The Mysterious Gait Deviation

Gait Deviations is one of the most perplexing ADL's to figure out. 

There are so many components that contribute to an efficient gait pattern, determining a patient's dysfunction can be extremely challenging when it come to treating walking problems.

Your patient will just not walk right. Or even better, they will walk perfectly out of your clinic after a session, and walk back in using their same old dysfunctional pattern.

I was dealing with this when I worked with my family member years ago. We were rehabbing at my home in spring time. After treatment, his home program would be to walk along the perimeter of the deck holding on the the railing with one hand and use the cane with the other.

He gait pattern was beautiful.

When he walked with the rolling walker on the sidewalk or 2 canes in the house, he reverted back to what I call his ugly gait:

• A small step length
• Narrow base of support
• Bent knee walking style.
• Slow deliberate cadence

What was going on?

He presented with what I call a Non Structural Dysfunction that was causing his Gait Deviation. What that means is that there wasn't a lack of range of motion due to an anatomical structure or tissue restriction that was physically blocking his range of motion that was causing the Ugly Gait.

It was something else.

Non-Structural Dysfunctions could be due to one of the following reasons:

• Inflammation
• Alignment
• Upper Motor Neuron or Lower Motor Neuron Disease or Injury
• Psychological Dysfunction including Fear
• Severe Atrophy

I noticed the same phenomenon in a toddlers gymnastics class the other day. A little one was walking the low  bean presenting with what I would consider to be a normal gait pattern. Yet when she went on the high beam, she presented with the Ugly Gait.

I realize now that my family members primary dysfunction was not a lack of range of motion, strength or even balance, it was a lack of confidence.

I was treating the wrong thing.

In addition to treating his physical symptoms, I should have also been doing things to boost his confidence and ease his fears. 

When the patient is a "train wreck" where do I start?

I was recently asked my advice on a complicated patient.

Although the patient was young in age and active, their past medical history read like Evil Knieval's (again I am dating myself). The therapist provided a through past medical history in about 3 pages of text.

Obviously both he and I understood that there were numerous areas with the potential for treatment, the question was where to start.

In spite of the therapist's complete description of the patient history, he forgot to include what I feel to be the most important component of the Subjective history. Questions that will be used to not only guide the evaluation, treatment, documentation and progress, but it will let the clinician know where to start, especially with complex patients.

It is: 

"What activities cause your pain and what activities do you have difficulty performing or can you not perform?" If my patient is being evaluated for balance and falling I then ask: "What were the circumstances of your falls or what activities cause you to feel off balance?"

This is usually is the first question that I ask when I meet my patient for multiple reasons:

1. I will now be able to provide functional goals for my documentation which are vital for insurance    reimbursement.

2. I can direct my evaluation to determine why a person is having pain or an inability to perform a task by; taking that activity,  breaking it down into its component parts, and evaluating each one. This will almost always show me the patient's dysfunction that is causing their functional problem or pain. As a result I now know where to start and what to treat. As a result, I can make significant gains in one visit.

3. While past medical history is important to avoid performing therapies that are contraindicated and understanding mechanism of injury, patients can spend their entire evaluation time telling you their life story. In today's healthcare setting we simply don't have the time and this information can be listed by the patient on their intake form.  I prefer to ask direct questions regarding these factors so I am in control of the conversation and can specifically ask the factors that are appropriate for their care right now.

4. While pain often inhibits ones ability to function, once the painful activity has been established, both the patient and I can determine their progress by the patient's ability to perform a certain activity rather than ask "how are you feeling?"

5. Their past medical history may not be a factor in their current functional deficit.

My greatest success using this process of evaluation was on a patient who had sustained multiple falls  resulting in fractured bones on 2 separate occasions. When I asked the circumstances of her falling, I had her safely repeat that motion. When she performed it, I observed that 1 of her feet was coming off of the ground prematurely.

Therefore, the reason that she was falling was that she was losing her base of support with only a slight weight shift.

I then determined why it was happening and treated her in one visit.

In the 3 years since that 1 evaluation and treatment she has not fallen.

It is interesting to note that this patient's fractures were on the opposite side of her dysfunctional foot and if I based my treatment on her past medical history, I would not have been treating the correct side of her body.

If you are not already asking these questions during your Initial Evaluation, give it a try, it is guaranteed to save you time and money while avoiding frustration and confusion.

Is Stretching Bad for you?

Is Stretching Bad for you?

If you are an athlete, Maybe.

Contrary to conventional belief and research in the 1980's and 90's, pre-exercise stretching neither improves performance nor decreases injuries.

Numerous studies have demonstrated that traditional static stretching actually decreases performance in activities that require strength, speed, and power. Studies of strength and power have demonstrated performance decreases of as much as 30% for up to 60 minutes after exercise.

A second major reason that many coaches and athletes still view static stretching as an important preactivity ritual is the belief that it reduces the likelihood of subsequent injury. Yet, A study of lower limb injuries among 1,538 male army recruits found that pre-exercise static stretching had no effect on injury rates after a 12-week stretching protocol.

So if you are stretching to prevent injury, while you are not doing harm, you are likely wasting your time.

Although the verdict is not out yet, other warm-up activities, including general muscle warming exercises
and dynamic active range-of-motion exercises, might be most beneficial in improving physical performance.

Prevent Ear Infections? Just Channel Carol Burnett

Prevent Ear Infections? Just Channel Carol Burnett

Once again I am dating myself here. 

For those of you who remember The Carol Burnett show, she would tug at her left earlobe at the end of each episode (In case you are interested, I have read that this was a way of communicating a hello to her Grandma).

Little did Carol know she may have been preventing ear infections, at least potential ones in her left ear as:

-There are a number of lymph vessels under the ear and tugging of it can help to stimulate lymph circulation secondary to movement and stretching of the skin.

 -A mechanism for ear infections is the blocking of the esutachian tubes. Pulling of the ear lobes facilitates the opening of them.

While there are other mechanisms for unblocking the esutachian tubes, none of the others can be as easily performed on young children as pulling of the ears and it is this population who are most susceptible to ear infections.

They are the primary reason for pediatrician visits, they can be associated with extremely high fevers resulting in visits to the ER, and multiple infections can result in the need for surgery.

It is interesting to note that the motion incorporated in the pulling of the ear lobe is similar to the action performed during breast feeding and it has been well documented in the literature that breastfeeding reduces the incidence of ear infections.

In order to perform this on your little ones, gently pinch your child’s earlobe with your thumb and index finger, tug gently up and down. You can even teach your older children to do this by themselves, particularly after bathing or swimming.

Traps like Mt. Everest?

Traps like Mt. Everest?

You know who I am talking about, the people who have their shoulders so elevated they appear to be trying to clean their ears with their Glenohumeral  joints. (see above)The ones that when you palpate their traps, accessory breathing muscles and especially their first rib, you feel like you need a hammer and chisel to break up the spasm.

They are often high strung; a little stressed out, and may have chronic pain, or even better RSD (chronic pain on steriods).

What is going on here?

Obviously, a lot of things but what these individuals will share is that they are breathing with their accessory muscles, not their diaphragm.  Most simply put these people are not breathing properly.

I calculated that person who takes the average 10 breaths per minute, breathes 16.560 times per day.

The diaphragm can handle this task; it is uniquely designed to do so, as it is both a smooth and skeletal muscle.  Smooth muscles do not fatigue. The traps and accessory muscles of the neck cannot, they are mere skeletal muscles, as a result of this unwanted demand placed upon them they become hypertonic and angry.  

The following is a link to watch the motions of the diaphragm.

https://www.youtube.com/watch?v=hp-gCvW8PRY

Aside from decreasing accessory muscle hypertonicity thus decrease neck and shoulder pain and pathology, other benefits of Diaphragmatic breathing include:

1.  Increased oxygenation
2. Stimulation of the parasympathetic nervous system to elicit relaxation
3.  Decreased emotional stress
4. Improved circulation and improved peristalsis due to the up and down action of the diaphragm on the abdominal viscera.
5. Decreased symptoms of chronic pain patient
6. Decreased symptoms of RSD and other autonomic disorders.
7. The patient has a lot of opportunity to practice (theoretically over 16,000 times per day)

The challenge is that it can be surprisingly difficult to teach. 

Traditional techniques included visualization, placing your hand or another item on your stomach and make it move. These work for some patients, but for the really tough ones I use the following;

3 easy ways to facilitate diaphragmatic breathing:

1.       Elevate your legs: This will put the weight of the abdominal viscera, and facilitate diaphragmatic breathing.

2.       Bend over so that your hips are at a 90 degree angle and make sure to rest your arms on a piece of furniture. Gravity is now acting on the abdominal viscera and facilitating the diaphragm to contract. In the picture below, note that the arms can be bent and supported closer to the trunk.

3.       Make an “OK” sign with your fingers, if you are old enough to remember Sasson jeans it is their logo.  It is called the Gyan Mudra and it is used in yoga and meditation practice to facilitate diaphragmatic breathing. 

If you don't know where to start with your treatment of a chronic pain patient begin the same as a human does as it enters the world, with a diaphragmatic breath. 

Forward head posture, its not in your head

We are a manifestation of our compensations.

Our bodies are experts at adapting to our environment.  They will even adapt to abnormalities within its own system. Unfortunately this adaptive ability may result in disease, injury, dysfunction and eventually disability.

Attempt the following

1.       Rotate your pelvis posteriorly (posterior pelvic tilt) to flatten your back. Make sure that you only move your pelvis.

2.       If you don’t move your thoracic spine or your neck forward,  you will feel like you are leaning backwards as if caught in a strong wind.  

Next:

1.       Keep your entire body stationary and bear 90 percent of your weight on your heels.


Again you will feel as if you are going to fall backwards and in order to maintain balance, you will need to compensate by moving;  either your head, trunk or both forward.

In these examples your center of gravity is being moved back and the body will feel off balance unless it compensates by moving the trunk, the head or both forward.  

The result being a forward head posture.

If the therapist treats the neck, shoulders or thoracic spine, there will be no carryover as the forward head posture is a compensation for their center of gravity being moved posteriorly. 

The therapist must treat the underlying cause of the problem, restoring center of gravity to it proper position in order to have success and carryover. 

In the previous examples a therapist will need to treat:

•  The Pelvis:  to increase anterior rotation
•  The ankle: Increasing dorsiflexion to increase weight bearing into the arch and toes.

    Only then would it be appropriate to treat the neck, thoracic spine and or shoulders.

Are Dead Bugs Poison for your back?

Dead bugs are a common exercise prescribed for lower back stabilization.

Pictured above, it involves the actions of both hip flexion and shoulder flexion.

I have mentioned in my previous posts that while most people, measure hip flexion range of motion within normal limits, they  lack the ability to flex the hip without compensating into the pelvis and lower back.When we consider this fact, stabilization in the lumbar spine would not be possible for many to achieve. For those individuals, this exercise would be a harmful waste of time.

To determine if this is the case in your patient, place them in supine or sidelying, gently palpate just above ASIS or just below PSIS, and have the patient slowly flex their knee toward their chest. At the point in the range of motion when the ASIS or PSIS begins to move, is their uncompensated hip flexion range of motion.

Beyond that range they will be achieving motion in their pelvis which could lead to SI problems or motion in their lumbar spine leading to pathology there. 

For me it is about 70 degrees.

Every time I sit, squat or lift my leg higher than 70 degrees of flexion, I am getting motion in my lower back. This explains why sitting for a period of time aggravates my back. 

If I performed  Dead bugs as outlined above, it would aggravate my back.

Uncompensated motion needs to be restored or range of motion for the needs to be limited or modified before any exercise is prescribed; otherwise the exercise may be contributing to our patient's problem.

Post Script:

While the focus of this entry was on the hip, it is important to note that a patient performing dead bugs may also lack shoulder flexion that is compensated for with back extension.

Stabilization versus Mobilization deciding how to treat

Location of pain is often not the location to mobilize

Look at L4 in the following video and note when movement occurs at that segment.

For this patient any and all ADL’s that involve the slightest amount of trunk flexion, including but not limited to; dressing, brushing teeth, doing dishes, cooking, and reaching for items all elicit mobility and pain to the L4 region where he has a HNP.  Even if we teach him to perform a full squat to retrieve an item off of the floor he will still elicit motion to L4, secondary to his severe limitation of trunk flexion without compensation (movement) to his lower back.

98% of pain is caused by hypermobility or excessive motion which causes, inflammation, more pain and greater instability as our stabilizing core muscles shut down by 1% for every cubic centimeter of inflammation. It is why surgeons fuse joints, we brace body parts, and doctors cast broken bones.

Unless there is a blunt trauma hypermobility is caused by hypomobility elsewhere. To adequately treat pain we need to stabilize the area hypermobility and mobilize the area or areas of hypomobility.

Recently, I evaluated a shoulder patient who was considering another RTC surgery secondary to pain and inability to play tennis. Like the above LB patient in the movie,  when observing almost every PROM of that upper extremity including, forearm supination, he presented with early and excessive movement (hypermobility) and crepitus at the Glenohumeral  joint. He would compensate for a lack of motion in the forearm and humerus with hypermobility at the GH joint.

Treatment for this patient was to stabilize the shoulder while mobilizing up the kinetic chain. The rationale for this is there will now be attenuation of movement forces through the system and a delay or elimination of motion at the Glenohumeral joint. Post mobilization of the the forearm, there was no motion at the shoulder with full supination only at the forearm where it should be. Post mobilization of the structures around the humerus early motion of the GH joint was delayed or eliminated. 

Note I did not mobilize this patients shoulder but provided stability in the GH joint where he was hypermobile and mobility to the structures of  forearm and humerus that were hypomobile. 

What the Heck is the ARMS Release Technique

What the heck is the ARMS Release Technique?

No. It is not a technique to treat someone’s arms.

ARMS is an acronym for Active Release with Manual Stability.

The ARMS release technique is a mobilization technique that utilizes the Therapy Principle that states you need to have stability in order to have mobility.

This ARMS technique evolved from: PNF developed by Maggie Knott and Dr. Herman Kabatt, Functional Mobilization developed by Gregg Johnson and used by the Institute of Physical Art, and as stated before, the Therapy principle that the human body needs to have stability in order to have mobility.

It was discovered when I was unsuccessful in mobilizing a sacral restriction on a patient using the techniques that I had been taught.

I was presenting at an inservice, I was embarrassed and flustered as no matter the technique that I tried,  I could not release that damn Right Sacral Base.  In the my moment of panic I recalled my Orthopedics Professor in PT school stating “You need to have stability in order to have mobility”.

I applied a stabilization force to this patient’s abdominal core based on PNF principles.  As my force to the patient’s abdomen increased the restriction completely released. To my shock and amazement, I did not even need to perform any other type of mobilize.

I hypothesize that restricted tissue; aka. Hypertonic tissue, dysfunctional tissue, trigger point, knotted muscle may be caused by a protective mechanism for instability elsewhere. 

I think this may be why some releases, dry needling, and injections are only temporary in their results.

To view an example of The ARMS Release Technique being performed on a finger click:

http://www.youtube.com/watch?feature=player_detailpage&v=ONBmgLewr0w

The Benefits of the ARMS Release Technique include:

• The ARMS technique involves patient movement during the treatment.
• It is less painful than other release techniques
• The Patient is in control and therefore will not move in a manner that will cause them harm.
• The patient is performing re-education and stabilization as they are releasing.
• Because the patient is performing; exercise, neuromuscular re-education and release, 97140, 97112, and 97110 will always be appropriate to bill. Depending on the movement that the patient performs 97530, 97535, and 97116 may also be appropriate.  
• It can be used to release any and all Connective and Nerve Tissue

When I showed this technique to a renowned PT and educator, he encouraged me to teach it to others. I have chosen to do so. 

Increase Dorsiflexion by Treating toes?!

How would you treat this patient, what do you notice?

I think that we all agree that this patient lacks dorsiflexion, especially since his knee is not in full extension causing his fibular head to be off of the ground. When the knee flexes with dorsiflexion it is compensation for a lack of dorsiflexion.

What would you treat?

If you asked me this question 5 years ago, I would have said the following:

•        Mobilize the gastroc/soleus
•        Mobilize the talus
•        Manipulate the talocrual joint

All of the above are valid answers, non of them are correct. 

Today, using the principles of Diagnostic Motion Evaluation (DME) I would say mobilize; the proximal phalanx, and the metatarsal 2 and 3.

How do I know this?

The rule of Diagnostic Motion Evaluation states that in an open chain activity the therapist should begin evaluating for motion distal to proximal.

This picture reveals lots of motion (hypermobility) into extension of the toes, another compensation for a lack of dorsiflexion.  You can actually see a dent in the skin between the base of the phalanges and the metatarsals.  The restriction to motion is definitely not in the toes.

There is no lifting of the metatarsals into dorsiflexion and that is where this person’s restriction is.

 Notice the difference in motion of the metatarsals in this picture:

Before using DME I would waste valuable time treating valid structures that could cause dysfunctional motion. Now I can easily find dysfunction that is inhibiting motion or causing pain.

The link below shows a patient who I restored full dorsiflexion, simply by treating her big toe. By the way she happens to also have Cerebral Palsy.

www.sigproed.com/res_before_after.html#neuropatient_dorsifexion

Learn this invaluable technique at our upcoming NY classes register now at

http://www.sigproed.com/live_seminars.html

Sitting is like smoking-unfiltered-menthols-while-easing-cheese-coated-lard-and-screaming-at-your-spouse bad

“Sitting is like smoking-unfiltered-menthols-while-easing-cheese-coated-lard-and-screaming-at-your-spouse bad. “ A quote I love from AJ Jacobs in his book Drop Dead Healthy.

He goes on to document research that shows that sitting puts you at risk for the following:

•   Heart disease
•  Diabetes
• Obesity
•  Cancer including colon and ovarian

Sadly, studies show that even regular gym going can’t fully undo the harm of sitting. A study conducted by the University of South Carolina and Pennington Biomedical Research Center compared heart problems in men who spent more than 23 hours per week sitting and those who sat for less than 11 hours. The sitters had a 64 percent higher chance of fatal heart disease. Of those studied many were exercisers a t the gym

Jacobs fails to mention the physical maladies, we see as Therapists that caused either directly or indirectly  as a result of prolonged sitting.

1.  Back Pain: The vertebrae are constructed to provide equal weight bearing about 3 points. When most individuals sit position themselves in flexion causing increased weight bearing to the front of the vertebrae which in turn squishes the malleable discs posterior. This in turn leads to degeneration, bulging, and ultimately herniation of a disc .
2.  Breakdown and decubiti: Because most people do not distribute their weight about the 6 potential bases of support, they bear weight on their Ischial Tubs or their sacrum leading to the breakdown of the skin
3.  Neuromuscular Deficit: When we sit in flexion or with our legs extended to compensate for a chair that is too low or too high. We do not weight bear into the bottoms of our feet and our pelvic floor. This contributes to a decreased stimulation which will decrease proprioception. Proprioception is the sense that tells our body where it is in space and is an integral component of balance. Research shows that proprioception decreases with age and there is a significant.

The reason that sitting so bad from a biomechanical standpoint is that in most people sitting reinforces the flexion components at your hips, pelvis and spine.

The reasons being:

1.  Chairs are the wrong size for most people. There are many varieties in the size of people, but when it comes to chairs, there is a one size fits all mentality. It is like having every person on earth wear a size 5 shoe.

2. Most people lack hip flexion. If you told this to me 5 years ago, I never would have believed it to be true.  I mean most people can easily bring their knees to their chest.  The fact is that neither I nor most patients can bring their knees to even 90 degrees of flexion without compensating up the kinetic chain.

Take the following test:

1.  Stand holding onto a stable surface with one hand.
2.  Take you free hand and place your fingers just above your ASIS on the same side as your body.
3.   Raise the leg that is on the same side that you are palpating.
4.  Stop when you begin feel your ASIS  move into your fingers.(This is the point when your innominate begins to move into posterior rotation).

At the point just before your ASIS begin to move should be the height of your chair.

For me this is about it is about 80 degrees.

Any height that is lower than that level will cause your innominates to posteriorly rotate and you will be weight bearing on your coccyx and sacrum versus your pelvic floor. This will also alter the force of gravity acting on your vertebrae and move the weight bearing onto your discs posteriorly.

What can we do? Studies show that we on average spend 56 hours a week sitting.

Here are some tips:

1.  Raise the height of your seat to the level just before innominate rotation. In my case I am now sitting on pillows so that the angle of my hips is in 80 degrees of flexion.  If the chair raises great, if not add pillows.
2. Straddle the chair. Take the above test again but this time abduct and externally rotate your hips. Notice you can now go lower without innominate rotation.
3.  Mobilize the structural restrictions in your thigh.

Ø  If you begin to rotate between 0-30 degrees palpate the circumference of tissue in the entire lower 1/3 of your thigh.
Ø  If rotation began between 30 and 60 degrees palpate the middle 1/3.
Ø  Between 60-90 degrees the upper 1/3.

Goto www.sigproed.com for a list of resources and our upcoming classes

The skill of palpation

Mastering Palpation is vital to being proficient in our profession.  Not only is it important for correct goniometric measurement, it is also important for the diagnosis and treatment of restrictions in the tissues which result in patient pain, lack of motion or inappropriate muscular recruitment. I term these as Structural Dysfunctions.

According to Wikipedia “Palpation is used by various therapists such as medical doctors, practitioners of chiropractic, osteopathic medicine, physical therapists, occupational therapists, and massage therapists, to assess the texture of a patient's tissue (such as swelling or muscle tone), to locate the spatial coordinates of particular anatomical landmarks (e.g., to assess range and quality of joint motion), and assess tenderness through tissue deformation (e.g. provoking pain with pressure or stretching). In summary, palpation might be used either to determine painful areas and to qualify pain felt by patients, or to locate three-dimensional coordinates of anatomical landmarks to quantify some aspects of the palpated subject.”

Easier said than done…

In my PT school training, I was taught to palpate anatomical landmarks by using a book that showed pictures and gave a verbal description of where a condyle, tubercle, tendon etc….should be, I was never taught to feel.

While your other four senses (sight, hearing, smell, and taste) are located in specific parts of the body, your sense of touch is found all over. This is because your sense of touch originates in the bottom layer of your skin called the dermis. The dermis is filled with many tiny nerve endings which give you information about the things with which your body comes in contact. They do this by carrying the information to the spinal cord, which sends messages to the brain where the feeling is registered.

The epidermis also contains very sensitive cells called touch receptors that give the brain a variety of information about the environment the body is in.

There are about 100 touch receptors in each of your fingertips. These receptors perceive sensations such as pressure, vibrations, and texture. There are four known types of mechanoreceptors whose only function is to perceive indentions and vibrations of the skin: Merkel's disks, Meissner's corpuscles, Ruffini's corpuscles, and Pacinian corpuscles.

The most sensitive mechanoreceptors, Merkel's disks and Meissner's corpuscles, are found in the very top layers of the dermis and epidermis and are generally found in non-hairy skin such as the palms, lips, tongue, soles of feet, fingertips, eyelids, and the face. Merkel's disks are slowly adapting receptors and Meissner's corpuscles are rapidly adapting receptors so your skin can perceive both when you are touching something and how long the object is touching the skin. Your brain gets an enormous amount of information about the texture of objects through your fingertips because the ridges that make up your fingerprints are full of these sensitive mechanoreceptors.

Located deeper in the dermis and along joints, tendons, and muscles are Ruffini's corpuscles and Pacinian corpuscles. These mechanoreceptors can feel sensations such as vibrations traveling down bones and tendons, rotational movement of limbs, and the stretching of skin. This greatly aids your ability to do physical activities such as walking and playing ball.

Some of the techniques which are used by individuals to improve their sense of touch include the following:

•   1.    Putting yourself in a position where you have the best mechanical advantage. Putting myself in a position where I can use my body weight to sink into tissue has made the biggest difference in my ability feel. I believe that if you are exerting force from your fingers and upper extremities, you asking your neurological system in those areas to multitask. Like texting and driving it is impossible to do more than one thing optimally at a time.
• 
  
•   2.  Close your eyes. We know that when you take away one sense the others will become more sensitive.
• 
  
•   3.  Relaxing in your own body. I recall being tested in Manual Therapy and was stressed in my body about something that happened earlier that day. At that moment, I would have trouble discerning a porcupine from a kitten.
• 
  
•   4.  Take a cleansing deep breath and put your intention to feel into your fingertips.

1. 
   

Here are some links to websites that have exercises to help improve your tactile sense.

http://www.visionaware.org/section.aspxFolderID=8&SectionID=115&TopicID=519&DocumentID=6036

http://superconscious1.blogspot.com/2008/01/improving-your-tactile-discernment.html

Oscar Pistorius' Gait Deviation

Many critics have claimed unfair advantage to South African runner Oscar Pistorius as he uses Cheetah Blades as a prosthetic for is double leg amputation

Watching his gait in running, I noticed that he is likely not getting the full benefit from his high performance, carbon fiber prosthetic.

As seen in this picture, his left lower extremity is in external rotation. Given the energy storing capabilities of the Cheetah, he is not gaining the full recoiling properties. To gain improvement in his mechanics we need figure out the cause of the left lower extremity external rotation. When evaluating patients, my bias is to attribute external rotation to a lack of dorsiflexion, for this individual it is clearly not the cause. 

Since there is no foot and hasn’t been one before ambulation began for Oscar (he was 11 months old at the time of amputation). The cause is likely a limitation at the femur, hip, innominate or sacrum causing him to compensate with femoral external rotation due to a lack of extension at the hip on push off. When you watch him walk he does not externally rotate on the left, this is why I do not think there is a limitation in hip or innominate internal rotation.

To test I would look at the following:

1.     Open Chain knee flexion- To rule out rotation at stump.

2.     Femoral extension: Should be 10 degrees without compensation above or below

3.     Innominate extension: With the femur should total 20 degrees without compensation above or below.

4.     Sacral Extension: With the femur and innominate should total 30 degrees without compensation above or below.

5.     Pelvic depression- He may lack range in pelvic depression causing him to compensate with external rotation at the hip.

To learn more about evaluating and treating gait dysfunction check out our course;

Restoring Efficient Balance and Gait Through Targeted Evaluation and Treatment Strategies

Greenville, SC September 15th and 16th, 2012

http://www.sigproed.com/live_seminars.html

Tennis player treatment with a surprise result

This patient, whom I had treated in the past for chronic falling (See post July 26, 2012) had now reported that she experienced a fall from tripping.

http://ptsperspective.blogspot.com/2012/07/carryover-2-years-after-treatment-for.html 

In my Balance Enhancement and Fall Prevention Course, I teach that when a person experiences tripping one should evaluate Ankle Dorsiflexion with the knee extended and pelvic elevation. If neither of those show any dysfunction, then look at the push off phase of gait as that is the predecessor to the swing phase of gait where tripping occurs.

When I observed her gait pattern, I noticed that she externally rotated the right lower extremity (often an indicator of a lack of dorsiflexion, presented with a narrow base of support, adducting her right leg toward her left, and abducted her arms with her arm swing.

See video: http://www.youtube.com/watch?v=c0jS6EXihe4

When I evaluated open chain active range of motion dorsiflexion with her knees extended this is what I observed. Please also note the alignment at her Bilateral femurs and patella.

http://www.youtube.com/watch?v=0o0F8S8Gjqo

During my evaluation of Passive Range of Motion her primary restriction was noted to be at the metatarsals, I also noticed callusing of the metetarsals on the soles of her feet as well (a telltale sign that there are restrictions in the metatarsals).  Using the ARMS technique for about 5 minutes, treating both of her feet, her Active Range of Motion Dorsiflexion and it had increased within normal limits.

See video: http://www.youtube.com/watch?v=0lUo0x-KpMg

In spite of this treatment I did not observe a significant change in her gait pattern, she was less externally rotated but there was still a narrow base of support that I noted. What appears most remarkable is the change in alignment at the patella and femur as a result of release to the foot.

At this point I evaluated her pelvis and began to work on that.

Post Treatment Gait: http://www.youtube.com/watch?v=5enNTcOWeqQ

At the completion of the treatment there was a mild improvement in her gait. She presented with a normalized arm swing and decrease hip external rotation. I was surprised and impressed by the improved alignment at the patella and femur with work solely to the metatarsals (excuse the pun).

As noted above open chain dorsiflexion was restored, home program is ankle pumps with toes in flexion.

Given her history of falls, I am concerned about her narrow base of support as falling occurs when our center of gravity moves beyond our base of support. As noted there is still mild rotation of the right femur and patella which may be contributing to her adducting her right leg during swing, and compensating with foot external rotation.

Next visit I will address the rotation of the femur and patella.

Come to a live class to learn how to perform this type of Gait evaluation and myofasical treatments at: http://www.sigproed.com/live_seminars.html

For additional Before and After Patient Results: http://www.sigproed.com/res_before_after.html

Carryover 2 years after treatment for repetitive falling

Last entry I spoke about carry over. I recently saw a patient who I treated 2 years ago for repeated falling. I tell her story in almost all of my classes as it was one of the first experiences that I had using Diagnostic Motion Evaluation that amazed me, here it is:

An older woman, who is an avid tennis player, had been falling on the tennis court. Her multiple falls resulted in an ankle fracture and pelvis fracture on her left side. As a result she was fearful that she would have to quit her favorite sport.

When I had seen her, I decided to perform the foot clock evaluation in the directions of 3-9 o’clock. My rationale was this; she had been falling only on the tennis court, not during her normal community ambulation. The motion in tennis that is distinctly different than walking are the lateral motion. When I had her do this action, I observed that her Right medial foot came almost completely off of the floor very soon after she began to shift her weight toward her right side. Bear in mind her injuries were on her Left and I assumed that her dysfunction would be on the Left side as well.

Based on the principle of Diagnostic Motion Evaluation, this was a closed chain activity,  therefore, my beginning observation point was just above the knee. Base on her compensation being with the first few degrees of motion, I realized that her dysfunction was somewhere at the proximal tibia. I brought her into sitting and moved her passively to determine if this was a structural or a non structural dysfunction. The dysfunction was the same and therefore was determined to be structural.

When I palpated, I found the structural dysfunction to be at the superior/medial tibia and I treated with ARMS. I re educated by facilitating her medial foot to stay on the floor as she shifted to the Right and her home program was foot clocks 3-9 with progression to side stepping and karaokes.

As I had mentioned earlier, until a few weeks ago, I had not seen her in over 2 years. I am thrilled to report that since our treatment she has not fallen on the tennis court and she continues to play consistently.

She did however, mention tripping over a step that she had not seen, so I decided to evaluate open chain Dorsiflexion and this is what I saw.

http://www.youtube.com/watch?v=ZZlWMNXOPhw

Her initial walking pattern revealed external rotation of the right foot, narrow base of support, widened arm swing and mild trendelenberg to the right.

http://www.youtube.com/watch?v=c0jS6EXihe4

I will post her treatment for her gait and dorsiflexion next post.

2 week follow up of Neuro pt's AROM Dorsiflexion

Here is a video of my patient’s AROM Dorsiflexion 2 weeks post treatment:

http://www.youtube.com/watch?v=rIk0YLXysT4

To see her original videos copy and paste the following link or go to www.sigproed.com, resources: www.sigproed.com/res_before_after.html#neuropatient_dorsifexion

 A frequently asked question during my classes is how to maintain the gains that we make in the clinic. Like my students, I find carry over to be the most challenging aspect of therapy. It is easy to gain range and function when the patient is in therapy, but when the patient is independent and at home we often see our gains disappear in as quickly as a day’s time.

My experience has been that carry over is impacted by the following:

1. Age: A younger patient will tend to have greater carry over.
2. Compliance to home program: Individuals who are vigilant with their home program have better carry over.
3. Duration of dysfunction: The less time that a problem has been going on the easier it is to rectify.
4. Patient Choices: Some individuals will make unwise choices in their activities and overdo leading to the undoing many of the gains made in clinic.
5. Patient’s level of activity: If I am working on the foot or gait in the clinic, I find significant carry over with patients who ambulate, as walking is their home program.
6. Treating the correct dysfunction that is inhibiting the function.

Since we cannot change a patient’s age or the duration of their dysfunction, we really need to focus on the factors that we can change.

Treating the correct dysfunction: Lets use our patient mentioned in the previous entry as an example: her dysfunction was a gait dysfunction associated with heel strike. This occurred secondary to decrease AROM in dorsiflexion in the open chain, lacking 24 degrees. At this point we do not know why she lacks open chain dorsiflexion, it could be due to any of the following reasons:

1. Structural dysfunction in the calf muscles
2. Structural dysfunction in bone, fascia or nerve of the calf and foot
3. Joint restrictions in the ankle joint
4. Non structural dysfunction due to her Upper Motor Neuron Injury of CP. 

I could have legitimately treated any of the above dysfunctions and gained range in clinic but my gains would not have lasted as I was not treating the dysfunction that was causing her to lack AROM dorsiflexion in the open chain.

Only by using Diagnostic Motion Evaluation was I able to determine that the reason she lacked AROM was due to structural dysfunction in her hallux. When that was restored we gained and maintained AROM, at this point 2 weeks post treatment.

Compliance: I have been told that Diane Lee tells her patients “I am not your aspirin, do your exercises”.  Everyone’s amount of time and level of compliance will be different. Find out what works best for your patients. A 5 minute routine 1 time a day, 1 minute of exercise 5 times a day or exercises that can be incorporated into their other ADL’s. In addition to modifying your home program to tailor patient’s lifestyles it is vital that the patient’s understand the importance of doing their home programs. Saying something like, “97% of my patient’s who perform their home programs have success in their rehab”.

Patient Choices: Educating the patient’s on what activities are appropriate to perform and what activities they should avoid or modify will impact carryover and healing. For the some patients it is difficult for them to give up, albeit temporary an activity or sport that they love, for others, it may be difficult to get them out of their favorite chair.

Providing a specific timeframe and guidelines to activities will be crucial in their not committing harm to themselves when they are on their own.   

Amazing increase in AROM on a Patient with Neurological Tone

As most of you know I have found great success in my practice using Diagnostic Motion Evaluation (DME) and the ARMS technique, there are occasion where I am amazed by what I find and the result in my patient's range of motion when I apply both techniques. I was particularly surprised by this result as the patient has neurological tone secondary to Cerebral Palsy.  

The following is an example of the power of (DME), I can say with certainty that I would not have fathomed that restriction in the big toe would have such an impact on open chain dorsiflexion as it did with this patient.

I had been working with a woman who was born with a mild case of Cerebral Palsy. Upon my most recent evaluation of her walking, I determined that we need to work on Open Chain Dorsiflexion on her affected side. Her primary therapist and I filmed her performing Bilateral AROM Dorsiflexion in the open chain. The film can be found at:

http://www.youtube.com/watch?v=hmXLNzvoEMM.

We also measured goniometrically, AROM to be lacking 24 degrees Dorsiflexion on her R. ankle. 

Because of the tone in her foot and ankle, her primary therapist and I were dubious about what if any AROM we could achieve. Keeping with the principles of Diagnostic Motion Evaluation I tested PROM going from Distal to Proximal beginning with the distal hallux (big toe). I found that there were structural restrictions there and treated with ARMS, I continued to evaluate and treat the hallux for a few minutes, no longer than 3, this was the result.

http://www.youtube.com/watch?v=50ZTO5VKRsw 

To see before and after side by side copy and paste this link www.sigproed.com/res_before_after.html#neuropatient_dorsifexion

FULL ACTIVE DORSIFLEXION RIGHT EQUAL TO LEFT WITH MOBILIZATION ONLY TO THE HALLUX!!

This caused me to ponder how to differentiate between palpating tone and structural dysfunction. I came up with the following differences:

1. Structural Restrictions will be point tender, tone will not
2. Tone may elicit clonus, structural restrictions will not

 Home program for this patient is ankle pumps.

Her next goal is to be able to achieve open chain ankle circles. Stay tuned, I will be posting her 2 week follow up next week.

Importance of Walking Speed

Recently walking speed has been termed the “Sixth Vital Sign” as it appears to be a strong indicator of health status, a predictor of future events, and is used to help determine outcomes such as; functional status, discharge location and the need for rehabilitation. 

A longitudinal study of 11 years found that people with a slower walking speed in middle age were one and a half times more likely to develop dementia compared to people with faster walking speed.  Other research supports walking speed as a predictor of the post hospital discharge location 78% percent of the time.

In 2009 walking speed was chosen by a panel of experts as the standardized assessment to measure locomotion for the Motor Function Domain category of the NIH Toolbox. The reason for this included the following: walking speed is safe, requires no special equipment, can be administered in less than 2 minutes, is easy to calculate, is highly reliable and has published norms.

While walking speed varies by age, gender and anthropometrics, the range for normal walking speed is 1.2-1.4 meters/second (m/s) or 2.64-3.08 mph.. Small changes in walking speed can greatly affect the functional status patients. In a 2006 study using a diverse group of older participants with varying diagnosis, only 0.05 m/s (0.11 mph) was calculated as the needed change for a meaningful improvement in walking speed. For patients without normal walking speed an improvement of at least 0.1 m/s or 0.2 mph has been shown to be a predictor of future well-being, while a decrease in the same amount is linked with poorer health status, more disability, longer hospital stays, and increased medial costs.

Walking is a complex functional activity with many variables that contribute to and influence walking speed. Research has demonstrated that very small improvements in walking speed are linked to function, independence and health status. Understanding, evaluating and treating the variables that affect your patient’s walking speed can mean the difference between independence and morbidity.

The Restoring Efficient Balance and Gait through Targeted Evaluation and Treatment Strategies is unique as it provides the PT with numerous functional approaches to determine exactly where a gait deficit occurs, why it is happening and whether the dysfunction a structural or neuromuscular dysfunction.  From this information appropriate treatment strategies that are quick and effective can be immediately incorporated into any practice settings with lasting results.

What makes Signature Allied Strategies class different than other Gait classes is the focus on the foot and ankle. The foot provides the primary generator of propulsive force in walking and its efficient function is vital to gait and improvements in walking speed. Additionally the foot is the base of support in walking and deficits in its function can lead to falling, neuropathy, slower walking speed, and painful conditions such as bunions and hammertoes.

To see improvements in gait which are the result of treatment performed only to the foot click the following link: http://www.sigproed.com/res_before_after.html

To view a list of upcoming classes including Restoring Efficient Balance and Gait click on: http://www.sigproed.com/live_seminars.html

To host a class or post a question or comment: http://www.sigproed.com/Contacts.html