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
Stephen Gangemi, DC, DIBAK
ICAK ANNUAL MEETING - JUNE 2014
Individualized Treatment Via Applied Kinesiology
• 100% Holistic, Individualilzed Approach:
• Assessment, Treatment, and Lifestyle Changes
• Rehabilitation
• Prevention
• Enhancement
• Advise and Educate
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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
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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
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Why Check Gait?
•
•
•
•
To restore function
To restore health
Gait dysfunction  Health dysfunction
So patients don’t “walk themselves back into a
problem”
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What Disrupts Gait?
• Those which influence the Triad of Health:
– Structural
– Nutritional
– Emotional
• Improper footwear
• Orthotics – a brace that supports dysfunction
and alters mechanoreceptors
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Modern Footwear
Soft Midsole
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Elevated Heel
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Line of falling weight moves
forward with heels
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Motion Control
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Footwear Industry Claims
•
•
•
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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
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The Recent Lawsuit - Vibrams: “Your foot can
become stronger by wearing FiveFingers”
• 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.
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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
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Barefoot, Shod, or Minimalist?
• Due to industry demand, minimalist footwear
is becoming more maximalist after just a few
short years.
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• 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.
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Improve Your Health Barefoot
Proprioception (sense of position)
Kinesthetic sense (the feedback your nervous system
receives from your feet)
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Barefoot and Minimalism
• Shock absorption: Foot strike  More mid/forefoot
• Solid support: Loading Rate  Center of mass
• Energy & Power: Elastic Recoil  Natural Spring
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• 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
Ideally the body’s
center of mass
should be over
the foot for the
lowest loading
rate
Midfoot/forefoot strike
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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
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Orthotics & Arch Supports
•
•
•
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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
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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
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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
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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.
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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
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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
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Orthotics Contribute to
Neurological Degeneration by
Altering Mechanoreceptors
• The nervous system thrives from movement and
sensory input
• Improve stability with instability
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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
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Is There An Ideal Shoe?
• 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)
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Low Stack & Drop
• Stack Height
11mm heel
• Drop
7mm forefoot
11-7=4mm drop
• “Zero-Drop”
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Shock
• No Stability or Motion Control – natural
pronation deflects shock
• Posterior Tibialis plays an important role
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Toe Box
• No cramped toe box – so the toes can splay
apart to soften landing
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Cushioning?
• Cushioning does not absorb shock – it tricks
the body by sending false information to the
brain – “Is this a soft surface or hard?”
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The Harder the Surface the Softer the
Landing
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• 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
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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
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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 minimalisttype shoes as the weakened and shortened muscles, tendons,
& ligaments regain their strength
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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)
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General Gait Test – Latissimus Should
be Inhibited
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General Gait Test – Biceps Should be
Inhibited
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New Addition to Gait Test – Wrist
Extensors Should be Inhibited and
Strengthened with AF
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New Addition to Gait Test – Wrist
Flexors Should be Inhibited and
Strengthened with AF
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Final New Addition to Gait Test Breathing & the Diaphragm
• Check the diaphragm with a full inspiration
and expiration, checking for gait disturbance
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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
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Workshop!
(remove your shoes)
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The Soleus & Gait
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Soleus: A New Way to Test
Original test by Simon King, DC
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Soleus: A New Way to Test
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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
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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
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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
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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
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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 overfacilitation of the pancreas related muscles
• Slight rubbing over the pituitary Chapman’s
reflex (glabella), will elicit the same response
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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 pain
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Evaluation & Correction - of the Dysglycemia
AND many TMJ Dysfunctions
For this…
And this…
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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
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Procedure
ACTH or TL to the pituitary CR weakens both [long head] biceps
(over fires the lats and triceps)
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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
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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
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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?
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Correction Continued…
COMMON OFFENDERS
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•
•
•
•
•
•
•
•
•
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
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Correction Continued…
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
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Correction Continued…
• 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
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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…
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• No need to be constantly performing the
painful origin-insertion technique on the
ptygeroid muscles over and over again!
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Pinto’s Ligament
Discomalleolar 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
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Questions, Information & Research
• Email: drgangemi@gmail.com
• Websites: drgangemi.com
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Thank you for your attention
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