1. Stephen Gangemi, DC, DIBAK ICAK ANNUAL MEETING - JUNE 2014 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

2. 100% Holistic, Individualilzed Approach: Assessment, Treatment, and Lifestyle Changes Rehabilitation Prevention Enhancement Advise and Educate Individualized Treatment Via Applied Kinesiology 2 Copyright Stephen Gangemi DC, DIBAK SockDoc

3. 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 3 Copyright Stephen Gangemi DC, DIBAK SockDoc

4. 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 4 Copyright Stephen Gangemi DC, DIBAK SockDoc

5. Why Check Gait? To restore function To restore health Gait dysfunction  Health dysfunction So patients don’t “walk themselves back into a problem” 5 Copyright Stephen Gangemi DC, DIBAK SockDoc

6. What Disrupts Gait? Those which influence the Triad of Health: – Structural – Nutritional – Emotional Improper footwear Orthotics – a brace that supports dysfunction and alters mechanoreceptors 6 Copyright Stephen Gangemi DC, DIBAK SockDoc

7. Modern Footwear Soft Midsole 7 Copyright Stephen Gangemi DC, DIBAK SockDoc

8. Elevated Heel 8 Copyright Stephen Gangemi DC, DIBAK SockDoc

9. Line of falling weight moves forward with heels 9 Copyright Stephen Gangemi DC, DIBAK SockDoc

10. 10 Copyright Stephen Gangemi DC, DIBAK SockDoc

11. Motion Control 11 Copyright Stephen Gangemi DC, DIBAK SockDoc

12. Footwear Industry Claims 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 12 Copyright Stephen Gangemi DC, DIBAK SockDoc

13. The Recent Lawsuit - Vibrams: “Your foot can become stronger by wearing FiveFingers” Copyright Stephen Gangemi DC, DIBAK SockDoc 13 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.

14. 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 14 Copyright Stephen Gangemi DC, DIBAK SockDoc

15. Barefoot, Shod, or Minimalist? Due to industry demand, minimalist footwear is becoming more maximalist after just a few short years. 15 Copyright Stephen Gangemi DC, DIBAK SockDoc

16. 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. 16 Copyright Stephen Gangemi DC, DIBAK SockDoc

17. Improve Your Health Barefoot  Proprioception (sense of position)  Kinesthetic sense (the feedback your nervous system receives from your feet) 17 Copyright Stephen Gangemi DC, DIBAK SockDoc

18. Barefoot and Minimalism Shock absorption: Foot strike  More mid/forefoot Solid support: Loading Rate  Center of mass Energy & Power: Elastic Recoil  Natural Spring 18 Copyright Stephen Gangemi DC, DIBAK SockDoc

19. 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 Midfoot/forefoot strike Ideally the body’s center of mass should be over the foot for the lowest loading rate 19 Copyright Stephen Gangemi DC, DIBAK SockDoc

20. 20 Copyright Stephen Gangemi DC, DIBAK SockDoc

21. 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 21 Copyright Stephen Gangemi DC, DIBAK SockDoc

22. Orthotics & Arch Supports 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 22 Copyright Stephen Gangemi DC, DIBAK SockDoc

23. 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 Copyright Stephen Gangemi DC, DIBAK SockDoc 23

24. 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 Copyright Stephen Gangemi DC, DIBAK SockDoc 24

25. 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. Copyright Stephen Gangemi DC, DIBAK SockDoc 25

26. 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.” Copyright Stephen Gangemi DC, DIBAK SockDoc 26 Wally Schmitt, DC

27. 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 Copyright Stephen Gangemi DC, DIBAK SockDoc 27

28. Orthotics Contribute to Neurological Degeneration by Altering Mechanoreceptors The nervous system thrives from movement and sensory input Improve stability with instability 28 Copyright Stephen Gangemi DC, DIBAK SockDoc

29. How Long Do You Want to Support Your Patient? 29 Copyright Stephen Gangemi DC, DIBAK SockDoc 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

30. 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) 30 Copyright Stephen Gangemi DC, DIBAK SockDoc Is There An Ideal Shoe?

31. Stack Height 11mm heel7mm forefoot 11-7=4mm drop Drop “Zero-Drop” Low Stack & Drop 31 Copyright Stephen Gangemi DC, DIBAK SockDoc

32. Shock No Stability or Motion Control – natural pronation deflects shock Posterior Tibialis plays an important role 32 Copyright Stephen Gangemi DC, DIBAK SockDoc

33. Toe Box No cramped toe box – so the toes can splay apart to soften landing 33 Copyright Stephen Gangemi DC, DIBAK SockDoc

34. Cushioning? Cushioning does not absorb shock – it tricks the body by sending false information to the brain – “Is this a soft surface or hard?” 34 Copyright Stephen Gangemi DC, DIBAK SockDoc

35. The Harder the Surface the Softer the Landing 35 Copyright Stephen Gangemi DC, DIBAK SockDoc

36. 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 36 Copyright Stephen Gangemi DC, DIBAK SockDoc

37. 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 37 Copyright Stephen Gangemi DC, DIBAK SockDoc

38. 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 minimalist- type shoes as the weakened and shortened muscles, tendons, & ligaments regain their strength 38 Copyright Stephen Gangemi DC, DIBAK SockDoc

39. 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) 39 Copyright Stephen Gangemi DC, DIBAK SockDoc

40. General Gait Test – Latissimus Should be Inhibited 40 Copyright Stephen Gangemi DC, DIBAK SockDoc

41. General Gait Test – Biceps Should be Inhibited 41 Copyright Stephen Gangemi DC, DIBAK SockDoc

42. New Addition to Gait Test – Wrist Extensors Should be Inhibited and Strengthened with AF 42 Copyright Stephen Gangemi DC, DIBAK SockDoc

43. New Addition to Gait Test – Wrist Flexors Should be Inhibited and Strengthened with AF 43 Copyright Stephen Gangemi DC, DIBAK SockDoc

44. Final New Addition to Gait Test - Breathing & the Diaphragm Check the diaphragm with a full inspiration and expiration, checking for gait disturbance 44 Copyright Stephen Gangemi DC, DIBAK SockDoc

45. 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 45 Copyright Stephen Gangemi DC, DIBAK SockDoc

46. Workshop! (remove your shoes) Copyright Stephen Gangemi DC, DIBAK SockDoc 46

47. The Soleus & Gait Copyright Stephen Gangemi DC, DIBAK SockDoc 47

48. Soleus: A New Way to Test Original test by Simon King, DC 48 Copyright Stephen Gangemi DC, DIBAK SockDoc

49. Soleus: A New Way to Test 49 Copyright Stephen Gangemi DC, DIBAK SockDoc

50. Part II: Digging Deeper into Dysglycemia and Its Effect on Gait, Health and Performance

51. Dysglycemia The TMJ will often reveal hidden blood sugar handling problems which can be easily addressed to improve overall health 51 Copyright Stephen Gangemi DC, DIBAK SockDoc

52. 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 52 Copyright Stephen Gangemi DC, DIBAK SockDoc

53. 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 53 Copyright Stephen Gangemi DC, DIBAK SockDoc

54. 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 54 Copyright Stephen Gangemi DC, DIBAK SockDoc

55. 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 over- facilitation of the pancreas related muscles Slight rubbing over the pituitary Chapman’s reflex (glabella), will elicit the same response 55 Copyright Stephen Gangemi DC, DIBAK SockDoc

56. 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 56 Copyright Stephen Gangemi DC, DIBAK SockDoc

57. Evaluation & Correction - of the Dysglycemia AND many TMJ Dysfunctions For this… And this… And this too 57 Copyright Stephen Gangemi DC, DIBAK SockDoc

58. 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 58 Copyright Stephen Gangemi DC, DIBAK SockDoc

59. Procedure ACTH or TL to the pituitary CR weakens both [long head] biceps (over fires the lats and triceps) 59 Copyright Stephen Gangemi DC, DIBAK SockDoc

60. 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 60 Copyright Stephen Gangemi DC, DIBAK SockDoc

61. 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 61 Copyright Stephen Gangemi DC, DIBAK SockDoc

62. 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? 62 Copyright Stephen Gangemi DC, DIBAK SockDoc

63. Correction Continued… COMMON OFFENDERS 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 63 Copyright Stephen Gangemi DC, DIBAK SockDoc

64. 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 64 Copyright Stephen Gangemi DC, DIBAK SockDoc

65. 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 65 Copyright Stephen Gangemi DC, DIBAK SockDoc

66. 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… 66 Copyright Stephen Gangemi DC, DIBAK SockDoc

67. No need to be constantly performing the painful origin-insertion technique on the ptygeroid muscles over and over again! 67 Copyright Stephen Gangemi DC, DIBAK SockDoc

68. 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

69. 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 69 Copyright Stephen Gangemi DC, DIBAK SockDoc

70. Questions, Information & Research Email: drgangemi@gmail.com Websites: drgangemi.com sock-doc.com Thank you for your attention 70 Copyright Stephen Gangemi DC, DIBAK SockDoc