex that may actually increase muscle tone. 
  • resist with a minimal isometric contraction (20-60%) and hold for 10 seconds.  You can inspire to enhance the effect.
  • relax and exhale slowly. It is important to wait and feel the relaxation. Stretch through the entire period of the relaxation. You should feel a lengthening of the  muscle.
  • repeat this 3-5 times

This technique can also be used with the force of gravity offering isometric resistance. In a hamstring stretch, you could lean forward while maintaining the lumbar lordosis and allowing the weight of the upper body to provide the stretch. 

Wasn’t that easy? Now you have another tool in your toolbox for yourself or your clients.

The Gait Guys. Giving you useful information and explanations in each and every post.

  1. Magnusson SP, Simonsen EB, Aagaard P, Sorensen H, Kjaer M. A mechanism for altered flexibility in human skeletal muscle. J Physiol. Nov 15 1996;497 (Pt 1):291–298
  2. Cornelius WL. Stretch evoked EMG activity by isometric coontraction and submaximal concentric contraction. Athletic Training. 1983;18:106–109
  3. Condon SM, Hutton RS. Soleus muscle electromyographic activity and ankle dorsiflexion range of motion during four stretching procedures. Phys Ther. Jan 1987;67(1):24–30 
  4. Mitchell UH, Myrer JW, Hopkins JT, Hunter I, Feland JB, Hilton SC. Neurophysiological reflex mechanisms’ lack of contribution to the success of PNF stretches. J Sport Rehabil. 2009;18:343–357 
  5. Youdas JW, Haeflinger KM, Kreun MK, Holloway AM, Kramer CM, Hollman JH. The efficacy of two modified proprioceptive neuromuscular facilitation stretching techniques in subjects with reduced hamstring muscle length. Physiother Theory Pract. May 2010;26(4):240–250 
  6. Osternig LR, Robertson R, Troxel R, Hansen P. Muscle activation during proprioceptive neuromuscular facilitation (PNF) stretching techniques. American journal of physical medicine. Oct 1987;66(5):298–307
  7. Mahieu NN, Cools A, De Wilde B, Boon M, Witvrouw E. Effect of proprioceptive neuromuscular facilitation stretching on the plantar flexor muscle-tendon tissue properties. Scandinavian journal of medicine & science in sports. Aug 2009;19(4):553–560 
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Podcast 82: Phasic vs Antiphasic Gait, Cross Over Gait & more.

Show sponsors:

www.newbalancechicago.com

www.lemsshoes.com

A. Link to our server: 

http://traffic.libsyn.com/thegaitguys/pod_82final.mp3

Direct Download: 

http://thegaitguys.libsyn.com/podcast-82-phasic-vs-antiphasic-gait-cross-over-gait-more

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”

 

Show notes:

 
Blog posts we reviewed:
 

Muscle Activity Differences in Forefoot and Rearfoot Strikers
http://www.runresearchjunkie.com/muscle-activity-differences-in-forefoot-and-rearfoot-strikers/

www.runnersworld.com/injury-treatment/forward-lean-while-running-might-reduce-knee-pain?cid=social33696857

Weight-Bearing Ankle Dorsiflexion Range of Motion—Can Side-to-Side Symmetry Be Assumed?
http://www.natajournals.com/doi/abs/10.4085/1062-6050-49.3.40

extras for this piece:

and you can use this to substantiate it: http://www.ncbi.nlm.nih.gov/pubmed/23997389

Effect of step width manipulation on tibial stress during running. J Biomech. 2014 Aug 22;47(11):2738-44. doi: 10.1016/j.jbiomech.2014.04.047. Epub 2014 May 21.