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Dear All

Please don't mistake this thread for a Rothbart rant or promotional attempt.

I would like any ones opinion on global proprioceptive medicine.
Myself and a few other practitioners got a chance to see a very good chiropractor demonstrating this technique. We were all very impressed by how applicable it was to our lower limb practice. The link between cuboid mis-alignment and tenser fascia lata weakness and navicular instability and adductor weakness was shown repeatadley on several of us.

Any comments? (Be gentle if think its hocus pocus)


Phil

Hi Phil,

How did the chiropractor demonstate these links repeatedly to you all?

Respectfully

Ian

I will rant..its crap. I wish those promoting this kind of stuff (including Rothbart) would look up in a dictionary what proprioception is!! - they clearly have no idea. Even when you point this out to them they continue on with it as they have hung their hat on 'proprioception' .

I know your question was not about orthotics, but I will start there. Apart from mechanical (kinetic and kinematic) effects, all orthotics can do is alter the pressure on the plantar mechanoreceptors. The CNS can then use this extra information to add to what it already gets to make a decision about change (if it wants to). BUT.... THATS NOT PROPRIOCEPTION ! ....its actually an exteroceptive pathway. And even then if it does work through these sensory pathways, it still have to reduce kinetic parameters for tissue stress to go down.

Back to your question. This is all to do with inhibition of reflexes. Reflexes are not part of the proprioceptive pathways --- so whoever claims that it is is talking out of a hole in their .....

__________________
Craig Payne
Department of Podiatry
La Trobe University
Melbourne, Australia
http://www.latrobe.edu.au/podiatry
__________________________________________________ ___________________________________
God put me on this earth to accomplish a certain number of things - right now I am so far behind, I will never die.
The views expressed above are those of the author and not that of La Trobe University
This is where I am, where are you?

Hi craig

I'm aware that you folk have done research in a way that maybe cuts off potential distal proprioceptive pathways and agree that exteroceptive pathways may likely be the source of information - in relation to orthosis role.

However, is there a proprioceptive role that is more proximal? If there is then is it correct to consider these information pathways as mutually exclusive? Is there not a synergistic relationship with, e.g. the exteroceptive one intially being a stimulator of the other?

Not sure how this fits in with the original post though:)

Ian

Isn't it just after 5.00AM in your neck of the woods?

I am far from knowledgeable in this area...but,

That are all parts of the sensory system. Information goes to the CNS for it act on through many different pathways - there is the exteroceptive pathways; the proprioceptive pathways; the reflexes; etc; from what I understand there can be some interaction at the spinal level, so yes they could stimulate each other.

But, don't forget what proprioception is: sensing body position.

All I am vituperating (a new word I just learnt) is those who pretend they know what they are talking about when they claim the effects of orthotics or the effect described above are proprioceptive when its exteroceptive (orthotics) or weakness (reflex inhibition).

__________________
Craig Payne
Department of Podiatry
La Trobe University
Melbourne, Australia
http://www.latrobe.edu.au/podiatry
__________________________________________________ ___________________________________
God put me on this earth to accomplish a certain number of things - right now I am so far behind, I will never die.
The views expressed above are those of the author and not that of La Trobe University
This is where I am, where are you?

Hi Craig

"Isn't it just after 5.00AM in your neck of the woods?"

Yep. One of lifes little need of sleep type people I'm afraid. Or maybe just a saddo who turns to Pod arena rather than ring the DJ on midnight radio!! Worked well for when I was finishing my top up degree this year though, as no one else was up!!

Thanks for the reply. Was not critiquing your "vituperating". The question kinda links to a post a long time ago when you intimated that there might be some research going on there as to proximal proprioception and gait.

Be glad to say hello at the Society Conference this year (I think you are there)

Cheers
Ian
PS. my knowlege in the area is nano size on a good day.

Can we therefore concede that the description was semantically incorrect but that the observed phenomenon was definate???

Phil, please elaborate on what was performed and the result.

Lawrence et al

The demo showed to us was done on 3 people and went something like this

Subject was supine and the adductor strength was tested by simply abducting the straight leg and the tester resisting adduction. If this was subjectively weak, the navicular was mobilised/manipulated.
In all 3 cases, the subjective strength increased significantly.
A similar test was performed for the cuboid.
The subjects had also been assessed and manipulated to give a stable starting point and these test were not just done in isolation.
The criticism of tester bias is valid but all 3 subjects felt that this was not the case.

The very basic explnation given was along these lines -
If a joint is subluxed/mal-aligned, then a confusing stimulus is sent along the CNS. The body cannot function as effectively with this 'interference' and some motor control of the limb is lost - maybe this is where the term propriceptive came from as when the testing is done, it seems to interfere with perceived joint position management by the body.
Some other interesting test were done but I am going to try and get the chiropractor on the forum to answer questions as I am not doing him any favour with my half understood explanations.
I am one of the most skeptical practitioners around but I beleive this may be a useful bit of stuff to learn. A couple of other 'lurkers' were there on the day, so hopefully they will add their comments.

Cheers

Phil

Thanku Phil

Do I remember Howard Dananberg demonstrating an increase in power of Peroneus Longus following fibular mobilisation?

Anyone else remember this?

This sounds to me a great deal like applied kinesiology. This is an alternative therapy whereby steady pressure is exerted on a muscle and the body is exposed to a physical or psychological stimulus (like a joint configuration elsewhere). If the muscle "weakens" the body obviously has a sensitivity to marmite or gerbils or whatever. If it strengthens then the body LIKES the stimulus.

Not to be confused with Kinesiology as in the study of human movement. Unfortunatly the Quacking masses have more or less hijacked the work. Google it and see what you get.

It is variously described as
On the health kinesology UK website

by the British Kinesology centre, and

By me on this website.

I saw this palour trick as part of a hypnotherapy course i did a few years back. My first inclination was that it was more to do with suggestion than anything else. My other inclination was to burst out laughing, but i surpressed that one. It was a very "right on" crowd.

But i will admit to being deeply substitious on most things. I seem to be one of 3 podiatrists in Great Britain who does'nt beleive in homeopathy judging by the society forum. Hey ho.

Regards
Robert.

applied kinesiology is different - it is based on exposure to any substance and using muscle power to assess tolerance of the substance i.e. allergy. It is indeed dubious. For instance a potato is placed on your chest and the "therapist" pushes down on your arm. If you cant resist them you have a "sensitivity".

It has nothing to do with using joint mobilisation to influence muscle reflexes.

.

Indeed not. However There are some alarming similarities.

My point is that IMO kinesiology works on the principle of suggestibility on the part of both the subject and the operator (who genuinely beleives what they are testing is a physical reaction). Its a good example of how our bodies are influenced by subconcious suggestions. There are several techniques used in hypnosis, mainly used as suggestability tests, which work on the this basis. The same mechanism could be at work here.

Of course i could be entirely wrong and there could be a genuine casual link. However until i see evidence to this effect i will suspect that this is another example of the well known established phenomenon. Occams razor you understand.

But like i say, i might be completely wrong. Thats always the risk of cynicism.

Regards
Robert

Here is a paragraph on proprioception from one of my physiology textbooks:

"Proprioception.The senses of joint movement and joint position are included in proprioception. The sensory information arises from receptors in muscle, joints, and skin. For proximal joints. such as the knee, the most important information is derived from the activity of muscle spindles in the muscles that move the joint. In distal joints, such as those of the fingers, Ruffini endings in skin and joint receptors also contribute. All of the information required for proprioception in the upper extremity ascends in the dorsal column-medial lemniscus pathway. However, a major part of the information needed for proprioception in the lower extremity depends on collaterals of the dorsal spinocerebellar tract that relay in the medulla."

In the same book, here is the lead paragraph discussing cutaneous receptors, which are those sensory receptors that are probably responsible for any effects of foot orthoses on the central nervous system from the skin of the plantar foot.

"Cutaneous receptors can be subdivided according to the type of stimulus to which they respond. The major types of cutaneous receptors include mechanoreceptors, thermoreceptors, and nociceptors."

from Berne RM, Levy MN, Koeppen BM, Stanton BA (eds.), Physiology. 5th edition. Mosby, St. Louis, 2004, p. 100, 108.

__________________
Sincerely,

Kevin

**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College

e-mail: kevinakirby@comcast.net

Private Practice:
107 Scripps Drive, Suite 200
Sacramento, CA 95825 USA
My location

Voice: (916) 925-8111 Fax: (916) 925-8136
**************************************************

"Of course i could be entirely wrong and there could be a genuine casual link. However until i see evidence to this effect i will suspect that this is another example of the well known established phenomenon. Occams razor you understand.

But like i say, i might be completely wrong. Thats always the risk of cynicism."

Agreed. No problem with this.

While I will not argue the semantics with Craig, I do see similar feedback after foot / ankle manipulations.

I have regularly seen an increase in range of motion and peroneal strength after AJ manipulation. As well, I have seen an increase in AJ rom after 3rd cuneiform manipulation.

None of these manipulations will hold if the orthosis prescription is not correct. Stretching and strengthening exercises do help in maintenance and recovery of rom, but if the orthosis prescription is not helping the foot to overcome its deficits in function, it, will rarely hold.

I did assist in a study that was not published utilizing surface emg before and after AJ manipulation and checking PL strength. It improved and held longer after manipulation in those who had limited AJ rom.

cheers.
Bruce

__________________
Bruce E. Williams, D.P.M.
Breakthrough Podiatry

Thats a shame ... I could have got to use that new word I learnt again --- vituperate I have seen this too in the apparent peroneal strength (and it NOT proprioception). I am not convinced its actually an "increase" in strength after the manipulation (also seen it after needling of trigger points) - there is some sort of reflex inhibition in place that is creating a 'pseudo-weakness'. The manipulation (or needing) is merely releasing that.

As for ankle ROM following manipulation - thats probably purely mechanical

__________________
Craig Payne
Department of Podiatry
La Trobe University
Melbourne, Australia
http://www.latrobe.edu.au/podiatry
__________________________________________________ ___________________________________
God put me on this earth to accomplish a certain number of things - right now I am so far behind, I will never die.
The views expressed above are those of the author and not that of La Trobe University
This is where I am, where are you?

Craig;
I think that most of it is "purely mechanical" as well. I do not discount an improved neruologic feedback from imroved mechanics, no matter what we are calling it now. :)

I agree as well that it is not increased strength, but a return to normal strength after manipulation. Howard calls it something specific that I can't for the life of me remember right now. Something along the lines of re-activation of the muscle, ie the Peroneus Longus.

The PL becomes inactive for 2 reasons I think. One is loss of AJ rom and decrease of fibular translation dorsally. Dorsal translation in late midstance should pull the PL dorsally as the fibula moves superiorily and also pull it laterally at the foot.

The second reason for PL dysfunction is that with an unstable MTJ position, calcaneal valgus, pronated STJ, hypermobile 1st ray, etc, the cuboid adn lateral column will pronate and this brings the midfoot potentially all into the same plane. When the lateral column supinates, then the cuboid should sit under the 3d cuneiform, thru the navicular. This shortens the length of the PL, and puts the MTJ and midfoot in a very stable and well articluated position. Also allows superior movement of the fibula I suppose.

I think you can manipulate the foot and ankle to get a better response in position that then effects the neurologic feedback and can potentially reactivate muscular activity to enhance foot and LE function.

Hence the mechanical stuff. done now with my vituperations!!! :)

Cheers Craig!
Bruce

__________________
Bruce E. Williams, D.P.M.
Breakthrough Podiatry

Since strength testing relies on volitional activation of muscle units via the central nervous system (CNS), then any inhibition to the CNS which prevents full volitional activitation is a true loss of strength or a true weakness, not, in my opinion, a "pseudo-weakness". If, indeed, manipulation creates a decrease in inhibition in the recruitment of muscle units to a specific muscle or group of muscles when the individual is asked to volitionally activate the muscles, then manipulation actually will create more strength during testing of that muscle.

If this does take place frequently, as Bruce, Howard and others say, then the next obvious question becomres is there any scientific research that has demonstrated this phenomenon for those of us who are a little skeptical of how this physiological mechanism works??

__________________
Sincerely,

Kevin

**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College

e-mail: kevinakirby@comcast.net

Private Practice:
107 Scripps Drive, Suite 200
Sacramento, CA 95825 USA
My location

Voice: (916) 925-8111 Fax: (916) 925-8136
**************************************************

After reading this stuff the other day I had a pt come who gave me an oportunity to dabble. As part of the assessment I checked leg adduction and found the affected side to be quite a bit weaker. Using the manipulation technique developed by JM Hiss (1940's period) I manipulated the navicular. Sure enough there appeared to be an improvement in the strength of the leg to adduct against resistence. I then rechecked this at the end of the biomech exam and whilst the improvement remained it had reduced by about a third (all subjective).

I suspect that further reduction will continue as am not sure that the high velocity manipulation is the preffered one, possibly a more discrete but sustained peripheral mob or Kaltenborn technique would have been appropriate to the task. Also the foot has very marked MTJ inroll and calcaneal eversion which begs the question as to whether such a manover can quickly become undone once gait is started again. I may apply one of the above mobs in the rehab approach and monitor it.

Certainly find that the mobs approach has lasting affects upon foot function.

Ian

I would imagine that I am the only one on this listserve that has taken course work in applied kinesiology –that’s my vituperate (and if anyone else has, please feel free to jump in). So, I would like to eliminate some of the confusion and give a basic overview of what it is. Applied kinesiology was started in 1963 by George Goodheart D.C. in Detroit, Michigan. The test that is used is a muscle test, in which a specific muscle is placed at its maximum contracted position and the muscle’s response to a gradual increasing force is tested. The ability of the muscle to lock (maintain an isometric contraction) is tested. One has to be careful not to increase the force too quickly, so as not give the patient time to respond to the increased tension. So the key to watch is 1. is a specific muscle being tested? (pushing down the arm is not a specific test) and 2. is the speed of the test to quick? Testing properly requires skill and knowledge. For example, I thought I knew how to test the peroneus tertius, but I never was able to find a weak one until I was showed that the toes have to be plantarflexed or the patient can cheat by using the EDL.

Before a muscle is tested, an examination is performed to help find a weak muscle. This is accomplished by history, postural analysis, examining the T-S line, and blood pressure in 3 positions. Then the suspected muscle(s) are tested to see if they do not lock. Once a muscle is found to be weak, then tests are performed to see if the muscle can strengthen. The latest way of approaching this is to first look for neurologic balance. This is done by cortical stimulation on one side, then the other; and then cerebellar stimulation of one side and then the other to see if this allows the muscle to lock. This test alone will focus determine if there is a cranial sacral dysfunction, or another area in the body that is involved, and which side it is on. If this is negative, then the pulse points are checked (for acupuncture meridian dysfunctions), the neurolymphatic reflex points, then the neurovascular reflex points, then nutrition, then associated spinal level, then proprioceptive deficits are tested (muscle spindle cells and Golgi tendon organs) in that order.

Interestingly, when the testing brings you to a joint, then all the muscles should be tested that control the joint, and these muscles should be tested in the above pattern, until you get to an end point (for example, the muscles around the joint are not weak, so it problem must be the joint). If the joint is what needs to be treated then a challenge is performed. That is, the joint is moved in a certain direction and the muscle is retested to see a change. This helps to determine the direction of manipulation. If a joint is manipulated back into position, and the muscle will lock. A challenge of the joint will be negative.

Applied kinesiology does not test for allergies. There are some primitive emotional tests and treatments (temporal tap), which is not commonly used. It doesn’t test for energy, it does however test the acupuncture system when indicated. Applied kinesiology doesn’t test for homeopathy, but the muscle tests could be used as a means of finding if a remedy is compatible. Classic applied kinesiology does not test ligaments, fascia, or periosteum (but I do, as I find this extremely important).
I hope this gets things straightened out a little.


Very astute Craig. The key is to find the "weak" muscle (the muscle that doesn't lock properly) and then to eliminate the cause.



I think this is only partially correct. When Bruce manipulates the lateral cuneiform, he finds the equinus is corrected. This does not specifically mechanically effect the ankle. The effect may be due to the fascia (the superficial front line could easily explain it), or it may be more, as the low ASIS on that side will usually be corrected. Am I vituperating again?

Stanley

Dear all

I have requested a few refernces to support the days finding from my Chiropractor friend and will pass them on ASAP.
Thanks to everyone for the input - the techniques are worth further investigation and I'll pass stuff on to the forum.
We are planning to do a teaching day in the future and are going to investigate the techniques on CP patients (C Palsy) as well as the more functional norms/musculoskeletal patients.

Phil

Phil

Hello Stanley and Phil.

Stanley, I am not sure that I understood above half of your posting, let alone find it convincing.

Phil, I do not wish to condemn any treatment method without investigation but you seem to be keen to teach this technique without satisfactory proof of its efficacy.

Would you both please post details of any RCTs carried out and explain why objective instrumentation eg. strain guages etc. cannot be used rather than subjective assumptions on the part of the practitioner.

Many thanks

Bill Liggins

Bill;
with all due respect, do you only utilize treatment methods that have been "proven" utilizing RCT's?

Please understand this is not an off the cuff question. I don't wish to degrade this or any other discussion to a pissing contest.

I just am curious to know if any RCT's have been done on every orthotic modification utilized out there, by you and by others?

I sincerely wish I had time to do RCT's for everything I utilize in practice. I do have enough data, to convince me anyway, from seeing before and after in-shoe pressure data to see changes after AJ manipulation. As I said before, I did a study at my local university that showed surface emg changes for the better in PL strength after AJ manipulation. It has not been published adn that is purely my fault on both issues.

I very much like open discussion on this and other lists. While I respect that RCT's would be extremely helpful for some in making decisions as to whether to experiment with a new technique, many are willing to make that decision without such proof. Much like I did while at university when presented with the majority of the biomechanics education that I received in the U.S. ! :)

If only Craig had been a professor of mine then, I'd like to think I could have progressed much farther by this time in my life.

respectfully;

Bruce

__________________
Bruce E. Williams, D.P.M.
Breakthrough Podiatry

Bill, It was not my intent to convince anyone, just to set the record straight. If you want to become more familiar with the technique and the science behind it, you can obtain Walther's Synopsis, at the following website:
http://www.systemsdc.com/product/text.htm His book is replete with references.

I find AK indispensable in my practice. The muscle testing gives me answers to questions that I have that I wouldn’t be able to find in any other way. For instance, just recently Bruce discussed the pronation of the fifth ray, and how he compensates for it in his orthosis. I went back to my office to see if he was correct. I evaluated 5 patients that day who had plantar fasciitis that was partially better with orthoses. I pushed up on the base of the fifth metatarsal and found this weakened the posterior tibial muscle’s ability to lock; and when I pushed down the muscle was able to lock. At this point I knew there was something to what Bruce had said, so I now adjust the orthosis to allow for the fifth metatarsal base to invert. I don’t have to wait for Bruce to do the RCT’s to decide on what is best for my patients now.

Regards,

Stanley

Bill:

I feel your pain.....I also don't see why we couldn't put subjects on Cybex II Isokinetic Dynamometers before and after these manipulations to see if there is actually a measurable and reproducible change in strength/performance http://ajs.sagepub.com/cgi/content/abstract/12/1/52

Naturally, the scientist/physiologist in me must ask the following basic questions regarding the effects of these manipulations on muscle strengh of the lower extremity:

1. Is this effect real, just a figment of the examiner's imagination or possibly due to the power of suggestion to the patient? In other words, would sham manipulations also cause the same effects?

2. How long lasting is this effect?

3. How significant is the effect?

4. Is the effect strong enough to alter the kinetics/kinematics of gait?

I would be much more impressed if those clinicians who advocate manipulation could provide us with some more hard data to hang out hats on. In other words, can anyone provide any experimental or research evidence that this effect actually works?

__________________
Sincerely,

Kevin

**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College

e-mail: kevinakirby@comcast.net

Private Practice:
107 Scripps Drive, Suite 200
Sacramento, CA 95825 USA
My location

Voice: (916) 925-8111 Fax: (916) 925-8136
**************************************************

Dear all, with respect.

Just wanted to throw a quick note of my own thoughts out there as I run out the door, trying to avoid explaining too much. I always want to write pages.

Just 'conjecturing' but have had reinforcement from the following.

I was involved in a small pilot study very recently where subjects had Emed recordings made before and after foot joint mobilisation. All 4 subjects were chosen because of presenting with ankle equinus. All subjects had seriously significant reductions in forefoot pressure readings after mobilisation. Interestingly they also had significant increases in hamstring flexibility after mobilising. You'll have to wait for the published full study could be out sometime late next year and for the moment I will only generalise and am not the researcher anyway.

I think (conjecture) that a system of inhibition (not sure that I'd call it pseudo-weakness)) has a real and major part to play in muscle dysfunction (tightness) and for one thing is tied into joint restriction. Any improvement in joint play is likely to also improve muscle flexibility( i.e. it doesn't need to be so protective anymore). If the overall jamming of a joint is caused by poor alignment then improvement may not last without other longer term treatment, but if it happened as a result of other insults then the results of mobilisation are long term.

I think we are a fair way away from having all the answers and there is more going on than we have inklings of.

Cheers
Shane

__________________
Shane Toohey
Artisan Orthotic Laboratory
http://www.artisanorthoticlab.com.au
2shane@westnet.com.au

Bill

I have no intention of teaching this and the aim of the teaching day is to get a group of open minded practitioners together to investigate the approaches used. There is no commercial input and the cost of the day will be shared equally amoungst participants. A chiropractor will do the leading/teaching who has been using the techniques for 4 years plus.
When I originally posted this thread I was very aware of the potential for comments such as 'where is the evidence' etc to be asked.
To clarify, I am NOT advocating these methods but have been impressed so far with their effects and would like to know more.
Once I start 'telling' rather than 'asking' then please feel free to ask for proof.
But, if you consider your self a musculo skeletal practitioner then I believe that there is validity to any method that can be seen to change function of the MS system. Once we have seen the methods in more detail then we can start asking the important questions.
Lets not throw things out just because we don't yet understand them - oh my god I sound like Rothbart et al!!!!

Regards

Phil

Hello Phil

Thanks for clarifying. If you look at my posting I did say that I was unwilling to condemn any treatment method without investigation. My point really was that, as Kevin has stated in more erudite terms, we need to investigate first using accepted scientific methods rather than embrace any new technique uncritically.

I do not accept the proposition that because 'in the old days' techniques were developed without due scientific rigour and were accepted because they were effective in practice, that the process should continue ad infinitum!

All the best

Bill Liggins

Stanley,
You use the expression "muscles that do not lock" repeatedly in your post, this is a term I am not familiar with. Could you explain please what is meant by "locking" of a muscle?

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I too had been thinking about the use of dynamometers in relation to this discussion.

Questions:
When is a muscle weak? That is how much torque should a given muscle produce? For example, how much torque should my peroneous longus produce when my foot is everted 3 degrees ? What about when its everted 10 degrees? Where is the torque measured from and to? i.e. about which joint axis, in what position and from which reference relative to this?

I'm sure this has something to do with cross-sectional area and Hill's equation, but my memory is getting poor and I'm getting too idle to go searching. For sure the bright young things will tell me.

Kendall's grading system not really withstanding, given some of the more subtle clinical presentations encountered, when performing a manual muscle test how do we know that the muscle is weak and similarly how do we know when it is too strong or just right?

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Science is the antidote to the poison of enthusiasm and superstition

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