stephen gangemi, dc, dibak icak annual meeting - june 2014 part i: the human gait: a comprehensive...

Stephen Gangemi, DC, DIBAKICAK ANNUAL MEETING - JUNE 2014

Part I: The Human Gait: A Comprehensive Evaluation & Treatment for Essential

Movement

Part II: Digging Deeper into Dysglycemia and Its Effect on Gait, Health and Performance

• 100% Holistic, Individualilzed Approach: • Assessment, Treatment, and Lifestyle Changes• Rehabilitation• Prevention• Enhancement• Advise and Educate

Individualized Treatment Via Applied Kinesiology

2Copyright Stephen Gangemi DC, DIBAK SockDoc

Educate and Heal

• Treat your patient as the individual he/she is

• Don’t fall into the “latest and greatest” research trap, media hype, or fad

• Address symptoms first and then focus on helping your patient become more fit and healthy, both mentally and physically


Moving - Gait

• Kinesthetic sense: the relationship between the nervous system and the sensory feedback provided by each foot – 7,000+ nerve endings

• Proprioception: sense of position, posture, equilibrium

• Mechanoreceptors: sensory nerves which affect the entire CNS


Why Check Gait?

• To restore function• To restore health• Gait dysfunction Health dysfunction• So patients don’t “walk themselves back into a

problem”


What Disrupts Gait?

• Those which influence the Triad of Health:– Structural– Nutritional – Emotional

• Improper footwear• Orthotics – a brace that supports dysfunction

and alters mechanoreceptors


Modern FootwearSoft Midsole


Elevated Heel


Line of falling weight moves forward with heels 9Copyright Stephen Gangemi DC, DIBAK

SockDoc

Motion Control


Footwear Industry Claims

• Run faster• Jump higher• Be stronger• Exercise muscles not otherwise used with

competitor’s shoes or while barefoot

Yet there has never been any research to validate such claims


The Recent Lawsuit - Vibrams: “Your foot can become stronger by wearing FiveFingers”

Copyright Stephen Gangemi DC, DIBAK SockDoc 13

• If the injury rates are still as high as 70% with traditional running shoes, then did those companies not make false claims as well?

• Shoes are only part of the problem. Footwear manufacturers, many shoe retailers, and most podiatrists recommend footwear that is not shaped like the natural human foot.

•Traditional shoes with high cushioned heels and motion control midsoles are severely inhibiting natural movement (running & walking).

• Poor training habits and the way people move is what creates injuries. Hence the need to evaluate and correct gait disturbances.

Injury Prevention Wearing Less

• Endurance running in minimal support footwear with 4 mm offset or less makes greater use of the spring-like function of the longitudinal arch, thus leading to greater demands on the intrinsic muscles that support the arch, thereby strengthening the foot - Miller et al ,2014

• Forefoot and midfoot strike gaits may protect the feet and lower limbs from impact-related injuries - Lieberman et al, 2010

• Flat, flexible footwear results in significant reductions in knee loading in subjects with OA - Shakoor et al, 2013

• The prescription of shoe type to distance runners is not evidence-based - Khan 2009


Barefoot, Shod, or Minimalist?

• Due to industry demand, minimalist footwear is becoming more maximalist after just a few short years.


• Experienced, habitually barefoot runners will avoid landing on their heel.

• The natural motion during barefoot running is to land with a midfoot, or even a somewhat forefoot strike.


Improve Your Health BarefootProprioception (sense of position) Kinesthetic sense (the feedback your nervous system receives from your feet)


Barefoot and Minimalism

• Shock absorption: Foot strike More mid/forefoot

• Solid support: Loading Rate Center of mass

• Energy & Power: Elastic Recoil Natural Spring


• A heel strike (while running) most often results in a significant stress to the body, whereas a midfoot or forefoot strike does not

• Most running shoes are developed to promote a heel strike, and therefore an unnatural running and gait cycle

Heel strike

Midfoot/forefoot strike

Ideally the body’s center of mass should be over the foot for the lowest loading

rate


Healthy Footwear

• No arch support – the arch needs to flatten upon impact to dissipate shock

• Arch supports support the arch, not the ends of the arch a weak and dysfunctional foot


Orthotics & Arch Supports• No true long term studies of their effectiveness or consequences • They support dysfunction rather than correct or rehabilitate• Arch supports push up on the arch to “support” rather than truly support and rehabilitate

the arch where it should be supported – at the beginning (heel) and end (forefoot)• No evidence that the shape or height of an arch influences injury rates or performance


Orthotics & Arch Supports: Research Against

• Orthotic use most influencing factor in medial tibial stress syndrome - Hubbard et al, 2009

• Flexible arch support promotes a medial force bias during walking and running, significantly increasing knee varus torque - Franz et al, 2008

• Orthotics related to a higher rate of knee and ankle pain - Chang et al, 2012

• Those who had used orthotics had a higher relative risk of developing Medial Tibial Stress Syndrome (MTSS) - Newman et al, 2013

• There is insufficient evidence to support the use of insoles or foot orthoses as either a treatment for LBP or in the prevention of LBP - Chuter et al, 2014

• No statistical differences shown between sham and custom orthotic groups – Rosner et al, 2014

• The activity of the soleus and gastrocnemius is delayed with orthoses – Dedieu et al, 2013


Orthotics & Arch Supports:Research “For” – Pain Reduction

• Orthotics control pain by restricting motion and changing mechanoreceptors - Guskiewicz 1996

• Patellofemoral pain syndrome: Multiple treatment modalities in addition to orthotics. 76.5% improved; only 2% pain free. Ages 12-87. - Saxena et al, 2003

• Rearfoot medially-wedged insole was a useful intervention for preventing or reducing painful knee or foot symptoms during running in runners with pronated foot - Shih et al, 2011

– *one 60-minute test.

• 75% reduction in disability rating and a 66% reduction in pain rating with foot orthoses - Gross et al, 2002

– *Plantar Fasciitis, orthotics worn only 12-17 days


Mechanoreceptors

• Mechanoreceptors (MRs) are sensory nerves that are stimulated by mechanical activity in a tissue – touch, pressure, vibration, movement

• These receptors carry sensory activity to the spinal cord and then on to the entire CNS including the cerebral cortex.


Mechanoreceptors

• “The frequency of firing of MRs controls both the function and metabolic health of all of the neurons that they affect throughout the CNS. Decreased MR activity creates functional deafferentation of any and all of these areas resulting in decreased function as well as decreased metabolism which, in the long run, can contribute to neurological degeneration.”


Wally Schmitt, DC

Orthotics Alter Mechanoreceptors

• Custom-fit orthotics may restrict undesirable motion at the foot and ankle and provide structural support in ankle injured subjects - Guskiewicz and Perrin, 1996

• Orthotics improved postural stability in patients with functional ankle instability - Hamlyn et al, 2012

• Orthotics may be an effective means of decreasing postural sway after an isokinetic fatigue protocol - Ochsendorf et al, 2000


Orthotics Contribute to Neurological Degeneration by

Altering Mechanoreceptors• The nervous system thrives from movement and sensory input

• Improve stability with instability


http://www.drgangemi.com/wp-content/uploads/2011/01/GANGEMI-GAIT.pdf

How Long Do You Want to Support Your Patient?


• Orthotics don’t rehabilitate

• Unhealthy people benefit from support

• Treat the whole person to correct the state of dysfunction. Practitioners who use orthotics don’t treat, or have the tools, as AK practitioners do.

• Short term “benefit” = Pain reduction

• Nothing worn on the foot can improve its function

• A bare foot moves in the most efficient, natural, and healthy way (in a healthy individual)


Is There An Ideal Shoe?

• Stack Height11mm heel 7mm forefoot

11-7=4mm drop• Drop

• “Zero-Drop”

Low Stack & Drop


Shock• No Stability or Motion Control – natural

pronation deflects shock• Posterior Tibialis plays an important role


Toe Box

• No cramped toe box – so the toes can splay apart to soften landing


Cushioning?

• Cushioning does not absorb shock – it tricks the body by sending false information to the brain – “Is this a soft surface or hard?”


The Harder the Surface the Softer the Landing


• The harder the ground the more the body will adjust with more knee flexion and pronation

• Pavement is the easiest to walk/run on barefoot

• Natural terrain is unpredictable


The Ideal Shoe?

• Depends on the individual perform gait test• But generally:

• Roomy forefoot (1/3-1/2” in front of big toe)• Close to the ground throughout (low to zero-drop and a low stack height)

• Wide Toe Box

• Flexible in all directions


Barefoot as much as possible, shoes when needed

• Using MMT the physician can determine what shoes will not harm the patient during their daily activities and during exercise

• Footwear should only protect the feet from damage that may occur from the particular environment

• Transition period into more barefoot walking and minimalist-type shoes as the weakened and shortened muscles, tendons, & ligaments regain their strength


A More Comprehensive Gait Test To Evaluate Footwear

• During normal gait, there is a continuous pattern of facilitation and inhibition

• The physician can easily determine a normal and abnormal gait pattern based on manual muscle testing (MMT)


General Gait Test – Latissimus Should be Inhibited


General Gait Test – Biceps Should be Inhibited


New Addition to Gait Test – Wrist Extensors Should be Inhibited and

Strengthened with AF


New Addition to Gait Test – Wrist Flexors Should be Inhibited and

Strengthened with AF


Final New Addition to Gait Test -Breathing & the Diaphragm

• Check the diaphragm with a full inspiration and expiration, checking for gait disturbance


Barefoot Gait Ok?

After testing the patient barefoot, test them:

• Standing in their orthotics

• Standing in their shoes

• Standing in their shoes with orthotics in


Workshop!(remove your shoes)


The Soleus & Gait


Soleus: A New Way to TestOriginal test by Simon King, DC


Soleus: A New Way to Test


Part II: Digging Deeper into Dysglycemia and Its Effect on Gait, Health and Performance

Dysglycemia

• The TMJ will often reveal hidden blood sugar handling problems which can be easily addressed to improve overall health


Temporomandibular Joint (TMJ)• Local tooth and jaw problems

• Immune system impairment

• Cranial faults

• Spinal subluxation

• Health distress anywhere in the body

• Blood sugar handling problems - Dysglycemia


Dysglycemia

• Disorder of blood sugar metabolism

• Blood glucose reading may be normal

• Headaches, feeling shaky, unclear thinking, fatigue, pain, moody, (*tinnitus)

• AK assessment: Latissimus and triceps rarely inhibited


The Main Players

• Pancreas: Insulin (glucose glycogen)– Glucagon : glycogen glucose (Glycogenolysis)

• Adrenal Glands: Cortisol (Lactate, amino acids, glycerol glucose) *Gluconeogenesis

– Epinephrine & Norepinephrine (inhibits insulin, stimulates glycogenolysis in the liver and muscles and glycolysis in the muscles)

• “Tug of war” between the adrenals and pancreas leads to an increased level of ACTH from the pituitary


Adrenocorticotropic Hormone(ACTH)

• ACTH – the missing piece to the puzzle of dysglycemia

• Barrage of ACTH to the pancreas• Homeopathic ACTH creates a neurological

response to the pancreas resulting in an over-facilitation of the pancreas related muscles

• Slight rubbing over the pituitary Chapman’s reflex (glabella), will elicit the same response


The TMJ’s Involvement With Dysglycemia

• Positive TL to left TMJ• Weak muscle strengthens with TL to left TMJ

regardless of another muscle, cranial, or immune involvement affecting the TMJ (must fix these first)

• Positive TL to right TMJ patient is switched, (neurological disorganization), this must be corrected accordingly

• May or may not have jaw or TMJ pain56Copyright Stephen Gangemi DC, DIBAK

SockDoc

Evaluation & Correction - of the Dysglycemia AND many TMJ Dysfunctions

For this…And this… And this too


Procedure

• Left TMJ TL is positive (strengthens a weak muscle) or TL to left TMJ with head in extension weakens a strong extensor muscle

• No change with any jaw movement• Spleen and lower sternum immune involvement is

not present or has already been corrected• Right TMJ TL? switched, or some other problem,

(such as a local jaw problem),which needs to be addressed


Procedure

ACTH or TL to the pituitary CR weakens both [long head] biceps (over fires the lats and triceps)


Procedure Continued…

• TL to left TMJ with the head in extension weakness (no change with any TMJ movement) or TL to the pituitary CR weakening the biceps will be negated by either ATP, glucose, or glycogen, (sometimes thyroid hormone or ribose), as well as TL to the pancreas CR

• TL to the pancreas [lateral] CR with ACTH will weaken any strong indicator muscle


Correction

• Investigate what caused the problem– Diet?

• Processed foods/sugars, skipping meals

– Offender?• Artificial sweeteners, caffeine, bad fats, food allergies,

medications, hormones (cortisol, estrogen)

– Nutrient imbalance/deficiency?• Used up during metabolism of glucose/glycogen and

stress on organs – Making ATP


Correction Continued…

DIET• Patient will strengthen with sugar (sucrose, not fructose),

glucose, and/or glycogen– Obviously a patient like this does not need more refined sugar, but

due to their dysglycemia and continuous blood sugar swings they will test positive for it

• Cortisol often the offender• Glycogen stores could be depleted from a low carbohydrate

diet or prolonged heavy exercise• More carbohydrates; eat more often?



COMMON OFFENDERS• Cortisol• Trans fats • Food allergies • Caffeine• Another hormone besides ACTH• Ammonia toxicity• Neurotransmitters• Medications• Excitatory chemical/neurotransmitter such as MSG, homocysteine, aspartic

acid/Aspartame• Heavy metals



NUTRIENT IMBALANCES OR DEFICIENCIES• Nutrients to effectively make ATP: (B1, B2, B3, B5,

B6, Mg, Zn, Mn, Biotin, Lipoic Acid)• To make glycogen: (B6 (P-5-P), Mg, Ca)• Check for COQ10 as it is the main component in the

electron transport chain– 500 to 1500mg of COQ10 a day may be necessary

for short durations• Thyroid helps modulate the CAC



• Treat the pancreas CR (parasympathetic activity – rubbing) with offender, (unless the thyroid has been shown to need treatment)

• Use ACTH if no specific offender can be found• Counsel patient on diet, especially if the pattern

reoccurs• Once corrected, TL to the left TMJ should be negative

and ACTH or glabella stimulation should not weaken the biceps


Lifestyle Adjustments to Resolve Dysglycemia

• Aerobic exercise• Maybe DON’T eat every few hours• Reduce or eliminate refined foods• High protein and good quality fats• Remove offenders• Monitor stress levels• Sleep…


• No need to be constantly performing the painful origin-insertion technique on the ptygeroid muscles over and over again!


Pinto’s LigamentDiscomalleolar ligament (Pinto's ligament)

New structure related to the temporomandibular joint and middle ear J Prosthetic Dentistry 1962

This is a ligamentous structure connecting the malleus in the tympanic cavity and the articular disc and capsule of the temporomandibular joint.

This anatomical relationship between the middle ear and the temporomandibular joint is supposed to be one of the explanations for the

aural symptoms associated with temporomandibular joint dysfunction. Rowicki & Zakrzewska, 2006

Tinnitus & TMJD• Link between the TMJ and the auditory system is evident by way of the

discomallear ligament- ligamentous structure connecting the malleus in the tympanic cavity to the articular disc and capsule of the TMJ

• Study in 1992 found that 19 of the 20 subjects had “one or more clinical, electromyographic, and radiographic indications of a temporomandibular disorder”, yet all were completely asymptomatic

• Other studies have shown that tinnitus can be a primary or secondary complaint of TMJ disorders

• October 2008, the International Journal of Oral & Maxillofacial Surgery published a study suggesting that “extreme stretching of the condyle in conjunction with the ligaments between the ossicles of the inner ear and the TMJ could be the reason for unexplained otological problems


Questions, Information & Research

• Email: [email protected]• Websites: drgangemi.com

sock-doc.com

Thank you for your attention


stephen gangemi, dc, dibak icak annual meeting - june 2014 part i: the human gait: a comprehensive...

Documents

dibak sockdoc slide

performance slide

human gait

dibak icak annual meeting

check gait

footwear manufacturers

footwear industry claims

gait kinesthetic sense