Pod 133: Two Gait Cases & their Gait Rehab

Today we discuss a few cases we have seen.  We discuss 2 cases, both involved poorly adapted gaits from injury, adaptations that had become the client's new norm. Once you get past Ivo's case presentation, which is very in depth, the discussions quickly go into very important topics that we all over look, namely gait and gait rehab, gait thresholds, metabolic thresholds, cortical fatigue, and how to use some neurologic principles to restore a problematic gait.

Key Tag words:
gait, concussion, head trauma, cortical fatigue, endurance, strength, gait analysis, gait problems, gait rehab, running, running injuries, run-walk, SCFE, slipped epiphysis, femoral growth plate, hip stress fractures, growth plate injury, hip dysplasia, limping gait, club foot, step length, stride length

Links to find the podcast:

iTunes page: https://itunes.apple.com/us/podcast/the-gait-guys-podcast/id559864138?mt=2

http://traffic.libsyn.com/thegaitguys/pod_133final.mp3

http://thegaitguys.libsyn.com/pod-133-two-gait-cases-their-gait-rehab

Libsyn Directory: http://directory.libsyn.com/episode/index/id/6184651

Our Websites:
www.thegaitguys.com

summitchiroandrehab.com doctorallen.co shawnallen.net

Our website is all you need to remember. Everything you want, need and wish for is right there on the site.
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Our podcast is on iTunes and just about every other podcast harbor site, just google "the gait guys podcast", you will find us.

Headbonking and gait

A great article (see reference below) just came out looking at the gait changes that come along with a concussion. Basically it says that folks that have concussions have more coronal plane (i.e. side to side) sway and they walk slower. This reminded us of some of the "decomposition of gait" pieces that we have done and one post on proprioceptive clues in children gait that we did about 5 years ago. Having a concussion causes decomposition of gait, and we move toward a more primitive pattern, just like we see in kids. Here was the post:

We can learn a lot about gait from watching our children walk. An immature nervous system is very similar to one which is compensating meaning cheating around a more proper and desirable movement pattern; we often resort to a more primitive state when challenges beyond our ability are presented. This is very common when we lose some aspect of proprioception, particularly from some peripheral joint or muscle, which in turn, leads to a loss of cerebellar input (and thus cerebellar function). Remember, the cerebellum is a temporal pattern generating center so a loss of cerebellar sensory input leads to poor pattern generation output. Watch this clip several times and then try and note each of the following:

• wide based gait; this is because proprioception is still developing (joint and muscle mechanoreceptors and of course, the spino cerebellar pathways and motor cortex)
• increased progression angle of the feet: this again is to try and retain stability. External rotation allows them to access a greater portion of the glute max and the frontal plane (engaging an additional plane is always more stable).
• shortened step length; this keeps the center of gravity close to the body and makes corrections for errors that much easier (remember our myelopathy case from last week ? LINK.  This immature DEVELOPING system is very much like a mature system that is REGRESSING.  This is a paramount learning point !)
• decreased speed of movement; this allows more time to process proprioceptive clues, creating accuracy of motion

Remember that Crosby, Still, Nash and young song “Teach Your Children”? It is more like, “teach your parents”…

Proprioceptive clues are an important aspect of gait analysis, in both the young and old, especially since we tend to revert back to an earlier phase of development when we have an injury or dysfunction.

Manaseer TS, Gross DP, Dennett L, Schneider K, Whittaker JL1. Gait Deviations Associated With Concussion: A Systematic Review.  Clin J Sport Med. 2017 Nov 21. doi: 10.1097/JSM.0000000000000537. [Epub ahead of print]

Will Smith's new movie "Concussion" terrifies the NFL. Here's the trailer.→

Gait and Concussions.

The big movie trailer just came out yesterday, click on the link above to watch the trailer for “Concussion” with Will Smith, slated for theater release in December 2015.  Hopefully this will raise even more awareness to TBI (traumatic brain injury), and remember, minimal TBI falls into these categories and discussions.  

Here is just a small sampling of some of the complications of concussions on human gait.  Head injuries are no joke, their effects on dynamic motor control and sensory-motor integration are potentially serious issues.  From the first 4 references that came up on the pubmed search this is what was mentioned:

- “the ability to control and maintain stability in the frontal plane during walking is diminished under divided attention” (1)

- “Adolescents with concussion displayed increased center-of-mass medial/lateral displacement and velocity during dual-task walking after RTA (return to activity), suggesting a regression of recovery in gait balance control. This study reinforces the need for a multifaceted approach to concussion management and continued monitoring beyond the point of clinical recovery.” (2)

- “concussion may have long-term observable and measurable effects on the control of gait stability”(3)

- “persons with a history of concussion adopt a more conservative gait strategy”.(4)

Do you see something strange on  your client’s gait analysis ?  Have you asked them about previous concussions and head injuries? Perhaps you should.  Take mTBI seriously, this is not a trivial matter. 

Dr. Shawn Allen, one of the gait guys

References:

1. Clin Biomech (Bristol, Avon). 2005 May;20(4):389-95. Epub 2005 Jan 28.The effect of divided attention on gait stability following concussion.Parker TM¹, Osternig LR, Lee HJ, Donkelaar Pv, Chou LS.

2. Med Sci Sports Exerc. 2015 Apr;47(4):673-80. doi: 10.1249/MSS.0000000000000462.Return to activity after concussion affects dual-task gait balance control recovery.Howell DR¹, Osternig LR, Chou LS.

3.Med Sci Sports Exerc. 2006 Jun;38(6):1032-40.Gait stability following concussion.Parker TM¹, Osternig LR, VAN Donkelaar P, Chou LS.

4. Arch Phys Med Rehabil. 2011 Apr;92(4):585-9. doi: 10.1016/j.apmr.2010.11.029.The chronic effects of concussion on gait.Martini DN¹, Sabin MJ, DePesa SA, Leal EW, Negrete TN, Sosnoff JJ, Broglio SP.

People tend to forget about the peroneal muscles. This is what it looks like when the brain forgets.

This client came to see us for obvious reasons but the case details are not what we are focusing on today. Gait gets pretty messed up when a critical component or phase is lost or forgotten.  

In last weeks teleseminar on www.onlineCE.com we discussed several gait cases. In these cases 5 things kept coming up when it came to looking at (specifically) neurologic gait compensations:

1. slowing of gait
2. wider based gait
3. increased ancillary movements 
4. utilizing support when needed or available
5. shorted step length and stride length

In this video, it is clear that this person has some serious neurologic problems engaging the peroneal muscles and controlling ankle and foot function and as a consequence you see evidence of some of the itemized issues above, namely, calculated movements, nearly zero arm swing and step length from left to right is abbreviated. 

It can go both ways. The neurologic problem can affect one’s gait, but one’s resultant gait can then affect cortical function, driving an endless loop. Recently, five studies presented at the Alzheimer’s Association International Conference in Vancouver Canada provided striking evidence that when a person’s walk gets slower or becomes more variable or less controlled, his cognitive function is also suffering.(2)  

A person’s gait and their neurologic function cannot be separated. The stuff just run’s too deep.  This is why we love gait so much, because to fully understanding someone’s clinical problems we must understand how and why they move.  There are clues in everyone’s gait that can help you clinically. The question is, will you notice them ? Do you know what normal gait is to begin with ? Will you understand what you are seeing and realize it is a compensation? Will you fix what you see or look deeper to find the cause of what you see ? 

Shawn and Ivo,

The Gait Guys

Gait Posture. 2013 Jul;38(3):549-51. doi: 10.1016/j.gaitpost.2013.02.008. Epub 2013 Mar 11.

Altered gait termination strategies following a concussion.

Buckley TA1, Munkasy BA, Tapia-Lovler TG, Wikstrom EA.

2.  http://www.nytimes.com/2012/07/17/health/research/signs-of-cognitive-decline-and-alzheimers-are-seen-in-gait.html?_r=1&

The effect of footwear and sports-surface on dynamic neurological screening (click for link)→

Shoes make the man, or in this case, the athlete. This study shows that shoes (much like skis) allow us to perform faster than our brain is able to compensate ( in other words, we lack the skill) and allow us to sometimes stretch our  abilities, often at the cost of an injury. We must remember that technology must keep pace with the rate of neural learning, not the opposite.

J Sci Med Sport. 2010 Jul;13(4):382-6. Epub 2010 Mar 15.