Carrick Institute

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CITV Presents: Ted and Fred’s Excellent Adventure! – Volume 3

Ted and Fred’s Excellent Adventure: Volume 3 is now live! Prof. Carrick continues to answer your questions in this captivating interview.

In volume 3, Prof. Carrick discusses:

– (1:05) What is something related to neurology that you once believed to be well-established and widely accepted that either yourself or another researcher has now proven to be false and replaced by a newly accepted axiom?

– (4:36) If only had 5 bedside tests you could use, which ones would they be and why? What are your top 5 therapies you love to use?

– (24:55) Gait observation – Can you give us some insight regarding the significance of heel strike? You have spoken many times about its importance and I would love to hear what happens at the moment where our body tries to win over against gravity. What control mechanisms are required? What are the most common failures? How does a well-integrated system benefit from the various stimuli associated with a successful heel strike?

 

Thank you to everyone who has submitted their questions so far.

If you would like to submit a question to Prof. Carrick, please fill out the form using the link below. https://forms.gle/iZBxqr4DwTc9DBZd6

#Carricktrained #drcarrick #carrickinstitute #CITV #neurology #functionalneurology #chiropractors #physicians #physicaltherapists

– Hello my name’s Dr. Freddys Garcia, we are here with Professor Carrick and we are back on Ted and Fred’s Excellent Adventure. This’ll be volume three, I guess, and we have more questions, and, professor, are you ready?

– Yes, I am. Good to see you.

– Good to see you, always a pleasure. All right, let’s see here, somebody did ask, did comment, “Professor Carrick, you’re beautiful! “What sort of skin care products do you recommend?” I swear to you, that’s a real question. I told them they could ask anything, this is what they submitted: They said, “You are beautiful!” With an exclamation point, not even a period for a statement. They really wanted you to know that you are beautiful.

– Well, you know, I mean brilliant question. And good observation. Boy, I could really have fun with that one, couldn’t I? Like I take eleven ers, I have no idea, well thank you.

– All right, we’ll get to a different question.

– Irish Spring, Irish Spring.

– Irish Spring, so, that’s the loveliest smell. All right, here’s a good one, I think.

– That’s crazy fun.

– What is something related to neurology that you once believed to be well-established and widely accepted, but either yourself or another researcher has now proven to be false, and replaced by a newly accepted axiom. That’s a great question.

– Boy, there are a lot of them, but one of the biggest one, is after concussion and rest. When I started in this clinical game, it was standard that if you got your bell rung, and you had a severe concussion, that you just rested, turned the lights off, and let things go. And up to very recently, that really was sort of the standard. And, I just didn’t like that, it never made sense to me. ‘Cause I’ve had some if you talk to me for a few minutes, and know I’ve had some head trauma, too. But, getting back up into the game was always very important for me and for patients. So, I was conservatively aggressive, where I would take patients, and get them doing things right away. So, we even have patients that could hardly walk, and I’d have them on the ice within a couple days. The results were phenomenal. So, the consensus, and I’m not saying it’s directly attributable to what I’ve done, but I can tell you, looking at our history of what people have done and what we’ve done, there’s been a big change. And now, in research, there’s great comparisons between the early introduction of aerobic exercise and other concomitants. And that idea of rest is just not cool. Same thing happened with low back. When I started, if you hurt your back, they put you in bedrest for a couple of weeks, and that’s something that we have never done, and our results were phenomenal. When I started practice, there was no evidence-based or evidence-informed aspect for anything that I do. Even musculoskeletal, there were no good studies for low back, or neck, especially with manipulation. Those are coming. If you wait for all the things to come, you’re going to be dead. So, observations, making common-sense activities. So, the idea of rest is something. Years ago, people would have a surgery and they’d stay in bed. Or deliver a baby, they’d stay in bed. Now, my gosh, the kid is up, the mom is up, and they’re getting them to move and walk and try to get home. Or if you’ve had a major surgery, you’re up and you’re walking. So, this movement and exercise has been a great paradigm shift from the things that we thought of before. And I think that’s revolutionized the treatment of neurological syndromes, whether it be walking and Tai Chi exercises to prevent dementia or Alzheimer’s disease, and bicycle riding with Parkinson’s and things like that. So, movement, not resting, getting up. And of course, in our job, movement is almost central to most of the things we do. If the joints can’t move well in what we call these kinematic chains, there are consequences. So, that’s been revolutionary, just a few years ago, and I think we’re going to find more things like it. There’s a whole load of other things, but we’d go on for the rest of our days. So, I think that’s pivotal.

– Excellent. I’m glad you mentioned kinematic chains, because I think the next question after this one will kind of go into that. But first, I have one that I think is a pretty good question. They said “Professor Carrick, if you only had five bed-side tests you could use, which ones would you be and why.” And they also wanted to know “What are your top five therapies you love to use?” So, let’s go bedside tests first. You could only have five. I mean, that’s a tough question. That’s a good question. That’s very tough.

– Well, I could answer that really easy on the top five tests if every patient that I saw had exactly the same presentations. And, quite frankly, what is really the top five for you, if you’re my patient, and the person next to you, might be completely different. So, some people demand different things. But the top, top, top ones, of course, blood pressure is really a super important test. I think the pupillary light response is just a must that I really, you know, go to. And now, we’ve got the, that pupillary light reflex app, that’s so cheap

– yeah, PLR app, yeah.

– That’s amazing, and I think that’s just really a, you know, a big big come home, too. One of the best tests that you can ever imagine is not doing any test, but just looking at somebody. That is, to me, 90% of the battle, whether their degree of blink responses have decreased, whether they have a type of hyponemia, their spontaneous aspects of smiling. When they’re walking into the room, is there a difference in an arm swing or not, is their gait parameters different, what is their stride length? So, I would say that the best tests are not doing a test, and just observing the function of an individual patient. I like to look at their intake forms, the way they sign their name, you know, looking at, especially with our older people, is their handwriting getting smaller, is there a diminution, things that we see classically in Parkinson’s. You can see a tremor in somebody’s signature. Even before you see them, you can give you an idea of things that are happening. But again, observations are the best. But the big thing, you know, blood pressure, or the pupillary light response is really, really super. I like to look in the eyes; for me, it’s indispensable. I like to see the caliber of the vessels. Really good with a variety of diseases, but also just looking at BA ratios and things like that. If you had to pick something that you wanted to see someone do, is like, can you stand up for me. Let’s see how they can get out of a chair. If they can get out of a chair without using their hands and that, usually, they don’t have a whole lot of things that are so wrong, which means their nervous system is basically functioning. They can stand up without falling down, they’re not ataxic, that’s a great test, then. And of course, we formalize it, like, how many times can you stand up and down over 30 seconds. We’ve got normative aspects, we’ve got the TUG, which is a Timed Up & Go test, and other things that, when people have a little difficulty, or if you see them, they’ve got to lurch forward, or they have some Ballismus, or so, that’s going to give you a little more of an inkling. One of the great tests, again, in regards to observation, is the color of their skin, their lips, their nail beds, you know, are they cyanotic, is there a difference from one side to the other? And all of the aspects that you see, from facial paresis or paresis of arms, to the presence of an involutional tremor. Again, it’s an observational aspect. I love reflexes, and again, motor strength, it’s really easy. You know, can you move your arms up and down, can they move against gravity? Gives me almost everything I need rather than saying “What is the difference between “my right side and left side?” to quantify it. So that type of observational constraints. And just the interrelationship. Do they seem with it, do they have a good affect, do they respond to your questions well? Almost the mini mental state examination that we get. Are they going to get 30 on it? You’re going to know pretty well when you’re talking to people. And also, one of the biggest part of the examination that many people forget is to talk to the people that love these people. In my job, have you seen any changes? The personality changing with them? You know, the “Yeah, they’re not, “don’t want to get out of bed anymore.” Sometimes they’ll come in and they’ll tell you different things. When we look at the top, I think you said top five therapies?

– Mm hmm.

– And the top therapy for me, always, without exception, is therapy that is directed toward autonomic integrity, which is cardiovascular sort of integrity. That’s emergent, you know. People can die if you do things inappropriately, if they’re massively hypertensive or so, many of the things that we’d like to do, we may not be able to do until that becomes under control. So, some therapies I wouldn’t do, I would send to a colleague that would have a greater expertise or needed a different type of formal kinetic type of intervention. So the first therapy is preservation of life, which is airway, breathing, cardiorespiratory. It’s always, always on my mind. And then, I’ve looked at the functional autonomic system and look at integrity, whether it be what happens on their tilt table for them, everyone is seeing this, where you get somebody, you put the table up to get them to turn over, and they become, if they have dysautonomia and they’re not getting blood, and you found it that way, you should find it before that time, of course. So, autonomic types of testing, whether you’re using grip-strength dynamometer for dysautonomia. I’m really careful to look at that. And then, when I look at the top, go-to therapies are dependent upon what the patient wants. So, when you see me, oftentimes there’s a whole load of comorbidities. I will always ask the people, “What do you want me to do for you? “If you could pick something that you wanted me to do, what would it be?” And they tell me what they want. And I would say that nine times out of 10, it would be different from what I would think they would want. You get some people, they can’t walk, or they’ve got this, and that’s not what they want to get better. They want to be able to hold a fork. They’re all — it’s different. So, the therapies that I choose are always in a hierarchal distribution to the patient’s desire or their expectation. And that’s always served me well to serve them well. So, there are some therapies and there’s certain patients, people say, “Gee, why didn’t you do this?” You go, “Well, because, that type of thing “would not be in concert with what they want. “Maybe we’ll get to it, maybe we won’t, “but let me do this individual type of therapy.” We deal with head injury, with patients that are sent from around the world. So, a lot of things that I do have relationships to eyes, head, vestibular, movement. And that type of conjoined therapy is something that I think are just instrumental, and I’d put that as one. I don’t look at vestibular rehab differently or out of sync with what I would do for a neck movement. In other words, I can’t get someone to do times viewing if their neck isn’t intact or vice versa. And then, therapies that are really important, and have always been, are exercise. Are we going to do it aerobically? We know we get a better bang for our buck with a concentric-loaded exercise than we do — or rather with an eccentrically-loaded exercise than a concentrically-loaded. So, little, wee things from stepping down from a stair or so, are really super important to not only get people’s athleticism up, but to look at their general health. And many of the therapies that we like to do are things that people can do at home. I’ve always been a big fan of making people autonomous so that they’re not dependent upon me. But I also don’t want them to do things that are not appropriate. So sometimes, you can get people to do a whole load of stuff that really can complicate things. So I like them to do things under my direction. For instance, if you’re looking at somebody that are doing fast eye movements to a target, I don’t like them to do that at home until they’re efficient at it. So, I won’t say, “Okay, go and do “these exercises on your own,” until they can do what I want them to do at different focal lengths, and then maybe I’ll give them that to do. But oftentimes they don’t need to do it by the time that comes. So, functional exercises, where I’ll get somebody who’s a skater, to do some gait stabilization when they’re skating and things like that. I think that manipulation of joints is really central to what I do. And I think that’s in central relationships with putting it in my top parameters of therapies is such that I do it with skill that I’ve developed. I’m very comfortable with that skill, and I don’t do anything that I’m not skilled at. So, that is something. And it also is something that is unique that other people in general don’t offer. So if they offer it, don’t do it to, to my personal level of skill. So, I’d like that, and I make a big difference in regards to people’s health, with joint manipulation. But, if you’ve had an adjustment by somebody who’s really skilled at it, it really for people, is miraculous, because things just feel different, whether it’s decreasing the neasusception, or increased fluidity, but all of the other things that haven’t been shown with research, you know, with different feelings of satisfaction. And well-being changes an autonomic system and other things, they’re going to tell you about that. And then, there’s some risk factors that you are going to take into account. But that’s one of the big ones, I think, for, for me. And then, one of your biggest therapies, or my biggest therapy, is letting people know that I care about them personally. And that I care about the timing. I’ll give you an example, you’ve been with me. Sometimes people, they’ll wait for a couple of years to get an appointment, which is sad, but once they get in, they may be waiting for hours in the office, before they get to see me. They may have an appointment at 11, and they may not get seen ’til three. And they go like, “Well, what the heck “have you been doing,” you know? Well, they know very quickly, that sometimes, if somebody needs more time than I’ve allotted, they’re going to get it. In other words, if they’ve had, their time with me is say, 15 minutes, and I need an hour, they’re going to get that hour. So people know that, and as a consequence, I never get complaints — But anyways, to me, but even to staff, that they have to wait. The first time sometimes, but as soon as they, they’re in that environment. So, I make sure that they know that I’m theirs and that I care about them, and that I’m going to do my best for them, and that if I can’t do something that’s really great, then, they’re gone, I’m going to tell them that we failed on them, I’m very honest. And it’s really interesting, because patients oftentimes don’t want to get fired. They come in, and you’re going “How am I doing, “because maybe he’s not going to keep me.” And, I, when I treat patients or attend them, I don’t treat them so that I can make them lifelong patients and see them. My goal is to see them as little as possible, that’s better for them, they become very vulnerable to what I can do. So, I work very diligently to see improvement, and if I don’t see improvement, and if they don’t see improvement, then they’re gone. So, I think that honesty, that integrity of caring is very important in my treatment parameter. I take that time to establish that meaningful bond. I don’t give them a spiel, but they know. I look at them in their eyes, I sort of hold them with my soul, and they know that I’m the right person for them. I oftentimes will see a patient and it just doesn’t feel good. You get people sometimes, you get ’em, saying “Well, you know, I’ve been to all these guys, “I figured I’d give you a shot,” and everything. That’s great. Hey, look, you know, I’m probably not the right person for you. If I don’t like them, or if, you know, there’s something that doesn’t mix well. And you know what it needs. Sometimes it doesn’t go. Then, I can’t help them, it’s not gonna do well and I have referred them, usually if it’s to someone I don’t like so well. You know, let them share the pain. But that’s — that happens. Usually, throughout the interview, people will come over to your side, but a lot of times, there’re just people, it just doesn’t fit, you know? And we see patients, at least I did, and I’ll them, say “Look it, it doesn’t fit,” and they’ll say “Okay, well what can I do to change?” I mean, you get this all the time because they know you’re going to fire them. And they hear the stories, because other patients “Oh man, you know, hopefully you can make the cut, “because there’s, you know, 100 people out there “in the waiting room that would love to have your position.” So, there it is.

– You know, professor, it’s funny you mention that, because you’re right, before I started doing Grand Rounds, I had never heard of a doctor ever ask the patient, “What would you like for me to do for you?” You know, I think health care’s become a very mechanical thing. You kind of get shuffled in and get shuffled out. I once remember a doctor left, and I was — The doctor left and I was waiting there for the doctor come in, the nurses wrapping me up, finishing asking me questions, whatever, I go, “I have a question for the doctor.” They go, “Oh, the doctor left for the day.” I go, “How can that be?” You know? They’re just done, they didn’t ask me what I wanted, they just kind of do what they have to do. So, I’ve always admired you for that. I want to go back to the beginning when they talked about the assessments.

– Yeah.

– So, when I’m teaching some of the clinical neuro science courses for the Carrick Institute, and which are teaching examination skills, and you mentioned how observation is really like the ultimate bedside test for you. I always tell people, or the scholars attending, I go, “Listen, Professor Carrick is an expert, because while he’s doing the reflex and assessing that, he’s truly observing what’s going on with the rest of the patient. So, I’ve been in Grand Rounds, and I’ve been the knuckle head where you say, “Garcia, did you see this when I did this?” “No, I didn’t,” you know? So you’re doing a reflex at the knee and then somebody’s shoulder goes. And so, you really taught me about real observation. Not this micro-observation. I mean, sure, you want to assess, you want to really observe what you’re testing, but really noticing what’s going on in the rest of the patient. You taught me about how you would communicate from one side of the patient to the other just to see their eyes deviate one way, and how you were observing their skin, if it was becoming flush. How you would use humor to see if they would have changes in their voice, in their face with expression. Having their eyes be positioned to the left or right, and what was going on. And that, to me, was very eye-opening as a clinician, and something that I think when people are watching or reviewing tape of you doing your work, they’re not observing all the things that you are observing, and I think that’s the difference between a novice, an intermediate, and then eventually, an expert. So I think it’s beautiful that you talked about observation, because that is what I think elevates people, when they really understand observation.

– You know, you’re right on. And sometimes you’ll hear someone say, “Well, I went to this really famous doctor, “and the guy didn’t do anything.” And you go, “Oh, you poor fool, they probably did a lot,” because sometimes it’s done — But you’re right. Like, I’ll look at somebody, and you’ll watch me, and I’ll walk to the right side, I go to the left side, and see how they follow me. I don’t have to go like, my hand’s here, hand’s here. I’m looking at it. Then I compare what I see there to what I see on the volitional or the involitional to the volitional. But the examination is very robust, and I think if we, for me, I think the best thing is to keep your hands off them. Keep your hands off them until you know what this person is. Especially with the movement irks disorders that we see. How much is involutional, what happens when you talk? You get some people that are coming in with tremors, and you’ll start talking to them, you’re looking, you go to one side, and all of a sudden the tremor will decrease. You understand hemnianopial stimulation, you’ve already got an edge on things. And then people are observing, all of a sudden they’ll see me come up and I’ll do something, this side here, and they go, “How the heck did he know how to do this?” Well, ’cause he already was talking to the guy, he’s got a good idea of what’s happening. So, I think that’s the biggest thing, is like, step back. Like, when you know your job, you want to jump in and do the test. Well, if you can hold back, and see if you can figure out what’s wrong with the person without touching them, this is marvelous. So, look at what we’ve got right now, with this COVID, we’ve got this telemedicine thing, where people now are talking to their patients and having to realize that they can’t pop in and look at this reflex, but they can get someone to bend their arm and leg, they can look at spasticities, they can do a variety of things. And the outcomes, the reports that I have from my colleagues, and these are colleagues in medicine, in different areas that patients, they feel it. They feel almost a more empathic nature. And you can’t be like a jerk, and then come in and then be empathic in your office and then go out and then be the jerk again. You either have empathy for people, or you don’t have it. And if you don’t have it, then health care’s probably not for you. And you can see people, they almost defraud the universe, because they’re not empathic people. They get in it, and then it’s like, you know, the crap. They, you hate to say “conning patients,” but yeah, you go through, and you do this, boom, boom, your going to sculp your knee, and you’re thinking of being on the golf course or something like that, so. I think empathy is really important, observations are great. So, your top, top, top thing is observation.

– Right on.

– And examination without your hands.

– You know, if I was gonna guess, because I was already kind of making a list in my head, and I thought for sure you were gonna, one of the first ones you were going to say was gonna be observing gait. Because I know you are a master of observing gait, and you have taught us, including me, how important it is, and how much information there is. And I’m still learning about gait. Like I, every time I learn something new, I am astounded at how valuable it is as an assessment, which leads me to this next question. Are you ready?

– Yeah.

– All right, this is specific to gait, they say, “Professor Carrick, can you give us some insight “regarding the significance of heel strike? “You have spoken many times about its importance, “and we’d love to hear about what happens at the moment “where a body tries to win over against gravity. “What control mechanisms are required? “What are the most common failures? “And how does a well-integrated system benefit “from the various stimuli associated “with a successful heel strike?” And they put their name on this one, that one comes from Dr. Russ Hornstein, Dr. Russ is awesome, so it’s good to see a question from him. Tell us about heel strike.

– Boy, that’s the rest of our life, sort of, the question. Heel strike is super important. When you look at gait, you can divide it into single stance phase, double stance phases, swing phases and things like that. So, when you look at heel strike, basically is the termination of the swing, and the ability to accept gravity on the heel rather than a flat foot is a whole constellation of discussions. But here it is: The faster you walk, or from walking to running, the greater the amount of force will be occurred when you end your stride. So, if you’re running, and you can imagine, “boom,” you’re gonna have a greater amount of force. Or, when individuals can’t accept a greater amount of force, usually their stride is less, or their stride may be less if they can’t balance themselves in regards to swaying or a variety other types of concombines. But at the basis of it is that the heel strike is a significant portrayal of the acceptance of force. It’s different than the push off, which is the transferring. Not plyometrically or so, but the pushing off generating force, the heel strike accepting force. And when you accept these forces you cause a percha basin of your head, largely, because you strike it, you have a shockwave if you can think of it that way that goes all the way up to your head, and it causes you to be like a little bobble-head. So, every time you hit the ground it comes up so much that an average person, not an athlete, just someone that’s having a little stroll in the park, talking to their neighbor, is going to bobble their head or have a percha basin of about 0.5 hertz, up to five hertz, which means oscillations per minute. If you’re running, you’re going to have 20 hertz oscillations. So, heel strike is really important to look at how the how the body accepts the force, and if you don’t have a good vestibular ocular response, and you have a very dynamic heel strike, then your head will bobble, and if your eyes can’t maintain focus, things are going to become a little blurry for you, so you’re not gonna do it, your gonna walk slower. So, we want to look at speed, the length of stride. A heel strike with somebody who strikes their heel just at the level of the length of the other foot is markedly different than the heel strike that’s two feet, or two foot-lengths ahead of that. A heel strike when somebody is walking where the heel should be in line, so heel, heel, heel, that heel strike is different than a heel strike that is off of the central line. A heel strike with someone who has a circumduction gait or somebody who has a peroneal nerve leisure, somebody that’s got a little bit of a foot drop, or somebody who’s got an abnormal hip mechanism, but they have to swing their foot in to accept that strike, will be seen with a different wobble, or a different change in their hip. So, without making people completely confused and thinking that my answer is worthless to Russ or somebody else, heel strike is dependent upon where the heel came from. So, that a heel strike in a central line gives a different parameter of windows from a heel strike coming up. So, if we look at ankle, knee, hip kinematics, if you swing your foot over and you strike your foot coming with the medial aspect, that torsion on your knee is markedly different than if you came in in a scissors type of a fashion. So, it’s important for so many different varieties, which is why we spend so long talking about it in detail, but it is not part of human gait, kinematics, that can be taken out of the whole. So, when we look at gait, we look at heel strike, push off, swing, single phase, double phase, time, cadence, and all of these parameters together. And that’s how you need to understand gait. Not by taking one of this infinite numbers of components out. You need to look at what’s happening with the arm, what’s happening with the head orientation, what happens with their mouth, what happens when they dual task, all of these other sort of things. But taking it right down, the heel, out of everything else, is that one moment in human existence, where the body is accepting force, and not generating, just accepting it. And the consequence of that force can be just, you know, phenomenal, it can resultly, if something hurts, you’re gonna, you’re not gonna strike so angular, you don’t have a flex or reflex afferent, then, and other things. So, the way a person accepts heel strike, can tell you what’s happening in their ankle, their knee, their hip, their low back, their shoulders, their head, from a biomechanical standpoint if they’re in line, the way they accept force can tell you a lot about their cerebellum, it can tell you a lot about their basal ganglia, and it can tell you a lot about the tones of muscles. If you can’t swing your leg forward, your heel’s not going to be striking, because you’ve got really tight hamstrings, for instance. So, we look at that in regards to the types of ellipse that they might have and everything else. It’s a wonderful question. One that we really could spend a lifetime talking about. It’s something that people have spent lifetimes talking about, just looking at, my gosh, go to the ballet, and look at, there’s a marvel — and want to know about heel strike, which is really cool, if you want to look at “Sleeping Beauty,” it’s a wonderful ballet, it’s an old ballet, and interesting music, and the best choreography was done by Nureyev, who did the choreography for the National Ballet of Canada, did that choreography. And they’ve got this wonderful aspect where they pass Sleeping Beauty from suitor to suitor, and she’s on tow for this whole thing, it just does this aspect, they turn her, it’s one of the most amazing choreographies you’ve ever seen, and there’s no heel strike, but there’s great heel strike on the suitors. So, I look at that sort of dichotomy of function, and generation of force abnormally from toe to heel, and it becomes absolutely majestic, so my eyes are bobbling, you know, just watching that type of activity. But that’s what I’d do in regards to that question, without giving you a formalized lecture, and that’s gonna maybe put some people, that are not so excited about human movement, to sleep.

– You know, professor, I remembered, I don’t know if you remember it, but there was one Grand Rounds patient where there was something about their vestibular ocular response, the heel strike, and part of the therapy was hitting the patient’s heel. Do you remember that case at all?

– No.

– See, I do, because I’ve watched these tapes. Gosh, I wish I could, and I just always want, I gotta review that one with you, but I remember part of the patient’s therapy was literally hitting the patient’s heel at a specific rhythm. And you were able to help that —

– Yeah, I —

– You’d been able to help that patient a lot, and I remember, and that was one of the first times that I started recognizing the neurological importance of heel strike, and its relationship to head, eye, vestibular movements.

– Right.

– And it was kind of

– one of those things, I’d go, “Whoa, I didn’t see that connection.”

– Yeah, we mimic those things, and I can’t recall one specific patient, but I can recall a lot of them where, when you look at the heel and it strikes and you have to maintain balance, but you can generate the same force when they’re not maintaining balance. So, it’s almost like a dynamic Romberg, if you would. So, oftentimes, I will generate force activity into the heel when they don’t have to balance. And when someone’s had a concussion, or whether they’re aged, you’ve got a variety of things that happen. Being able to stand up without falling is something we take for granted until you start getting older, or your mind starts to go, or you have frontal lobe lesions, and then, people have a hard time, because more energy is generated just to keep you up from falling, then it is to do other things. So, then, cognitive functions decrease or you can’t walk and chew gum at the same time, the dual tasking. So, in these sorts of cases, if you see one patient, other people have seen, you know, sometimes I do it a lot, sometimes I won’t do it for a month or so, I will take, and I’ll bang the heel, and I’ll look at what happens when they’re not weight bearing to see things, or I’ll give them different rhythms, sometimes I’ll do it if I want to change a gait with the hip externally rotated, and I’ll do it, or if I have someone who’s had a circumduction sort of a gait, I’ll come in, and I’ll externally rotate their hip, and I’ll start to give them a different aspect that has really great therapeutic consequences. We’re talking out of isolation, but if we looked at an actual patient, when you see I’m doing it, people go like, “What the hell?” then all of a sudden these people get up, and they’re walking like they’d never walked before, and they go like, “What the hell, why did he “wack ’em on the knee,” or “Why did he kick ’em “in the pants, or why did he do this?” you start to understand why it makes sense. And sometimes, I’m usually pretty good, I don’t usually do things that I don’t expect to work, but I can give you an infinite number of examples when I do something that definitely doesn’t work, or it makes them worse. And I’ll tell the patient, I go, “Well, that definitely wasn’t good for you, “I’m not going to do that again.” Or you’ll say, okay, “Do so cause at this target, “that’s probably what you need.” All of a sudden, then I try it, and it’s not good for them. I go, “We can’t do that. “What I would normally do, we can’t do,” and the reason I know it is because things go wrong, and then you gotta — you always have to have your escape hatch. So, in our job, when you do any therapy, you’ve always gotta know how to take it back, which means that you’ve got to be graded in what you’re doing, and realize that what you could be doing could be wrong. The idea is to make it less and less a chance, but as you regress ’em, you’re gonna make mistakes. If somebody doesn’t do things that are wrong, then they’re not pushing the envelope, because people are going to demand that you make an error, because if you’re not going for it, you’re not hitting that backhand, you know, you’re gonna lose the match. I don’t like to lose it, so I’m gonna make errors. So, every time I do something, I’m always thinking of what I’m gonna do to compensate for the evil that I do as a consequence of my mistake. And I think that’s a good, well it’s a good lesson for me, because I’m ready for bad stuff, every time I do any thera — I’m ready for bad stuff, so my therapy gets a little graduated, and I go, “Wow, great, I’m gonna –” you know, I can throw them in the deep end, they’re not going to drown down there, whereas other people, I just want the toes tickling the pool water, you know?

– I totally get it. Well, professor thank you very much, so again, some very great shares, I really appreciate it, I think that’ll wrap up this volume of Ted and Fred’s Excellent Adventure, we have more questions coming, so we’re going to get together again, and then we’ll keep going, is that okay?

– Yeah, that’d be great.

– All right, thank you professor, we’ll see you next time.

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