this thing off.
Kelly, welcome to the podcast.
Thanks so much for having me.
You're in the Mile High State.
You're a physical therapist at UC Health.
Do I have that right?
Yeah, that's correct.
Look at that.
I can Google.
Congratulations.
You're presenting at the AMT Conference,
which is far from Colorado.
It's at sea level.
Are you going to be okay?
Are you going to adjust to
that coming from Colorado?
I'm going to feel great.
You're going to feel good.
That's what you learned.
Minus the humidity.
Right, right.
But it's October.
That's October, November, December.
That's when you want to be in Florida.
That's the way to do it, Kelly.
You're smart.
You train, live in Colorado,
come to sea level,
and you can blow us away.
So you're presenting at the
AOMT conference,
and we want to give a little teaser.
So let's just start from the start.
What do you get to share?
What do you get to teach
people this year at AOMT?
And we'll learn a little bit.
This is the tease before the tease.
Yeah, good question.
So I will be presenting with
two of my colleagues.
on an out-of-the-box
approach to regional
interdependence specific to
the lower extremity.
So the title of our presentation,
it's going to be two parts.
The first part is going to
be talking about a top-down approach,
and the second part will be
talking about a bottom-up approach,
and in both,
we'll be giving case scenarios,
showing videos of gaits
from different patient presentations,
and then, you know, giving some
attendees some different
ideas of techniques they
can use to treat those deviations.
You've got to mention your
co-presenters or they would be,
they would feel left out.
They're not here right now,
but who are they?
Yeah, they would.
So it's Dr. Laura Baum and
also Dr. Mary Beth Geiser.
Now you're good.
You've got them in there.
You've snuck them in.
We got them in.
So let's give a little tease.
The presentation with your
co-presenters is going to
be a little more robust and
that's how we get you, right?
We're going to teach you
right now while you listen
on the podcast or watch
them on the video.
But you're going to learn
more when you come in person.
And I've been to the AM conference,
pretty robust.
So go to the website link in
the show notes in the bio
to to find out more.
But let's start with this.
Help us understand the
importance of gait analysis
and physical therapy.
You know,
how does it impact patient outcome?
Like what's the outcome?
Patient outcomes,
particularly in your area,
orthopedics and lower
extremity amputee care.
Yeah,
so gait analysis is an extremely
important tool in our
toolbox as physical therapists.
And this is certainly true in orthopedic,
but other areas of PT practice as well.
You know,
we use it as an assessment in
terms of how does someone
use their range of motion, their strength,
their flexibility, right,
all those good things,
and execute a very
necessary functional task.
And I think sometimes we
forget about movement
observation as an
assessment tool that
actually provides more
meaningful information for
me than a single special
test when it comes to assessment.
As for the patient outcomes
part of your question, you know,
I can't tell you how many
times a week patients tell
me their goal for therapy
is to walk again.
Whether it's they want to walk pain-free,
they want to walk further,
they want to walk faster, right,
or walk periods.
And what better way to help
them meet that goal than to
provide specialized
intervention based on the way they walk?
And I think that's
especially true when you're
working with individuals
following limb loss,
but the added layer is
figuring out whether their
gait deviations are driven
by musculoskeletal impairments,
prosthetic alignment issues,
or a combination of the two.
All right, so we mentioned top-down,
bottom-up, right?
Burning the candle at both ends.
Go a little deeper, elaborate.
Top-down,
bottom-up approaches you mentioned.
How do those strategies
differ besides the top and bottom,
obviously?
And in what situations would
each be most effective?
Yeah,
so both strategies are based in
concepts of regional interdependence,
right?
And so I think in school we've all learned,
or in the clinic,
we have all learned some element of
You know,
your knee pain may be related to
impairments at the hip or, you know,
foot and ankle pain might
be related to impairments up at the hip.
Our presentation is just
going to be providing a
more systematic way of
looking at that and treating that.
So, for a top-down approach, you know,
that term is going to be
referring to starting at
the hip and then
systematically going down
to the knee and then this
to the foot and ankle.
And bottom up will just be vice versa.
Start at the foot and ankle,
then work your way more
proximally up the kinetic chain.
For simplicity purposes, right,
this is a teaser.
You might choose a top-down
approach when you're
treating an individual who
has low back pain, hip pain, pelvic pain,
right?
Because looking at the hip more proximally,
that might be the most plausible,
you know,
explanation for their symptoms
or their gait deviations.
but maybe the patient isn't
improving the way you thought they would,
or their gait deviation isn't changing.
And then you could start to consider,
following our approach,
looking at the knee and
then the foot and the ankle.
As for bottom-up, you know, same idea,
it might be most relevant
for a patient experiencing
foot and ankle pain, right?
That kind of makes sense to us.
But kind of as I was mentioning,
if they don't respond to
the way you're expecting them to,
you have to start
considering contributors more proximally,
because the foot and ankle
is really just the first contact point
on the ground in the gait cycle.
And then a lot happened from there.
All right.
Well,
we've got to bring in some sort of
manual therapy technique, right?
Because you're presenting it
and that's sort of a common thread.
So help us understand,
maybe give us an example of
a few techniques that you
might use and explain how
they address gait-related
problems specifically.
Sure.
So let's start at the head.
So let's say you see a
patient who is having a
really short stride length,
meaning they're not getting
into full hip extension at
that terminal stance phase of gait.
Maybe you try going to a
prone P to A or posterior
to anterior mobilization to
the hip to improve extension.
And I think we would maybe
all logically start there.
Also looking at, you know,
I know you asked about
manual therapy techniques,
but also looking at hip
flexor length and kind of
other contributors to that
limited mobility.
But a more out-of-the-box
approach to that specific
gait deviation would be to
maybe use the sideline
lumbopelvic mobilization or
even manipulation to build
more anterior rotation of that innominate,
which is a very necessary
part of hip extension.
So kind of thinking out of
just that femoroacetabular joint.
At the knee,
a common deviation I see is
patients remain in slight
knee flexion throughout the
entire gait cycle,
which would be abnormal
into stance phase.
Very important that patients
be able to access that
terminal knee extension.
And so I would start by
assessing various accessory
motion around the knee
joint or the knee complex.
But we have to think about, you know,
not only a posterior glide
of the femur on the tibia
or an anterior glide of the
tibia on the femur,
but think about the screw
home mechanism of the knee
and that combination of
that glide and rotation that happens,
as well as that proximal
tibiofibular joint, right?
Is that joint moving as well?
We could also consider doing
some interventions for
superior patellar glide.
But we have to kind of
figure out why isn't that
patient able to access knee extension?
Well, do they have it?
And then are they able to access it?
And, you know,
our presentation
particularly is going to be
really incorporating a lot
of themes from that screw
home mechanism and more of
those combined movement patterns.
Next,
kind of going down to the foot and ankle,
the most common thing I see,
and I'm sure other
therapists when they hear
this are going to be like, yeah, me too.
is limited ankle dorsiflexion.
That's, you know, by and large,
the most common deviation
at the foot and ankle.
And so that might look like
an early heel rise in gait,
or they may externally
rotate their foot that
they're avoiding
dorsiflexion and great toe
extension and midfoot
pronation altogether.
We've all learned that
talocral distraction manipulation.
I also like to treat the
subtalar joint for that
with a similar technique,
but just changing the
pre-positioning of the foot
and the ankle to bias one over the other.
And then I like to follow
that with a talonavicular
joint treatment.
So whether that's a
mobilization or a manipulation,
I typically treat that in
prone because we know that
dorsiflexion and pronation
are coupled movements.
Right.
Especially, you know,
applicable to that stance phase of gait.
And keep in mind that in mid stance,
we also need controlled
internal rotation at the hip.
So going right back up the chain.
Yeah.
Bottom up, top down.
Your presentation at the M
Conference this year is
going to emphasize the
collaboration and
synergistic movements
within that lower extremity
in the kinetic chain.
How can physical therapists
ensure that they're not
missing critical links?
PTs are always scared.
What are we missing?
Should we record it and have
them do it again?
So how can you make sure PTs
ensure they're not missing
critical links in the chain
when assessing and treating
their patients?
Yeah, great question.
I think the main message
that we want to send with
our presentation is
consider impairments in
other areas of the kinetic
chain that might contribute
to symptom development.
I think in PT school or
maybe in residencies or if
you pursue fellowship,
you really get hammered
home with more of that look
elsewhere approach.
But it's easy to get into
the clinic and start seeing
patients and get into a
rhythm and you kind of
start to forget about
things that are outside of that patient's
pain zone, right,
or their exact location of symptoms.
But the human body is complex, right?
Gait is a complex movement
and something that we're
all doing every single day.
You know,
I would also argue that looking
at some of the impairments outside of,
you know,
that exact area of pain could
also explain ongoing or
persistent symptoms.
You know,
maybe that is that missing link
to why someone keeps coming
back to you with the same
symptoms once a year.
right?
Or maybe it's every two
years or something like that.
And, you know,
we do have evidence support
that when someone has
experienced low back pain,
they're at an increased
risk for recurrent back
pain again in the future.
And so I would offer that if
we begin to consider those
other areas and think about, you know,
how someone moves more generally,
I think we might be able to
decrease that risk and
fully return people to function.
I think it's also helpful to
I think I may have mentioned this already,
but when you get stuck with
a patient and you're just like,
I do not know what else to
do for this person.
I assessed their foot and ankle.
I treated what I found and I
don't understand why it's
not getting better, right?
We've all been there where
we get frustrated and you
run out of treatment ideas.
And so I would say turn
towards function and start
to assess their gaze.
And one way you can really
make sure you're not
missing more subtle
deviations or asymmetries
is to use video analysis.
You know,
there's a lot of really great
apps out there that are
totally free or just the
iPhone camera has that slow-mo feature.
And sometimes that gives me
enough of a brief look and
I'll even record it on the
patient's phone, right?
So they can see it.
And then you get that buy-in
and you can record it again
on their phone a few months
from now and they can
compare their progress.
So I've had good success with that.
And also,
if you do record on your own phone,
just remember with HIPAA to
delete it because
and not keep it on your phone.
But video analysis can be super helpful.
Yeah.
All right.
Well, physical therapists love examples.
We love the case.
I was working with this person.
I'd like to share.
Give us a real-world case
study or example where the
application of the
techniques you just talked
about are going to help
improve a patient's gait.
And what were the key
takeaways from that
particular experience?
Yeah,
so the case that kind of stands out
the most to me where this
has happened recently is I
had a patient with a really
complicated orthopedic history,
relatively young guy.
He fractured both of his
tali with a relatively low
impact incident.
He brought his dirt bike to a stop,
put his feet on the ground
and broke both of his tali,
which is kind of crazy.
So he had a surgery.
They did an open reduction
internal fixation and
For both of them,
long journey in recovery.
I did not treat him after
that original surgery.
But that surgery was
successful for his left ankle.
His right ankle, on the other hand,
continued to have pain and
just ongoing mobility
limitations and felt super stiff.
So he went back to the
surgeon and they decided to
take the hardware out and
see if that could help with
his pain and his symptoms.
And so that's when he was
then referred to me,
was after the hardware was taken out.
So when I looked at his gait
during the evaluation,
I noted a few different things.
So I saw that he had a
really early heel rise.
So kind of showing some of
those signs of that lack of
ankle dorsiflexion.
He had decreased midfoot
pronation in that stance phase,
a lack of terminal knee extension, right?
All of those movements go together.
So that does make sense.
And then he also had that
decreased stride length
that I was talking about,
a lack of hip extension.
So in my examination,
obviously I'm going to look
at range of motion, strength, right,
all those bread and butter
things that we all know and love in PT.
And in doing so, I cleared his hip.
So I think most people, when they,
you know,
would get that referral for
someone after hardware
removal in the ankle,
they may not go look at the
hip on day one.
Um, but I did right.
Just to clear it.
And so I didn't find any
substantial impairments at the hip.
And so that kind of led me towards,
I think this is really more
foot and ankle driven,
which is more kind of
traditional based on the
referring diagnosis.
Right.
Um, so when I looked at his knee,
I actually found he had a
lot of hypo mobility or
decreased movement at that
proximal tibiofibular joint.
which again,
makes sense when you're
talking about the ankle complex,
but might not be something
you would look at with every, you know,
post-op foot and ankle patient.
So I treated that joint with
manipulation a few times,
a couple sessions,
and that actually cleared
that up pretty quickly.
And that restored his knee extension.
So that was pretty cool.
And then I focused most of
my time and energy on those
impairments in the foot and ankle.
So I did a lot of treatment to his
talocrural joint,
the distal tibiofibular joint,
subtalar joint,
and then his talonavicular
joint was just super locked up.
Makes a lot of sense with
the injury that he had,
but I actually think
treating his talonavicular
joint restored more of a
normal gait pattern than
even treating talocrural,
which may surprise some people,
certainly surprised me in this case.
He benefited from treatment of both areas,
but ultimately,
That approach was successful
in minimizing his gait deviation.
So the time to his heel rise was delayed.
It's still not perfect if I'm being picky,
but he got back full
pronation in stance phase
and his drive length is symmetrical.
So to me, that's a huge win in terms of,
you know,
kind of where's his plan of care now.
His dorsiflexion is still a bit limited,
but in communication with his surgeon and
She's kind of said she
doesn't think further
improvement is really possible.
He's certainly developing
some of that early
post-traumatic arthritis.
So we're really in a
maintenance phase of care now,
transitioning towards
independent management with
a gym program.
He does a lot of
self-mobilizations at home,
which has helped us get a
lot more carryover.
And a lot of corrective exercises, right?
This is certainly a manual
therapy conference,
but shameless plug for
corrective exercise, right?
You have to do that to get
those corrections to stick.
And for him,
that's been a huge component as well.
So we're really just trying
to optimize things as much
as we can and prolong time
to another potential surgery.
That's great.
I like how you told that in the story.
A lot of takeaways from that.
Most importantly for me is I
now know what the plural of talus is.
Yeah, I don't know.
I'm hoping I got that right.
I didn't take Latin in high school.
I think you said it on the podcast.
And since it's recorded,
no one can change it.
Yeah, there we go.
And if they're going to confront you,
it's going to be when you
walk off stage at the AM
conference this year.
And we had a really fruitful
discussion about the plural
form of talus.
That's the thing to have
over a drink in the networking hour.
It's my suggestion for that.
Kelly,
last thing we do on the show is
final thoughts.
Is there anything you'd want
to sort of leave with the audience?
This is your chance for a
plug to be there for your
presentation in person.
But what would you want to
leave with the audience of
your colleagues today?
Yeah, sure.
I would say just a message
to continue to look above
and below the area of the
patient's pain involvement.
Think about them as in their
movement as more generally
as a human being, right?
What do they need to execute
the task that they're
having trouble with?
And we could even go on and
on and on about into the
trunk and mobility limitations there.
But I think that's really
the take home message.
And then obviously have to say,
come to the presentation to
learn more techniques.
And we're going to be
creating a video gallery
and a private YouTube channel
that people can take with them.
Cause I don't know about you,
but sometimes I go to these
great courses or
conferences and in the moment I'm like,
I'm totally going to remember this.
And I don't, right.
You know,
you get back to clinic and you're like,
how, where were their hands again?
And you know,
everyone's trying to take
videos on their cell phones,
but you get someone else's
cell phone and your view
and it just doesn't work well.
So we're going to actually
create a video channel
afterwards where people can
go back and look at those
techniques and hopefully
use them more consistently
and successfully in the clinics.
That's what I like to hear.
Kelly, I hope to see you in Orlando,
maybe with Mickey Mouse or
Minnie Mouse ears.
You're so close in proximity.
You've got to kind of touch
on Disney for the day.
But thanks so much for
sharing what you'll be
talking about with your
colleagues this October with Amt.
Yeah, thanks so much for having me.
And that's it.
Anything we didn't ask?
Anything we, you know.
No, that was easy peasy.