FROM THE GROUND UP… - c.ymcdn.com

1 FROM THE GROUND UP . Presented by Dr. Dar Griffeth Multidisciplinary Practices MD/DC & PT relationships Kinetic Chain Models Integration Techniques Multidisciplinary Practices Know your role: Common GROUND /scope of practice Having a plan Proper documentation/reporting Proper follow-up (re-eval). Knowing your limits The postural patterns of the body and the cascade of events that are created in an attempt to adapt or compensate the various bodily functions it takes to survive in today's stressful world depend heavily on the congruent interconnectivity of the human body as a whole. Why is this important??? Is it enough to provide adjustments only versus adding stabilization and rehab ??? Postural pattern analysis Normal vs. abnormal Neurological with Musculoskeletal Imbalances & Biomechanics Biochemistry and The Stress response Posture Patterns It appears that, in a weight bearing model that most postural patterning works from the base up. As Dr. Greenawalt liked to say: It all changes when your foot hits the GROUND .

2 American Academy of Orthopaedic Surgeons (AAOS) - a faulty relationship of the various parts of the body which produces increased strain on the supporting structures and in which there is less efficient balance of the body over its base of support.. - Kendall FP. 1993. Definition =POSTURE. Webster's - 1) a: the position or bearing of the body whether characteristic or assumed for a special purpose <erect posture> b: the pose of a model or artistic figure. Dorland's - posture. the awareness of the position of the body or its parts in space, a combination of sense of equilibrium and kinesthesia; called also Position S. Neurological - The body's attitude which facilitates maximum efficiency of a specific activity without causing damage to the body system. Posture is the ability to: Conform to the supporting surface symmetrically and with weight distributed equally through the load- bearing surfaces Select and adopt the alignment of body segments appropriate to the efficient performance of a specific activity Balance and stabilize the selected body attitude relative to the supporting surface Posture is the ability to: Adjust to changes within the body or support the body while maintaining balance and stability Free the parts of the body required for movement from their load- bearing role Secure a fixed point about which the muscles can act Patterns Walking force projection = 2 times your body weight Running force projection = 3 times your body weight Patterns 1980's study done by NIKE ( Phys Sports Med 1998) determined that.

3 Walking created 5 N of force at heel strike Running created 7 N of force at heel strike even after all the areas were absorbed N of force still existed at the jaw it can be determined that there are 728. possible postures of each area (head, thoracic cage, and pelvis) in 3 dimensions, for a total of 7283 or 385,828,352 possible upright human postures!!! . The possibilities are staggering . Harrison et al: 2000. 4 Global Postural Distortions Commonly Found Together 1. bilateral/asymmetrical foot pronation 2. pelvic tilt 3. ant. translation of pelvis 4. ant. translation of cervical spine Pronation Pronation (like Supination): is not a visual assessment but a triplanar mechanical effect at the sub-talar joint of the foot; that manifests functional and structural anomalies. PELVIC TILT=PRONATION..unilateral pronation or asymmetrical bilateral pronation has the effect of producing pelvic tilt, OR the unlevel pelvis may cause the pronation. Harrison D.,et al (1988).

4 Low Back Pain & Pelvic Tilt 25 hospital patients Pronation was greatest on the side of the longer leg, indicating that the pronation was a functional adaptation to reduce pelvic unleveling.. - Langer S. (1976). Developmental Distortions Ross laboratories, What parents should know . Stages of development: Feet & Legs Birth to 2 years Bow legs and toeing in are common Age 3 to 5 Knock knees and toeing out is more common Age 6 to 7 Knees and feet (arches). should resemble adult positioning Developmental Distortions Because (hyper-pronation) becomes established by age six, functional foot orthoses after that age may be invaluable in maintaining a normal medial longitudinal arch until the foot reaches skeletal maturity during the early teens.. Michaud TC. 1993. Plantar Vault 3 Facts About the Feet 1. The most common subluxation pattern of the foot is: EXCESSIVE PRONATION. (Nearly all excessive pronation is BILATERAL but ASYMMETRICAL). 2. Most foot subluxations do NOT create foot symptomatology.

5 3. Whatever one arch in the foot does .so do the other two. Arch Stability The highest relative contribution to arch stability was provided by the plantar fascia, followed by the plantar ligaments and spring ligament. Plantar fascia was a major factor in maintenance of the medial longitudinal arch.. Huang et al. 1993. Muscles in the Foot The first line of defense of the arches is ligamentous . muscles did not come into play until a force greater than 400 pounds was exerted.. Basmajian JV et al. 1963. PLASTIC DEFORMATION. Low intensity forces for prolonged periods of time create PERMANENT. plastic changes Weight bearing vs. Non- Weight bearing If subtalar joint motion .. is measured in a non- weight-bearing rather than full weight-bearing (casting), then 37% of the available ROM may be overlooked.. Lattanza L. et al. 1993. Rigid Orthotics 1. Do not permit adequate biomechanical motion 2. Create hypomobile and hypermobile joints Weight-bearing diagnostics can help determine Extent of plastic deformation Specific corrections needed Better fit and function Accommodating vs.

6 Functional Stabilization Accommodating: Functional: Molded to the Molded to the foot deformity (non- (weight bearing). weight bearing) Designed at the To provide lowest end of normal comfort??? Blocks excessive motion Allows normal motion Balanced-Symmetrical Medial Crescent Arch Line Shape Transverse Arch 50-50 Weight Distribution Lateral Arch Minimal Pressure Calcaneus Centered Optimal, Mild, Moderate or Severe? Optimal V7+ Key Features Pronation/Stability index- Calculated measurement that reveals individually the severity of pronation for each patient. Pronation/Stability Index Pronated or Supinated? Supinated Line from great toe falls medial to the midline of the calcaneus Indicates rigid . angular foot Deep curvature of medial arch present Pronated Line from great toe falls lateral to the midline of calcaneus Medial arch (MLL). migrates medially Typically more flexible Body Assesment Demonstrates patterns of spinal misalignment Pelvic Assesment Posterior view of pelvic unleveling Indicators of Excessive Pronation Foot flare/toe out Dropped navicular/ falling arches Posterior lateral heel wear Achilles tendon bowing (inward).

7 Patellar approximation/ internal tibial rotation Superior lateral tracking of the patella Decreased muscle tone of hip abductors Plantar surface callus formations at the 2, 3, 4 met heads Excessive Pronation Subluxation Pattern BONES SUBLUXATION DIRECTION. Navicular Inferior & Medial Cuboid *Superior & Lateral (or Inferior & Lateral). Cuneiforms Inferior Metatarsal Heads 2-3-4 Inferior Metatarsal Heads 1 & 5 Superior and Lateral/Medial Talus Mostly Anterior & Slightly Lateral Calcaneus Everted & Plantar Flexed Fibular Head Posterior & Lateral Excessive Pronation Subluxation Pattern Navicular (inferior and medial subluxation). Cuboid (superior and lateral subluxation). Cuneiforms (inferior subluxation). Met Heads 2-3-4. (inferior subluxation). Talus (anterior and lateral subluxation). Calcaneus (plantar flexed everted). Fibular Head (posterior lateral). Gait System Analysis 3 Primary Components Kinematics = Analysis of movement without calculation of forces Kinetics = Analysis of Forces and Movements acting on the body segments Neuromuscular Activation and Proprioceptive Coordination Gait Cycle Typical gait/running systems #1 Heel Strikers (80%).

8 #2 Mid-Foot Runners (<10%). #3 Toe Runners (<5%). Optimal stride is steps per second = 180. steps per minute or 90 strides (for a running gait). Gait Cycle Stride length The average distance between heel strikes (The longer the stride the greater the impact). Stride Rate The number of heel strikes per second (The lower the rate the greater the impact forces). Gait Cycle Vertical Oscillation The height the body elevates during walking/running (high VO. = greater impact force). Swing leg flexion/extensions between heel strikes Foot flare the angle of internal/external tibial rotation at heel strike Gait Cycle Knee flexion (self explanatory) as the leg gets straighter the greater the force at impact on the knee Biomechanical Response of Connective Tissue from the GROUND up Cumulative Injury Cycle: Chronic Inflammation Muscle Spasms &. Adhesions Trigger Points Muscle Imbalances Inflammation & Joint Dysfunction Altered Kinetic Chain Neuromuscular Defects Control Cumulative Sheer & Repetitive Stress WHAT IS NORMAL?

9 ?? Haas et al describes a series of Biological processes plausibility's . that appear to demonstrate the situations that would allow cervical kyphosis and other anomalies as normal variants that: have no effect on physiology or long term postural defects. WHAT IS NORMAL??? Harrison and Toyanovich state that: although spinal anomalies occur in the human body there are processes by which the body remodels and abnormal spinal loads over time DO cause pathologies.. According to Yochum And Rowe's Essentials of Skeletal radiology' 2nd edition: Cervical Lordosis = approx. 40 - 45 . Thoracic Kyphosis (depending on age and gender) = approx. 20 - 50 . Lumbar Lordosis = approx. 50 - 60 . Ranges of motion Cervical Spine: Flexion = 30 - 45 . Extension = 40 - 55 . Rotation = 70 - 80 . Lateral Flexion = 40 - 45 . Ranges of motion Thoracolumbar Spine: Flexion = 90 . Extension = 30 - 35 . Rotation = 30 - 35 . Lateral Flexion = 30 - 40 . How is it Normal??? Neurologically there are several factors to consider: Spinal mechanoreception/Proprioception Left brain/right brain controls Cerebellar controls The vestibular system The righting reflex just to name a few The Concept of NOCICEPTIVE or PROPRIOCEPTIVE.

10 NOISETM. MECHANORECEPTORS. Provide continuous feedback about where the body is in space Position sensitive Motion sensitive Vibration sensitive Pressure sensitive Thermo sensitive Chemo sensitive Inhibit perception of pain Types 1, 2, and 3. mechanoreceptors _____. Type 4 mechanoreceptors (aka Nociceptors). _____. NOCICEPTORS. a continuous tridimensional plexus of un-myelinated nerve fibers and weaves (like chicken-wire ) in all directions .. -Neurological Aspects of Pain Therapy. 1980. NOCICEPTOR LOCATION. Skin Periosteum Subcutaneous Muscles tissue Tendons Adipose Fascia Joint capsules Aponeurosis All spinal segments Dura mater Blood vessels Epidural tissue Cancellous bone -Grieve G. Common Vertebral Joint Problems What are the nociceptors in your wrist/foot doing right now that they weren't doing when your wrist was in a more neutral position? _____. What is the final destination of the nociceptive impulses, created in your wrist/foot, if they are not inhibited ?