Hmmmm…
The question is: “is the earlier activation a good thing”?
What do you say?
“A study of patients with chronic ankle instability (CAI) suggests the onset of knee and ankle muscle activity occurs significantly earlier when shoes and orthoses are worn than when the patients are barefoot.”
Eating up a cardinal plane.
Simple post, simple principle today. We found this case on the web, somewhere. Wish we could remember so we could give credit.
Looks like simple right leg length discrepancy but the point we wanted to make is that any time you deviate into a plane, you eat up length. In this case, the right knee is severely valgus and that has at least in part contributed to a shorter limb and unleveling of the pelvis. And, it is not uncommon that rotation axis are changed when frontal or sagittal planes are compromised. It is easy to see this on the x-rays, if the foot posturing isn’t at least noted, look at the spacing between the tibia and fibula . . . . rotational planes have changed as well. Is it from the femur or tibia? That is the topic of another day.
In the larger photo you will notice that even with the right foot lifted there is still a pelvis unleveling. How can that be, unless it was further unleveled that what we are seeing ? Well, just because you lift to fix doesn’t mean the lift will not enable further collapsing into the weakness and deformity. We have described this principle on the topic of EVA shoe foam deformation. When the foot presses the foam into the deformation, it leaves more room for possibly further and faster deformation loads (perhaps more so than had a new shoe been prescribed). So in some cases, more lift can allow more deformation. How far, well as in this photo, at least until the right knee slams into the left knee and stops further deformation.
So, seeing a plane deficit clues you into possible unleveling of the pelvis and abnormal joint loading responses. It should clue you into looking for another cardinal plane compromise as well. But make no mistake, just adding a lift doesn’t mean the deformation is remedied and not enabling further deformation. It is possible that you can make your client worse if you do not teach them how to find the appropriate motor patterns with the lift so they can learn to protect the parts. Often teaching these types of clients how to control their deformities (when and if possible) is where the gold lies, not in just leveling out the foundation.
One more “beating of the dead horse”, lift the whole foot, heel and forefoot with a sole lift when you are “lifting and leveling”. Lifting only the heel puts them into ankle plantar flexion and can often facilitated earlier and faster forefoot loading and even earlier knee flexion. Save the heel lift as a possible consideration when there are posterior compartment contractures or inflammation. Certainly we could have gone into functional and structural leg length discrepancies, but we have blogged excessively on that topic in the past. Go ahead and search our blog if you want more on those topics.
Take home point, “just because you lift, doesn’t mean you are truly lifting, you may enable the opposite”.
Shawn Allen, one of the gait guys
What types of tests do YOU use to assess lumbopelvic control? We have talked about the multifidus lift test before; here is another
“The clinical test of thoracolumbar dissociation was devised into assess a patient’s ability to perform anterior/posterior pelvic tilt in sitting while attempting to maintain a constant position of the thoracolumbar junction.
The results demonstrate that the clinical test of thoracolumbar dissociation has acceptable inter-rater reliability when used by trained physiotherapists. This test described here is the first to assess the ability to dissociate movement of the lumbopelvic region from that of the thoracolumbar region.”
From: Elgueta-Cancino et al., Manual therapy (2015) 418-424(Epub ahead of print). All rights reserved to Elsevier Ltd.
Welcome to Monday and News You Can Use. Got Arm swing? This exercise, borrowed from Shirley Saurmann can be a great adjunct to your rehab program, dispensed with some muscle physiology : )
Do it on your self
Try it on a client
Teach someone else
Happy Holidays from The Gait Guys
Twas the night before Christmas, and all through the land, and the Gait Guys were there to give St Nick a hand.
This poor fellows knees had been in pain as of late. He had taken up running to help lose some weight.
To his clinician he went, who prescibed an orthotic for pronation, without a look or thought, or a very methodic examination.
So across the country, Dillon, Chicago and the nation, He went to see the Gait Guys for a comprehensive evaluation.
They watched him run on the treadmill and analyzed his stride and they saw he had a heavy foot strike on one side
And his knees fell outside of center, left side more than the right and an adductory twist, from a heel cord wound too tight.
They looked at each other and at the same time said they thought that they knew what the problem was with the man who wore red.
Then they placed him on the table, with the highest efficiency, they found that he had a left sided leg length deficiency.
When his knees were straight, his feet pointed to the middle; internal tibial torsion they thought, and that solves the riddle.
An orthotic for internal torsion, without a valgus post is sure to macerate the meniscus, and turn it to toast.
That orthotic they took, from his shoe in a jiffy and knees were more midline, now wasn’t that spiffy
and a sole lift for his shoe, to correct the difference, even though it was small, it had a significance…
And exercises they gave, to be done three times each day to anchor the medial tripod, and push off through the 1st ray.
“Thanks Gents”, he said, as he took off running with a smile, His knees were much better, even after running a mile.
Shawn and Ivo looked at each other feeling fulfilled, Having helped this poor fellow, and they hope they instilled
In each and every reader and follower and student the desire to look closer and do what is prudent
Happy Holidays we wish to all our sisters and brothers, We hope we have inspired you to continue to learn and teach one another.
Have a great one : )
We always like to try and reproduce the problem. We like to say “If we can reproduce the pain, we can probably fix the cause”, which seems to hold true in many cases. This article makes us think about seeing the patient at a point in their training that they feel the discomfort or are having the problem (after 30 minutes, after 20 miles, etc). There may be some value to scheduling their exam later, rather than sooner. A nice fatigue article from one of our favs “LER”.
http://lermagazine.com/article/running-in-an-exerted-state-mechanical-effects
An interesting take on “heat” conditioning by one of our new favs, Dr Rhonda Patrick. Some pretty cool stuff here. We have a talk on hyperthermic training on an upcoming PODcast. Check her out
More on the Minimalist Debate
“Nearly a third (29%) of those who had tried minimalist running shoes reported they had experienced an injury or pain while using the shoes. The most common body part involved was the foot. Most (61%) of those reports involved a new injury or pain, 22% involved recurrences of old problems, and 18% were a combination of both old and new musculoskeletal problems.
More than two thirds (69%) of those who had tried minimally shod running said they were still using minimalist running shoes at the time of the survey, but nearly half of those who had stopped said they did so because of an injury or pain. The most common sites of pain or injury that caused survey participants to discontinue minimally shod running were the foot (56%) and the leg (44%).
While some runners who tried minimalist running shoes suffered some pain and discomfort, a greater percentage (54%) said they had pain that improved after making the switch. The anatomical area most often associated with improvement was the knee. The results were published in the August issue of PM&R.”
Welcome to Monday and News You Can Use!
Any of your patients of clients taking anti inflammatories? Especially after a rehab session or dry needling/acupuncture? They may be thwarting the healing process. Excerpted from a recent lecture, Dr Ivo talks about how they can down regulate the healing process.
60 second audio pod. Our mental state changes our gait, and our gait changes our mental state.
We highly suspect that this is not the “bouncy” gait we typically refer to, the loss of ankle rocker gait.
http://www.scientificamerican.com/podcast/episode/bouncy-gait-improves-mood/
Calf strength screen? Um, maybe not. Specifics matter.
Thanks to barbellphysio.com for putting this up. We would like to take this deeper, because it is very important.
This screen in our strong opinion is mostly for testing sub optimal endurance, sure there is some strength assessment going on but if you are trying to determine strength, is it single rep strength ? Very likely what he truly meant is how does the calf strength hold up at a 20 rep endurance challenge. This is more accurate and we are fussing about specifics here, but specifics matter.
*However, the potentially BIG HOLE here in the assessment, is that “perceived” top end calf/heel raise ROM is not necessarily top end FULL ROM. If one side is truly weak, and you cannot get to top end strength (say the heel is 10% lower than the other side) someone has to be there to assess and notice that top end strength failure (a top end ROM that could reduce as endurance challenge continues, but someone has to be there to observe. Going on just “feel” alone is a bad recipe there). One like is not going to feel that top end range loss even if it is large, you will perceive the effort which could feel the same as the good side but actually be a loss. And is 20 reps enough? Sure, it is a start but is your test really telling you what you think it is telling you ? This is being shown as a gross screen in our opinion but it has holes even as a screen. Top end strength, something we talk about here often, is critical to performance. Top end loss means terminal plantarflexion ROM is insufficient, and this can lead to a whole host of injuries and biomechanical flaws including achilles tendonopathy to mention just one. Remember, the gastroc does not play alone here (and gastrocs crosses the knee joint posteriorly, some of the other posterior compartment muscles do not). There is soleus, peronei, tib posterior, long flexors etc. So are you doing your test with bent knee or locked ? It makes a difference if you are trying to tease things out. Are you ramming your toes into flexion to get more out of them to make up for a loss elsewhere ? Is the forefoot or rearfoot inverting or everting on the up or down phase ? These things matter. Specifics matter. For example, you can see in this video that the hip is a little lateral to the foot placement. This will mean that the heel rise will result in a lateral forefoot weight bearing load. Do you want to see if the peronei are doing their job during the heel rise ? Well then you should go into a hip hike to posture the hip over the foot so that you can get the weight bearing transition to occur terminally over to the big toe, the peronei and lateral gastroc help drive that last little shift and if they are weak and you are not driving that last piece of the movement the test may not show you the whole picture you are thinking it is. Clue, if you cannot feel the lateral compartment contract to finalize that medial foot weight bearing load shift, you may be weak there. You better assess then.
Can you do 20 reps at 80% of the full plantarflexion ROM or can you do 20 reps at 100% full plantarflexion ROM ? There is a performance difference, and to the client unobserved, the 80% on one side may feel and perform like the 100% on the other side. But make no mistake, there is a world of difference. Someone has to watch that you are comparing apple to apples, and not apples to figs, oranges, turnips or squash.
-Dr.Shawn Allen, the gait guys
https://www.youtube.com/watch?time_continue=55&v=QdWiXHsI8Q8
Ever wonder why Vladimir Putin Walks Like That?
the quotes below are from the NBC article referenced below.
“Neurology professor Bastiaan Bloem of the Radboud University Medical Center in the Netherlands and colleagues had noticed that Putin often walks with his right arm held rigid, while his left arms swings freely.”
Might it be Parkinson’s disease, which can cause stiff movements?
in an old Russian KGB manual it was discovered:
“According to this manual, KGB operatives were instructed to keep their weapon in their right hand close to their chest and to move forward with one side, usually the left, presumably allowing subjects to draw the gun as quickly as possible when confronted with a foe.”
https://www.youtube.com/watch?v=K2yj2uMTqSs
http://www.nbcnews.com/health/health-news/why-does-vladimir-putin-walk-n480611
Compensations and adaptive motor patterns that alter the normal joint mechanics can cause injury.
This study discusses whether a 10% increase in running cadence has a correlation to injury incidence.
“With increased cadence, there was a decrease in peak knee flexion and a later occurrence of peak knee flexion and internal rotation and shank internal rotation. Segment coordination was altered with most changes occurring in mid-late stance. Coordination variability decreased with an increase in cadence across all couples and phases of gait. These results suggest examination of coordination and its variability could give insight into the risk of intervention-induced injury.”
The paper discusses the reorganization of movement patterns. It is suggested that one follow our SES (Skill, Endurance, Strength) principles as adaptation ensues. Gain safe skill on the new pattern and drive it suboptimally at high repetition (ie. gain endurance on the new skill set). Then heighten the skill again, and then again drive more endurance on it. Then add some strength, then more skill, then more endurance, … . rinse and repeat).
Anything too much, too fast, for too long is a risk. The CNS needs time for adaptation. Any change, even if globally deemed good, can be a problem.
The Gait Guys
http://www.tandfonline.com/doi/abs/10.1080/02640414.2015.1112021?journalCode=rjsp20
Changes in coordination and its variability with an increase in running cadence.
Jocelyn F Hafera*, Julia Freedman Silvernailb, Howard J Hillstromc & Katherine A Boyera Accepted: 20 Oct 2015Published online: 20 Nov 2015
Client presents to you:
On the exam table they have plenty of ankle dorsiflexion range of motion (ROM), full knee flexion ROM, full hip flexion ROM.
You then ask them to perform all 3 together in the form of a squat. The result is that they cannot even squat past parallel thighs. They have used a mere portion of the ranges which they showed plentiful on the exam table. Why ?
Possibilities: The exam showed passive movements, not active loading. Perhaps lack of Skill (unfamiliarity of the skill), lack of coordination (lack of knowing how to put the pieces together), lack of balance and body mass space awareness (ie. where do i put my parts so i do not fall over), lack of hip, knee, pelvis-core stability, etc.
“Just because you have it, doesn’t mean you own it. Nor does it necessarily mean you know how to use it or have the right to push the limits if you have never been there before.”
You are walking to the sink to wash dishes:
Your Brain: “ok, we are about 3 more steps from the sink, you had better slow down … . ok, 2 more steps … 1 more step, this is the last one … . ok, that is it, you have arrived at the sink, both feet I now command you to stop moving … . . now, initiate double stance support, 50% weight on both feet… . . begin standing mode.”
Can you imagine being unable to stop moving graciously? Imagine that every attempt to halt your walking or running was like smacking into a wall or stumbling to a halt ? Kind of like that amateur driver who uses no grace or finesse, every start is a stomp on the gas and every stop is a slamming on the brakes.
We take stopping for granted, as do we underestimate the complexity of initiating movement. It is one of those things, you do not know what you have until you lose it. Sometimes it is the simplest of things which we take for granted.
There is a brainstem pathway specifically dedicated to control locomotor arrest. Activating this pathway stops locomotion, while inhibiting the pathway enables locomotion.
enjoy this short blog post today: http://tmblr.co/ZrRYjx1ycc8Q4
“Those who walked an average of seven blocks per day or more had a 36%, 54% and 47% lower risk of CHD, stroke and total CVD, respectively, compared to those who walked up to five blocks per week.”
http://www.sciencedaily.com/releases/2015/…/151119122246.htm
“Foot posture measures can explain only a small amount of variation in foot kinematics. Static foot posture measures, and in particular the FPI, were more strongly associated with foot kinematics compared with foot mobility measures. These findings suggest that foot kinematics cannot be accurately inferred from clinical observations of foot posture alone.”
“In physics, angular momentum is the rotational analog of linear momentum. Like linear momentum it involves elements of mass and displacement. Unlike linear momentum it also involves elements of position and shape. It is an important quantity in physics because it is a conserved quantity – the angular momentum of a system remains constant unless acted on by an external torque.” - wikipedia
The Gait Guys Podcast #101 launches later this week. Here is a tickler. On the podcast we delve a little into this article based on Angular Momentum. We are not physics guys, but we try to give this idea some critical thought. Chime in if you know more than us, we would love to hear your research backed thoughts.
“To most runners and coaches, running is a series of jumps, says Svein Otto Kanstad, a physicist and former competitive runner based in Volda, Norway. Gravity isn’t considered helpful, because its force is perpendicular to the direction a runner is moving. But this mindset neglects the concept of angular momentum, Kanstad says. Rather than thinking of running as a series of jumps – leaping off one foot and landing again on the other – runners should view their sport as a series of falls, aided by gravity, he says.” -Boyle
Read the Rebecca Boyle and Kanstad articles then watch the World Record race video by Michael Johnson. Study his leg turn over on the straight away as compared to his closest 2 competitors. Something is different. His steps are shorter, and it is difficult to determine, but is he doing what Kanstad is suggesting ?
video: https://www.youtube.com/watch?v=6FEh7hDpGp0
As Rebecca Boyle suggests, “a runner’s hips rotate to bring each leg forward, he or she gains angular momentum. But most runners don’t make the best use of this. At the moment their leading leg hits the ground, the second leg is usually stretched out behind. In Kanstad’s revised gait, the second leg will already have rotated forward again before the leading leg hits the ground. By doing this, the runner’s centre of mass is tilted far forward allowing for more forward momentum, but the recovery leg is there to stop a fall.”
As Kanstad suggests in his research: “A theory is developed to determine the magnitude and nature of these effects of gravity, showing that more than 10% of the energy needed for running can be obtained from the field of gravity. Likewise, at a particular optimum velocity, walking may become entirely driven by gravity-induced angular momentum without any muscular effort.”
*Addendums (copied discussions from our Social media pages, we have smart people follow our work, so we wanted to include some dialogues here. We do not necessarily agree with everything said here, but in turn we also do not know everything. So, it is worthy of sharing in the hopes it takes us all further down the road to enlightenment).
reader: For some interesting applications and background on whole body angular momentum check out Anne Silverman’s work (Col School of Mines). There’s some interesting implications for how gait is regulated. Hope all is well. http://www.ncbi.nlm.nih.gov/pubmed/22325978
Gait Guys: Dear X, we very much appreciate your contributions and thoughts here. You seem to be a strong advocate of Romanov’s work. Can you furnish us with some of his research, we like to see the numbers and studies. His stuff has been around for awhile, certainly there has to be a few good papers you can lead us too to cut down our search to the good ones.
another reader: After reading this (original article) I didn’t know whether to laugh or cry! It’s still amazing to me the confusion and mayhem surrounding running gait mechanics. With Nicholas Romanov already establishing the idea of gravitational torque as the propulsive force in running, how can Kanstad’s “new ” belief be taken seriously: vis-a-vis the Pose Method being conceptualized during the 1970’s. It truly makes me wonder whether scientists, researchers or coaches are actually trying to understand the truth or just emblazon their own reputations. From Bobby McGee to Daniel Lieberman, the misinterpretation of how we move in a gravitational environment is profound. The idea that we can generate anti-gravitational force via muscular effort to generate movement has an almost ludicrous logic to it. The idea of “just run barefoot” or “take smaller strides” or “land of the midfoot” trivializes the unique hierarchical interplay at the core of all human movement.
As a Movement Specialist, former student of Dr. Romanov’s and someone with a passion for the history of biomechanics, the fundamental flaw is obvious: science observed human gait and tried to conjecture based on the idea of the human body being a machine, rather than the body as another biological system on this planet. The ideas of everyone from Aristotle to daVinci, Galileo to the Weber brothers concluded that the the body must move in harmony with nature. Perhaps it was the rush of modern civilization via the Industrial Age which signified a change in the scientific method. Whatever the specific catalyst, the onslaught of data collection as evidence was born.
Even today, with all of the technology available, the idea of the foot being a fulcrum for the body to rotate over, is lost. What’s even further not understood is that the body, as a lever arm, must be aligned properly - if not, the fall forward is interrupted and all of the mistakes taught in classical stride mechanics (push-off, drive, etc.) become common error. It’s ironic that Kanstad mentions Michael Johnson (who I agree ran with proper “pose"technique), but who even today, would describe his own form differently. Which is why Usain Bolt, the who does pretty much everything correctly, is still a scientific conundrum.I can provide Pose-related research (though I suggest looking at the information in his Pose Triathlon book). But as you know, there are many contrary arguments and much conflicting information out there that is seemingly supported by data research as well. What I tried to elucidate is that it’s difficult to consistently quantify proper running technique. Research studies would have to be designed differently, the athletes trained for longer periods of time, acclimated to both normal ground and treadmill surfaces, freed from any musculoskeletal and psychological inhibitions to running better. With any athlete I work with, there is usually a period of (at least) a year’s time of training which must be performed: longer periods for endurance or injured athletes. Studies can try to isolate certain physical elements or characteristics of form: these clearly miss the perceptive and sensory aspects most critical to better form. Essentially what it always come down to is basic: where are you when your foot hits the ground, how long do you spend on the ground and what do you look like at terminal stance? If these concepts could be studied, then I’m all for it. Unfortunately, studies continue to observe and rely on the factorial by-products or results of error-filled running technique. In the end, who is deciding if the subjects are actually doing things well enough to warrant studying them?
another reader: As a PT I agree with Kanstad. While Michael Johnson appears to be fully upright, his chest and stomach are leaning forward. I’m willing to bet his COM is anterior to his trunk while he’s running. There’s probably some give and take though, just like anything else. Leaning too far forward will make you unsteady and you’ll end up slowing down to prevent a fall. Leaning too far backwards or even being vertically upright would, as Kanstad suggests, would prevent any angular momentum via gravity from assisting a runner, and would even work against them and push them backwards.
another reader: Sir Isaac Newton is turning over in his grave…and he is likely doing that by using zombie muscles to push down to overcome both the downward force of gravity and his inertia and then using multiple muscle to rotate about his transverse plane. http://naturalrunningcenter.com/2013/07/30/posing-question-proper-running-form/
Reference sources:
Rebecca Boyle, https://www.newscientist.com/article/dn28246-physics-of-falling-says-professional-athletes-are-running-wrong/
http://rspa.royalsocietypublishing.org/content/471/2181/20150287
Gravity-driven horizontal locomotion: theory and experimentSvein Otto Kanstad, Aulikki KononoffPublished 16 September 2015.DOI: 10.1098/rspa.2015.0287
Achilles tendonitis: Lift the heel, right? It does not appear so.
There was a recent article in one of our favorite journals, Lower Extremity Review which reviewed and expanded upon another study from Medicine and Science in Sports and Exercise titled “Running shoes increase achilles tendon load in walking: an acoustic propagation study.” We discussed some perspectives of this topic in one of our recent podcasts.
The article discusses a new technique (1,2) for looking at tensile loads in the achilles and looks at 12 symptom free individuals on a treadmill barefoot and in a shoe with a 10 mm drop (heel is 10mm higher than the forefoot) and found:
“Footwear resulted in a significant increase in step length, stance duration, and peak vertical ground reaction force compared with barefoot walking. Peak acoustic velocity in the Achilles tendon (P1, P2) was significantly higher with running shoes.”(1)
According to LER: “The researchers also found changes in basic gait parameters associated with walking in running shoes versus barefoot, which the author Wearing said may help explain the increased tendon load with shoes. Shoes increased mean ankle plantar flexion by 4° during quiet stance as measured by electrogoniometry. When walking with shoes, participants adopted a lower step frequency but greater step length, period of double support, peak vertical ground reaction force, and loading rate than when walking barefoot. The researchers also noted that participants’ stance phase was relatively longer (4%) during shod walking than during barefoot walking.” (3)
Why would an increase in step length result in increased tension?
Perhaps, as the force that the heel would hit the ground would be increased because of a longer acceleration time (F=ma), and it so happens this is what they found. The friction of the heel striking the ground would accelerate anterior translation of the talus, which plantar flexes, everts and abducts, accelerating pronation. The medial gastroc would be called into play to slow calcaneal eversion and this would indeed increase achilles tension.
Or perhaps it’s the fact that
the foot will strike in slight greater plantarflexion
(at least 4 degrees according to the study) and this results in an immediate greater load to the Achilles tendon. Go ahead and try this while walking even if you’re barefoot. Walk across the floor and strike more on your forefoot. You will notice that you have an increased load in the tricep surae group.
Does this slight plantarflexion of the ankle contribute to greater eccentric load during stance phase?
This would certainly activate 1a afferent muscle spindles which would increase tensile stresses in the achilles tendon.
This seems to fly directly in the face of the findings of Sinclair (4) who investigated knee and ankle loading in barefoot and barefoot inspired footwear and found increased achilles loading in both compared to “conventional shoes”.
Of course this also begs the question of what type of shoes were they wearing? High top or low top shoes and were the shoes tied or not? High top shoes seem to reduce Achilles tension more so than low top shoes, especially if they are tied (5).
Whatever the reason, this questions the use of putting a lift or a higher heeled shoe underneath the foot of people that have Achilles tendinitis. Once again what seemed to make biomechanical sense is trumped by science.
We think training people to have greater amounts of hip extension as well as ankle dorsiflexion, as well as appropriate foot and lower extremity biomechanics with the requisite skill, endurance and strength is a much better way to treat Achilles tendonitis regardless of whether they’re wearing footwear or not.
Dr. Ivo Waerlop, one of The Gait Guys
References:
1. Wearing SC, Reed LF, Hooper SL, et al. Running shoes increase Achilles tendon load in walking: An acoustic propagation study. Med Sci Sports Exerc 2014;46(8):1604-1609. http://www.ncbi.nlm.nih.gov/pubmed/24500535
2. Reed LF, Urry SR, Wearing SC. Reliability of spatiotemporal and kinetic gait parameters determined by a new instrumented treadmill system. BMC Musculoskelet Disord 2013;14:249.
3. Black, Hank. Achilles oddity: Heeled shoes may boost load during gait. In the Moment:Rehabilitation LER Sept 2014 http://lermagazine.com/news/in-the-moment-rehabilitation/achilles-oddity-heeled-shoes-may-boost-load-during-gait
4. Sinclair J. Effects of barefoot and barefoot inspired footwear on knee and ankle loading during running. Clin Biomech (Bristol, Avon). 2014 Apr;29(4):395-9. doi: 10.1016/j.clinbiomech.2014.02.004. Epub 2014 Feb 23.
5. Rowson S1, McNally C, Duma SM. Can footwear affect achilles tendon loading? Clin J Sport Med. 2010 Sep;20(5):344-9. doi: 10.1097/JSM.0b013e3181ed7e50.
Welcome to News You Can Use. Listen as Dr Ivo explains some twists in the standing tripod exercise.
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