resourcesABOUT MT AUTHOR GUIDELINES CLASSIFIEDS EDITORIAL CALENDAR MEDIA GUIDE MASSAGE MART SCHOOLS & EDUCATION FEEDBACK
Time for World-Wide Growth
Acupuncture is the organically growing around the world. The legislative body in Quatar has said acupuncture is "okay." The United States has five states to go to have every state recognized and regulated.
Treatment of Type 1 Diabetes Mellitus: The Latest Breakthroughs
There are now more than 29 million diabetics in the U.S. and 10% of them have Type 1. The incidence has been increasing in recent years at an epidemic rate.
Shoulder Rehab: The Gait Connection
Shoulder problems can be difficult to rehab completely for several reasons. The shoulder is made up of several joints that must function together smoothly to provide the extreme mobility that is possible and necessary for many activities.
Diet, Nutrition and the Context of Risk (Part 2): Food Poisoning
Other than the morbidity and mortality linked to eating too much food, "all-natural" organisms that contaminate our food cause more illness, more hospitalizations and more death than food contaminated by heavy metals, plastics, preservatives, artificial colors, emulsifiers, artificial sweeteners and pesticides combined.
Case Studies and Answer Analysis for NCCAOM Exam in Foundation of Oriental Medicine
Case studies are very common for acupuncture school students, either in class exams or during taking the national board exam. Most test takers feel they have no idea where they should start and how they should start to analyze those complicated cases.
Acupuncture at a Pain Clinic
Introduction: Pain is the most comprehensive human experience. The experience of pain is associated with the somatic, emotional and social impact. Pain has not only somatic symptoms, but also psycho-social dimension, especially in case of chronic pain.
Does Anyone Know You're a Good Chiropractor?
If you had a chance to read the recent article in Time magazine (April 6), you know it provided some good information about the efficacy of chiropractic to the magazine's substantial consumer audience.
We Get Letters & Email
Another Slap in the Face for DCs; I Know Where to Find the Missing Chiropractic Patients; Clarification on Vitamin D Study.
How to Bill Evaluation and Management Codes
Q: I am in need for guidance on how to bill evaluation and management (E&M) codes in addition to acupuncture the same date of service, I have never been paid for an exam when done with acupuncture and I believe I am doing it wrong.
Herbal Medicine Continues to Evolve
Product manufacturers, industry partners, distributors and practitioners work as a collective Traditional Chinese Herbal Medicine (TCHM) community to produce high quality TCHM prescriptions that bring low-risk healthcare to thousands of patients everyday.
What Should You Call Your Patients (and What Should They Call You)?
When I walked into the exam room, the new patient looked uneasy, fumbling with his cellphone. He was a huge Polynesian man, probably in his 40s, with unrecognizable island tattoos.
Are Herbs Useful for Chronic Pain?
The human nervous system is what makes us special, but our greatest strength also makes us vulnerable: witness the growing incidence of chronic addictions, anxiety, depression, sleep disorders and chronic pain syndromes.
Introducing the Dynamic Chiropractic Digital Edition
In response to the changing habits of our readers, Dynamic Chiropractic is proud to introduce a digital edition of the publication beginning with the July 2016 issue.
Who is Your Ideal Patient?
Being in a healthcare practice requires you to think critically about many things including your equipment, techniques, documentation, financial goals, and the retention of clients and staff.
The Eight Extraordinary Confluent Points
The eight extraordinary confluent points are a very popular set of acupuncture points in the modern practice of acupuncture. They are also called the intersection, meeting, command, opening, master, and the flowing and pooling points of the eight extraordinary vessels.
Day in the Life of an Advanced- Practice DC (Pt. 2)
Let's continue our Q&A with Stephen Perlstein, DC, APC, chair of the New Mexico Chiropractic Association PAC and president of the American Academy of Chiropractic Physicians. Part 1 of this interview appeared in the May 1 issue.
Immunotherapy: Where Molecular Medicine Crosses Into Holistic Thinking
Immunotherapy, and its promise as a cancer treatment, has been in the news a lot in the last few years, and for good reason. Real shifts are happening in oncology and exciting researchers, clinicians, and patients.
The Effectiveness of Chinese Medicine in Treating Infertility in the Philippines
Infertility is defined as the inability to achieve a successful pregnancy after 12 months or more of regular unprotected intercourse.
Chiropractic Needs a Lesson in Education
The American Chiropractic Association has launched a campaign, The National Medicare Equality Petition, to enact federal legislation that would achieve full physician status for DCs in Medicare.
The Good, the Bad and the Successful in Social Marketing
You might be thinking, "social marketing, don't you mean social media?" No, I mean social marketing. Every day, I keep reading, hearing and learning more and more about the changes happening in social media.
2016 Trudy McAlister Foundation AOM Scholars
This year, the Trudy McAlister Foundation (TMF) received a record number of excellent applications for the 2016 scholarship awards and has awarded five scholarships for $2000 each. More information is available on our website: AOMScholarship.org
The Liver: The Official of Planning
The Liver, with its paired Official, the Gall Bladder, belongs to the Element Wood within us. Wood grants us the power of birth – new beginnings, growth, breaking through boundaries and surging forward. It is the vigorous, exuberant energy of the spring season.
F4CP Campaign Addresses Public Misperceptions of Chiropractic
In late 2015, results of the Gallup-Palmer College of Chiropractic Inaugural Report: Americans' Perceptions of Chiropractic were published. The report found that 33.6 million U.S. adults (14 percent) had utilized chiropractic care within the previous 12 months.
Five-Element Reaches Out to Serve the Community
In 2006, a student at the Institute of Taoist Education and Acupuncture (ITEA) approached the administration about an idea for his senior project.
August, 2008, Vol. 08, Issue 08
Don't Get Married, Part 2
By Erik Dalton, PhD
Humans are designed to move in order to survive - locomotion must precede all other activities. The past few decades have witnessed the emergence of two diverse schools of thought, each with their own biomechanical explanations detailing the seemingly simple act of walking.
Both disciplines generally agree that cross-patterned gait (opposite arm and leg moving at the same time) is a normal function of walking and running. However, advocates of the traditional "pedestrian model of gait" insist the legs are the main-event in locomotion and upright walking is a basic design where the legs propel the passive passenger - the trunk - through space. Pedestrian model groupies tend to lump the torso, arms and head together and generally dismiss the upper body as a critical player in gait mechanics.
As discussed in part 1 (Feb. 2008 issue), Canadian nuclear physicist Serge Gracovetsky, PhD, rebuked the pedestrian model by declaring that counter-rotation of the shoulders and pelvis is an essential key to locomotion and force is not generated by the legs, but instead arises through a complex muscle/skeletal interaction propelled by what he calls a "spinal engine."1 He further explains, "Evolutionarily, locomotion was first achieved by the motion of the spine. ... The legs came afterward as an improvement, not as a substitute."
If Gracovetsky's theory that the spine is the primary engine driving the pelvis has "legs to stand on" (no pun intended), then manual therapy assessments and rehabilitative corrections must be modified accordingly. Since low back pain is the most common disability among people under the age of 45, the consequence of this reinterpretation of spinal function could be far-reaching. Today, researchers and clinicians worldwide are experimenting with Gracovetsky's intriguing hypothesis.
Tempted to Marry
Since both schools of thought are supported by sound research in the gait-analysis community, I'm trying hard not to marry a single model of locomotion. To prevent the suffering that accompanies divorce, I've developed assessments and corrections based on gait studies conducted by two renowned experts in the field, Serge Gracovetsky and my mentor, Philip Greenman.2 This osteopathic and physics collaboration paints a broader, more comprehensive picture of the walking cycle. Unfortunately, in the process of marrying the two methods, some of Gracovetsky's brilliant spinal-engine concepts have been altered. To avoid misrepresenting the views of either researcher, the proposed model in part 2 will simply be referenced as the "myoskeletal engine."
The Myth of Leg Locomotion
Dr. Gracovetsky convincingly asserts, "If the legs were truly the mobilizing force propelling the body through space, a competitive sprinter with huge powerful legs and a small torso should be the fastest." (Figure 1) Obviously, this image does not fit the picture we'll see at the Beijing Olympic Games or even in the photo of a 21-year-old South African double-amputee runner Oscar Pistorius, who finished second against the world's top athletes in a 400-meter race at the Golden League Meet last year in Rome. (Figure 2)
Initial observation of Pistorius' stride reveals a rhythmic cross-patterned gait and strong pelvic/shoulder counter-rotation that appears as the driving force propelling his lower extremities. Figures 3A and 3B illustrate global and core muscle "slings" that store and release kinetic and elastic energy that help him run at such high speeds. In the absence of lower legs and feet, one might conclude these anterior and posterior spring systems alone provide enough thrust to propel Pistorius' pelvis and extremities. But apparently, the International Association of Athletics Federations (IAAF) disagreed. They voted to ban him from formal competition based on the conclusion this artificial "springing" mechanism somehow amplified his interaction with gravitational ground forces.
Appeals to the Court of Arbitration for Sport (CAS) and subsequent studies confirmed the carbon-fiber blades did not give him an unfair advantage. So, does Pistorius run fast because of the recoil delivered by curved blades, or are humans endowed with a similar recovery pulse capable of transmitting gravitational forces up the kinetic chain to enhance power in the other spring systems?
Flat Tire - Flat Foot
Since the human body relishes energy conservation, it's reasonable to assume kinetic (movement) energy shouldn't be lost into the ground as described in the pedestrian gait model. Gracovetsky uses the analogy of running in sand versus on a firm surface to make a point that efficient movement demands a recovery pulse that springs from the arch, up the leg and through the pelvis and torso to help drive the spinal engine. Furthermore, it makes sense that any "kink" along this myofascial or skeletal (myoskeletal) chain would be reflected as a kink elsewhere in the system that would only serve to slow down the engine.
For example, if a car has a low tire and the tread begins wearing unevenly, the vehicle will begin to shake sooner or later. As the vibration makes its way through the suspension system, the tie rods start working loose. If left untreated, damage spreads to the motor mounts. Eventually, the "shaky" engine sputters to a halt. Although the low tire was the root of the problem, it's tempting to blame the engine because the car no longer runs.
In this regard, it's easy to see how a deflated tire might perpetuate a chain of events manifesting as compensations elsewhere. To remove kink(s) from the system, an experienced mechanic won't immediately pull the hood and begin checking for loose spark plugs and battery cables. Tracking down the dysfunction typically starts by consulting with the owner, conducting a thorough history of onset, symptoms, etc., and then performing a detailed inspection that leads to the "key lesion" - the low tire. From information garnered during the evaluation process, the mechanic is able to systematically work their way though the suspension system, motor mounts and fuel-injection system to restore optimal motor functioning.
The same applies to the client with a flat foot and short leg. A good body mechanic doesn't treat a hyperpronated foot in isolation but looks for compensations along the kinetic chain that might have developed as a result of the shortened extremity. Kinks traveling from the head down (TMJ, O-A, scoliosis, cranial distortion, etc.) are labeled descending syndromes, while asymmetry caused by pronated feet, short legs, knock-knees, etc. are referred to as ascending syndromes. (Figure 4) Any soft-tissue or bony compensation that distorts the vertebral column's S-shaped curve will overwork the anterior and posterior spring systems, resulting in stress and pain.
Stirrup Spring System
The automobile analogy provides a nice segue for introducing a third biomechanical "sling" critical in driving the myoskeletal engine. Known as the stirrup spring system (SSS), this antigravity propulsion pump delivers energy from the tibialis anterior/peroneus longus stirrup through the biceps femoris and sacrum to provide rotary torque that "winds up" intervertebral joints and deep collagen structures. Figure 5 depicts a few key SSS muscles activated during running. Although, I agree with Gracovetsky that efficient movement requires humans to possess some kind of recovery pulse to avoid loss of kinetic energy into the ground during gait, the biomechanics of how that pulse is delivered is debatable.
Gait analysis is best understood when viewed just prior to heel strike, as illustrated in Figure 5. For the SSS to achieve optimum elastic recoil, two neurologically driven maneuvers must orchestrate in perfect harmony. With hip extensors (biceps femoris and G-max) maximally stretched:
Walking and running trigger various degrees of force through the stirrup, knee, lateral thigh, biceps femoris and sacrotuberous ligament. The amount of force at heel strike determines how much lumbopelvic counter-rotation takes place and what muscles/ligaments are recruited. Once the pulse reaches the pelvis, the mechanics become more complex.
At this point, Gracovetsky and I part ways. He believes the recovery pulse at right heel strike possesses sufficient strength to travel unimpeded up the leg, through the sacrotuberous and long dorsal sacroiliac ligaments, and into the ipsilateral multifidi, longissimus and iliocostalis. Erector spinae contraction then causes right lumbar sidebending and reciprocal pelvic counter-rotation. Although this intriguing firing order does play a major role in running, it differs a bit from my interpretation of Greenman's heel strike mechanics during walking.
Myoskeletal Engine Possibility
Notice in Greenman's illustration (Box 1, Figures 1 and 2) at right heel strike, the sacrum, pelvis and lumbar spine are all left rotated. This implies that during the walking cycle, heel strike probably doesn't transmit adequate force to sidebend the lumbars and counter-rotate the pelvis, as Gracovetsky infers. A myoskeletal-engine firing order that seems to best fit Greenman's illustration has the stirrup pulse traveling through the biceps femoris and sacrotuberous ligament, tugging on the lateral sacral angle, and (with help from the quadratus femoris and G-max), left-rotating the entire pelvic bowl in a transverse plane.
Gracovetsky's spinal engine theory is based on the assumption humans possess no muscles capable of directly rotating the pelvis. But if one follows the chain of events beginning at heel strike to the stance phase, it appears the sacrum and pelvis perform complex maneuvers enhanced by many smaller but extremely important muscles that do possess the capability to directly and indirectly rotate the pelvis. At first glance, it seems an insignificant point, so long as the final result is a smooth cross-patterned gait. However, it implies the possibility of a different SSS firing-order pattern traveling through the lumbopelvis and thus the need for alternative assessment and treatment sequences.
Stance Phase Is True Coupled Motion
The myoskeletal SSS theory relies on Harrison Fryette's 1st Law of Spinal Motion3 which (paraphrasing) states that in the presence of normal lumbar lordosis, vertebral and sacral rotation and sidebending occurs to opposite sides. (Figure 6) Gracovetsky believes this coupled motion takes place at heel strike and I see it happening during the stance phase. In my model, the following actions occur during the one-legged stance phase (right limb):
Last, but not least, the lateral spring system (LSS) depicted in Figure 8 might be one of the most unappreciated of all the body's antigravity structures.
Driven by the hip's abductors, this elegant myofascial gait-enhancer "cocks' the ipsilateral innominate and, just prior to push-off, right-sidebends the rotating pelvis so the other three spring systems can smoothly swing the left leg through. (Box 1, Figure 5) All is well if gluteus medius and minimus are properly toned and firing in correct sequence. Regrettably, this spring system commonly is skewed as other abductor muscles overpower the weak glutes.
Figure 9 illustrates the need for greater contralateral OL recruitment in athletes such as hurdlers and running backs. However, during normal gait, both quadratus muscles should be relatively silent. Thus, the ideal abduction firing-order pattern from stance through toe-off should be: gluteus medius/minimus; co-contraction of the ipsilateral adductors; tensor fascia latae; piriformis (synergistic stabilizer) and quadratus lumborum.
A greatly underestimated source of discogenic and facet joint pain arises when the ipsilateral QL fires first, "hip-hikes" the innominate, and forces the ipsilateral leg to try to swing through.
These people walk like a block with a labored gait. Seen in many golfers and other athletes who participate in one-sided sports, this common QL substitution pattern is quite easy to assess and correct. Figures 10A and 10B demonstrate two QL releases that help drag down a hip-hiked (posteriorly rotated) ilium. Unfortunately, fixing the QL problem won't completely restore proper firing order if the glute medius/minimus are weak. Fast-paced spindle-stim techniques and "clam" home re-training exercises using resistance tubing are a simple solution. Although most clients like deep gluteal massage and stretching, these traditional bodywork maneuvers alter the hip-abductor firing order and destabilize the pelvis. Weak glutes = future hip replacements.
Sports and the Spring Systems
Many athletes (and therapists) believe if a little stretch is good, more is better. Bombarding the physiologic barriers through over-stretching and excessive deep-tissue work not only jeopardizes ligamentous stability, but also causes loss of recoil and balance in the body's intricate spring systems. No one questions that chronically shortened (fibrosed) tendons, fascia, ligaments and joint capsules require restoration of flexibility, but what about weak, overstretched and neurologically inhibited tissues? Certain structures such as the thoracolumbar and lower abdominal fascia must retain a certain amount of stiffness to store and release elastic energy while providing core stability. Myofibroblast receptors embedded in deep fascial tissues might prove to be the missing link responsible for enhancing power in the four spring systems.4 See Box 2 for spring-system balancing tips.
Fast-paced myoskeletal spindle-stimulating techniques combined with Vladimir Janda's upper- and lower-crossed syndrome balancing routines are a complementary and essential starting point in the myoskeletal engine method. Tonifying typically weak muscles via "spindle-stim" maneuvers and home re-training exercises helps establish proper firing-order patterns while restoring cross-patterned gait. Loss of reciprocal (coupled) motion between the lumbar spine and sacrum probably is the leading cause of chronic low back pain. A testament to this assertion is the fact the L5-S1 intervertebral disc receives more surgical procedures than any other spinal segment. Bottom line: Discs hate sustained compression but love storing and releasing rotary torque.
The theoretical approaches presented in this two-part series represent an ongoing personal journey into the captivating world of gait. Attempting to blend Gracovetsky and Greenman's gait-analysis theories has opened a Pandora's Box of additional inquiries questioning how ascending and descending syndromes (flat feet, TMJ, knee injuries, etc.) destabilize pelvic and lumbar spine balance. What seems clear is the necessity for restoring perfect coordination and antigravity function to all four spring systems. Energy conservation during walking or running demands all systems fire in a precise order at just the right moment to accomplish this task. I've become married to the idea that all the body's global and core structures must work harmoniously to produce rhythmic and effortless movement during normal activities and athletic endeavors. Try experimenting with spring system balancing routines and elevate your hurting clients and competing athletics to a new level of health.
Click here for previous articles by Erik Dalton, PhD.
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