The Ankle-Foot Orthosis : Another option for foot drop.

Do you have a client who suffers from some foot drop ? Do they have a classical AFO but it drives them nuts ? Foot drop occurs when the anterior compartment of the lower leg (mostly tibialis anterior and/or long toe extensors) gets compromised neurologically leaving a persons gait compromised during the swing phase and early half of stance phase.  Early to mid stance phase of gait requires that the anterior compartment muscles slowly (eccentrically) lowers the foot to the ground in a controlled manner.  When this is compromised the foot quickly, and without strategy, slaps to the ground thus rushing the persons gait onto the forefoot.  This often occurs in an uncontrolled fashion and renders some balance and weight transfer complications. Then, during late stance phase, when the foot comes off of the ground merely by forward body progression, these clients leave the foot in the pointed plantarflexed position leaving the toes without proper clearance. This often leads to tripping and stumbling.

Always looking out for newer and better solutions, we came across this variation on the AFO (ankle-foot orthosis) strategy. It seems like it could have some advantages from a logistical side. Whereas the typical AFO comes under the foot and maintains the foot in a 90 degree ankle rocker (dorsiflexion) position this one has a bit of a dynamic effect. The bungee cord-like device should slowly lower the foot to the ground as well as help to spring the foot back into dorsiflexion for swing phase clearance so that the toes are not catching on the ground.  Seems so simple we have to wonder.  We might give this one a try on a few patients who have varying degrees of footdrop and report back.

Regardless, we wanted to share……. we love outside the box thinking. Especially when it is so simple !

bravo !

shawn and ivo…………. toss in a side of orthopedics and a main course of neurology, sprinkle a little biomechanics on that and you have a well rounded meal.  We are …… The Gait Guys

Pants around your thighs.  We have this gangster gait on our list of things to do.

Parkour Running: Taking gait and running to another level.

Nike Commercial: How to outrun a chicken .

Sebastian Fouucan vs. David Belle

The Gait Guys indirect link to Sidney Crosby of the NHL and his head trauma.

So, how did the Gait Guys get so smart ? Both Dr. Allen and Dr. Ivo studied in the field of chiropractic neurology. Dr. Ivo had the wonderful opportunity to study directly under Dr. Carrick for several years. Dr.Carrick is the leader in the field of functional neurology. Dr Ivo studied under the best out there. Dr. Ivo is a diplomate of the chiropractic neurology board, one of the most challenging diplomates to attain.

Most recently Dr. Carrick was asked to evaluate and treat Sidney Crosby arguably the best player in the NHL.  EVeryone was failing on helping Sidney, until Dr. Carrick was begged to come into the picture to help. 

Here is an awesome press conference with Dr. Carrick’s talk starting at 7:40 into the press conference. Enjoy

The Gait Guys, ……. Ivo and Shawn……. not your average doctors.

Reebok International Ltd has agreed to pay $25 million to settle charges that it made unsupported claims

what we were saying all along about these types of shoes and MBT’s…….

____________________________

By Diane Bartz in Washington and Nivedita Bhattacharjee in Bangalore | Reuters

WASHINGTON (Reuters) - Reebok International Ltd has agreed to pay $25 million to settle charges that it made unsupported claims that its “toning shoes” provide extra muscle strength, the U.S. Federal Trade Commission said on Wednesday.

The money will go toward consumer refunds.

Reebok advertisements said the shoes strengthened hamstrings and calves by up to 11 percent more than regular sneakers, and toned the buttocks by up to 28 percent more, the FTC said.

read the rest here…… link below

http://shine.yahoo.com/channel/health/reebok-paying-to-settle-charges-over-shoe-claims-2571097/

Life’s the same, except for the shoes….

Ric Ocasec

Happy Friday

Ivo and Shawn

Gait Forensics: Gait Recognition Software.→

Imagine you are a wanted criminal or terrorist. You know that in the soon-to-be police state that America is leaning towards, there will be cameras on every corner, in every building, on every public transportation service. Heck, it is in many of these places already.  So, what is a criminal to do ?  Hiding their identity was once the way but it is coming to an end because of the improving facial recognition computer programs currently being used. A once simple process of growing some facial hair, wearing sunglasses, changing haircut or color, wear hats is coming to an end.  Still, there are so many other ways criminals can hide amongst us and from the pending camera-happy America that we are soon becoming.  So, what is America’s next step to stay ahead of all this ?

Yup, why not begin a database of gait traits that can be identified; sort of like an AFIS for feet? After all, people do have different foot types, and combining that with gait patterns provides unique clues to an what makes us unique.

In the above article , “A team of New York University researchers has honed in on motion capture as a particularly promising approach to analysis. Associate computer science professor Chris Bregler is studying whether potential security threats can be identified via unique patterns of movement. How might someone walk if he was carrying a bomb in his backpack?” “A person’s body moves differently when it must compensate for some unnatural burden, such as a heavy backpack or even high-heeled shoes, says Bregler.”

“Bregler and his team have identified certain movement signatures with the help of the same motion-capture technology used for special effects in the Lord of the Rings and Harry Potter movies.”

In present day America, one unfamiliar with suicide bombers, we feel safe most of the time.  But as these guys are investigating, carrying excess weight that one is not typically accustomed to, could generate some traceable gait characteristics that a camera could pick up on. But the problem, as we see it, is that if the terrorists know what we are looking for, they can train themselves to adapt to the added weight.

It took a decade or more for facial recognition software to become perfected by the government.  It is so simple now that Facebook has thrust it upon all of our photo galleries.  So who knows, in another decade or so, all of our gait patterns could be mapped and logged for the government and the “next Facebook” phenomenon. 

Hopefully these companies will come calling on the guys of gait……. the experts.

Shawn and Ivo…….The Gait Guys

in the infamous words of Steven Tyler, …..“walk this way”……. or

the immortal words of James Taylor…..“there’s something in the way she moves …..”

want more from the article ?  here is the link below

http://www.pbs.org/newshour

In this weeks Neuromechanics, Dr Waerlop discusses the importance and significance of the “Central Integrated State” of the Nervous system; What is is, and what influences it. Many thanks to Dr Ted Carrick, who hammered this into Dr Ivo’s head while completeing his diplomate in neurology.

Enjoy!

Are Barefoot Shoes really better ? NewYorkTimes article.→

Read the full article, it is quite short…… but here is the gist of it…..

“The American Council on Exercise, a nonprofit group that reports on fitness, recently sponsored a small study to learn more about the popular footwear. Researchers from the University of Wisconsin, La Crosse, asked 16 women, all healthy recreational joggers ages 19 to 25, to spend two weeks getting used to running in the Vibram FiveFingers, a snug, glovelike shoe that weighs less than five ounces. The women were advised to use the shoes, the best-selling brand of barefoot sports shoes, three times a week for up to 20 minutes a day.”

“The researchers found that half of the women who switched to barefoot running or minimalist sports shoes failed to adjust their form, resulting in more wear and tear on their bodies, not less.”

Really? 2 weeks to “get used to them”? As we have said, countless times; you must earn your right to go minimalistic or barefoot. Foot competence is not created in a day, or in 2 weeks for that matter….

Shawn and Ivo. Two guys promoting gait competence

Green bodies: Lactic acid as a fuel source?

Your body can be greener? We don’t mean being a leprechaun. We mean being a better recycler. Read on…

For years, we’ve been told that lactic acid is a waste product that burns and shuts down muscles. It’s something athletes and fitness exercisers are urged to avoid. You’re told to work out just below your lactate threshold, where lactic acid begins to accumulate.

Well, some of that is correct, but it seems, most of it is wrong. 

The aerobic and anaerobic energy systems have long been thought to operate as separate and distinct systems. Lactic acid was considered the enemy of aerobic metabolism, with the power in sufficient accumulations to bring it to a halt. But we are smarter than that now…

 UC Berkley integrative biology professor George A. Brooks,  has been studying lactic acid since doing his doctoral dissertation on the subject in the ‘70s. Brooks says the idea that lactic acid is bad and to be avoided “was one of the classic mistakes in the history of science.”

“The understanding now is that muscle cells convert glucose to lactic acid,” Brooks explains. “The lactic acid is taken up and used as a fuel by mitochondria, the energy factories in muscle cells. Mitochondria even have a special transporter protein to move the substance into them.”

So, your ability to recycle lactic acid into the Krebs (or Citric Acid Cycle) reflects a great deal about your aerobic performance and capacity. Aerobic metabolism and anaerobic metabolism, in fact, operate side by side in the mitochondria. The heart, slow-twitch muscle fibers, and breathing muscles actually prefer lactate as a fuel during exercise. In short, lactic acid is a significant energy source, actually a good thing.

Hinting, or perhaps suggesting, how athletes can and are using this revelation, Professor Brooks said in a recent press release: “The world’s best athletes stay competitive by interval training. The intense exercise generates big lactate loads, and the body adapts by building up mitochondria to clear lactic acid quickly. If you use it up [as an energy source], it doesn’t accumulate.”

Too much lactic acid is still bad, however. It causes distress and fatigue during exercise, altering the local pH of the tissues and changing chemical reactions.  In extreme circumstances it can damage muscle cells.

So how can you learn to use lactic acid to your advantage? Stay tuned for the next lactate installment, coming to a Gait Guys Tumblr Blog near you….

Ivo and Shawn

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

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

Plasticity of Locomotor Patterns & Gait Conditioning via Controlled

Biomechanical intervention  

Amir Haim, MD (Ph.D candidate)

Supervisor: Dr. Alon Wolf

Biorobotics and Biomechanics Lab,  Faculty of Mechanical Engineering

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

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

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

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

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

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

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

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

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

Amazing video example of human movement. Taking gait to another level of body awareness.

This cool cat is something else.  We like to keep weekend info pretty light, Monday-Friday is time for learning and concepts, weekends are time for experiencing the richness of it all.

Enjoy, Shawn and Ivo

Shoes are like oven mits for your feet. Railing walk. A different kind of gait today.

You will not be able to do this in traditional shoes that is for sure.  The feet are amazing adaptable receptor organs, feedback is critical. Shoes dampen feedback.

Imagine if you had oven mits on all day long …… the hands would be handicapped.

have a great weekend fellow gait geeks.

shawn and ivo

Neuromechanics Weekly: No video this week, but check this out….

a little neuro that is, at least, peripherally related to running, for this beautiful Saturday Morning…

A question from one of our readers.

Dr Ivo

I am a runner and often get fatigued and tired, even after a short run. I have had a complete blood work up which was negative, as was my physical exam. My Dr prescribed Zanaflex for muscle spasms and I take ibuprofen prn

The short answer: Stop taking Zanaflex (Tizanidine)

The long answer…

Hmmm. Let’s see. Tizanidine ( mm relaxant ) is a alpha 2 adrenergic agonist (ie they promote activity of alpha 2 receptors). This means it acts on adrenergic receptors (ones that respond to epinephrine and norepinephrine) as opposed to cholinergic receptors (which use acetylcholine as a neurotransmitter). Adrenergic agents usually causes a sympathetic response, like pupil dilation, or increased heart rate.

Adrenergic receptors are usually either alpha or beta subtypes. Alpha receptors usually cause vasoconstriction of arteries to the heart, vasoconstriction of veins, and slowing of the GI tract.

There are 2 classes of alpha adrenergic agonists,

alpha 1: Alpha-1 adrenergic agonists stimulate alpha-1 receptors coupled to G proteins and phospholipase C. They cause vasoconstriction (contraction of blood vessels) and mydriasis; they are used as vasopressors, nasal decongestants and in eye exams. They can be classified in two groups: those which do not cross the blood-brain barrier and have peripheral effects and those which penetrate into the brain and have mainly central effects.

alpha 2: inhibit adenylyl cyclase activity.  alpha 2 adrenoceptors are often located on the sympathetic nerve terminals that inhibit the release of norepinephrine and therefore act as a feedback mechanism for modulating the release of norepinephrine. In other words , they inhibit release of epinephrine and norepinephrine (or slow sympathetic activity). Sympathetic activity (like increased heart rate with exercise and vasodilation of capillaries in muscle, to provide more oxygen supply and remove metabolites) is necessary for us to function during exercise performance. Tizanidine falls into this category.

Aren’t you glad you asked?

We remain, undisputedly, Gait AND Neuro Geeks…The Gait Guys

Wouldn’t want to walk a mile in these shoes….

Read all about it here: http://www.dailymail.co.uk/femail/article-2041188/Top-teen-model-Lindsey-Wixson-takes-tumble-Versace-shoes-blame-her.html

Have a great Friday

Ivo and Shawn

Another Gait variant: The Apropulsive gait style

Here is another important video for all you gait fanatics out there. You will see some of these components in your athletes, patients, family or even yourself if you are paying enough attention.

These animated videos are great because they exaggerate the pathology.  Here we see several things:

1. excessive forward arm swing: this is attempting to create a forward propulsive action to help them move over the suspected primary biomechanical gait pathology.
2. forward head “bobbing”: again, this is attempting to create a forward propulsive action to help them move over the suspected primary biomechanical gait pathology.
3. a heavy forward lurching lean: this is attempting to create a forward propulsive action to help them move over the suspected primary biomechanical gait pathology.
4. pronounced knee lift-hip flexion: this is attempting to create a forward propulsive action to help them move over the suspected primary biomechanical gait pathology.

So, what is driving all of these attempts to create more than normal forward propulsion ?

If you look down at the feet you see a lack of ankle rocker (dorsiflexion) as evidenced by early heel departure. This fella puts his foot on the ground and then tries to move across his ankle but he hits a restriction at the range limitation. He cannot move forward sufficiently to normalize a sound effective and efficient propulsive gait.  At the moment his ankles lock out from hinging further forward he must go into the above strategies to pull his body mass forward past his foot plant and literally pull the foot off the ground and move forward to the next dysfunctional step. Everything he is doing is to try to create forward propulsion sufficient to move across ankles that do not dorsiflex enough.

* IMPORTANT: Remember: premature heel rise typically leads to premature activation of the calf muscles, gastrocsoleus. And when this happens, the gait becomes vertical and bouncy in nature as the calf muscles are being used to lift the body more than to propulse it forward. This can lead to posterior compartment injury. Additionally, this causes a quick premature forefoot loading response which can create increased burden on the METatarsal head and fat pad but it will also create a grip response of the toes and possible hammering which can disable the lumbricals and other foot intrinsic muscles).

And if that isn’t bad enough, on the sagittal views, we see the knees hinging outside the normal forward progression line and if that isn’t bad enough, on the views from behind he clearly is dipping the contralateral hip-pelvis during stance phase (when standing on the right leg, the left pelvis drops) which is a key sign of suspect gluteus medius weakness. 

even the simple cases have nice topics for review.  Failure to have sufficient components for effortless forward motion in gait will result in compensations to get the job done.

TAKE HOME POINT: identifying and restoring ankle rocker is pretty darn important. And that does not mean simply via stretching the posterior compartment. Frequently the anterior compartment is the weakness driving the pathology, but not always.

Pixar should call us……… Shawn and Ivo

The Guys of all things Gait

John Travolta’s Pathologic Gait “Strut”.  One of the most memorable Hollywood gait patterns of all time !

First thing you must notice right away, even from the head shot as he exits the door, is the up and down head bob.  We will get back to this most important part in #2 below and keep you in suspense. 

Another thing you will see is that he has no arm swing, particularly on the right.  He also is over pronated in his upper limbs which is what gives him the “kucxkles forward” primate-type hand position but that is not his fault we would guess, men typically have little skill in higher heeled footwear, in this case a cowboy-style boot (we are trying to give him a manly excuse, the men’s higher heeled nightlife footwear of the 1970’s wasn’t exactly manly in our opinion).  Those things are hard enough walking in let alone what Travolta did in them on the dance floor.  Our point here, most men are not used to the drop down onto the forefoot that comes from the initial heel strike on a higher heeled shoes.  Men are not usually used to walking in such high heeled shoes, and so we do not realize that we have to dampen our instinct to heel strike.  In these cases men have difficulty with two things:

1). with each successive step, again stepping back up onto the heeled shoe after just descending down onto the lower forefoot from the previous step is a challenge. In this video we see some of his strategy. If you watch closely you will see that the abnormal “knuckles forward” posturing of his upper limbs allows him to most likely get his pectorals and triceps more in to the posterior propulsive swing phase action in a manner of “pulling himself up and thrusting forward with each step”.

2), this is a continuation of #1 and what we were hinting at first off …… you see a abrupt up and down movement of his head in his initial exit from the doors of the club.  This is once again a product of the higher heeled shoes-boots.  Travolta is obviously a sufferer of anterior shin splints.  After each heel strike he drops abruptly onto the forefoot with each step. This cycle is repeated and is synchronous and it is what gives the up and down head movement.  It is what also gives him his “Strut”.  He likely  suffered with terrible anterior shin splints in this movie as a result of this. This is the type of gait you will see in young ladies new to high  heeled shoes.

If one insists on choosing this footwear, this Up and Down oscillation strut can be mediated by:

1) shortening ones step

2) ensuring that the forward foot contact is met with as little difference between heel strike and forefoot load, meaning, that the wearer must move the foot forward in relative plantarflexion essentially always trying to stay on one’s forefoot, essentially trying to avoid heel strike as much as possible.  Watch any woman skilled in high heel shoes, you will see this pattern.  It is easier to stay plantarflexed and on the forefoot rather than suffer the slings and arrows of outrageous gait misfortune, that being clear heel striking and devastating your anterior compartment shin splint muscles and toe extensors.

Regardless, Travolta is still the man ……. on the dance floor or strutting down the streets of NYC in high heeled shoes or not.  Don’t believe us men ? …… then head off to yo momma’s (or wife’s) closet and give it a shot …… we dare ya !

We remain, shockingly knowledgeable about high heels shoe biomechanics……. and pleading the 5th as to how we know this stuff .

…… we are both Staying Alive and Jive Talking, and still the undisputed heavyweight champs of all things gait.  We are……

Shawn and Ivo …….. The Gait Guys

Barefoot? Minimalism? I thought barefoot WAS minimalist?

Barefoot fever has really caught on over the last year or so. It seemed to start with the advent of the Vibram 5 fingers several years ago (which Dr Waerlop was a biomechanics and design consultant for) and seems to have blossomed to include many different types of footwear.

In the strictest sense, barefoot means NO SHOES or UNSHOD. There are hygenic and social reasons we cover  (or need to cover) our feet, and thus the advent of the many types and styles of footwear we are seeing crop up in stores everywhere. This shoes have minimal amounts of bells and whistles (read support and rigidity) and thus promote a barefoot STYLE of walking or running. These “shoes” also have a low (or no) ramp angle. The ramp angle is how much higher the heel is in elevation than the forefoot.  Most traditional running shoes have a 2:1 ratio…..the heel is twice as high as the forefoot.  The average might be a net 10-20mm rise in the heel height over the forefoot rendering a ramp angle of approximately 15degrees.  So when we say barefoot and include these minimalistic shoes we are referring to shoes with a ramp angle of less than 2-3 degrees and less than 5 mm heel rise.

According the the last two studies published in Nature, by Dr Daniel Lieberman, barefoot or minimalistic activites appear to have many advantages: less stress on the joints, less impact forces on the body and increased proprioception (awareness of your body parts, in this case feet, in space).

The barefoot model is based on the simple fact that the movement of our anatomy for thousands of years has been always been that the heel and ball of our foot rest on the same plane. This is the ground work for the normal workings and biomechanics of the foot.  When we take the heel and raise it onto a level above the forefoot (as most running and dress shoes do) the body will have to make biomechanical changes to that very same anatomy that loves level ground. It is now being proven over and over again that this altered positioning and corrupted biomechanics may be what are driving much of the foot and lower limb problems we see out in the world.  Whether it is plantar fascitis, shin splints, achilles problem, toe problems, or just general foot or ankle pain, these altered biomechanics are highly suspicious culprits.

This is not to say that everyone can go barefoot or is ready to immediately go barefoot, despite the picture the shoe vendors and media are painting. Some folks have to gradually work their way down into lower ramp angled shoe affording the time and tissue changes that will come with adapting to different heel heights.  It can take some time for the calf muscles and achilles to restore their original length or take time to regain the strength of the foot intrinsic muscles so that the foot can no longer depend on the shoe for stability but rather it can learn to depend on the anatomy of ligaments and muscles to provide the support like our shoeless ancestors of centuries past.  This is where  minimalsitic shoes come in. They provide a transition from where you are to where you want to be. Other folks have anatomic foot types that just cannot cope well with a pure “barefoot technique” and will probably need to remain in some type of transitional shoe.

There are exercises and drills, along with types of manual therapy and muscle activation techniques that can help speed the transition from your current footwear to being a minimalist. Make sure you consult with providers with plenty of experience that are familiar with and competent with these methods.

We are still 2 foot nerds, out there making a difference…The Gait Guys

Hip function and knee pain, again.

And once again…… another study validating the fact of weak hip stabilizing muscles in causing knee pain.  The study showed that increased activation of the gluteus maximus in individuals with patellofemoral knee pain suggests that these subjects were attempting to recruit a weakened muscle, perhaps in an effort to stabilize the hip joint.

J Orthop Sports Phys Ther. 2009 Jan;39(1):12-9.

Differences in hip kinematics, muscle strength, and muscle activation between subjects with and without patellofemoral pain.

Souza RB, Powers CM.

Source

Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA, USA.