Should Toe-Walking Concern me?

Kids walk up on their toes. Sometimes it is for fun. Other times it is to reach up to grab something, usually something they shouldn’t be! But, there are other potential medical causes of toe-walking as well. Most toe-walking in kids is benign and resolves with just “tincture-of-time.” But, because potential causes of toe-walking fall on a spectrum of varying scariness, it is important for a child who toe-walks to be evaluated carefully.


A child’s toe-walking typically falls into one of four categories:

  • Neuromuscular
  • Orthopedic
  • Sensory-based
  • Idiopathic


For the neuromuscular type of toe-walking, it is most often caused by one of many conditions that result in an increase in tone in the calf muscles. This increased tone causes the foot to push down into a toe-walking position involuntarily. Possible causes include but are not limited to cerebral palsy, stroke, brain or spinal cord tumor, and tethered cord. These kids will very often have other challenges such as weakness, poor balance/coordination, or impaired motor control. If the cause is in the spinal cord, bowel and bladder function may be affected as well.

Toe-walking can also be caused by weakness. If the muscles a child depends on to stand and walk are weak, that child may need to use various compensation patterns to support their body. The muscles involved are typically are the ones that extend the hips and knees. Most commonly, the muscular weakness is due to a muscular dystrophy or myopathy. In these conditions, the muscle fibers do not function normally, resulting in the weakness. Depending on the type of muscular dystrophy or myopathy, a child may have weakness from when they were a baby or the weakness may develop later on in life.


Conditions that result in either shortening of tendons or joints getting “stuck” can result in toe-walking. Because of their positioning in the womb, some babies are born with tight Achilles tendons. The tightness may not be noticed until that child begins to walk. Because of the tightness, the child cannot stand or walk with their feet flat on the ground. In other cases, a person who spends a considerable amount of time with the ankles in the “toes-down” position can develop tightness in the Achilles tendon or ankle joint itself. This may occur when one has an injury and spends a few weeks in bed. But, even a change to a more sedentary lifestyle can result in this type of tightness developing. I’ve seen kids during the COVID-19 pandemic with remote learning spend so much more time doing their schoolwork and recreational activities sitting or lying down, they developed Achilles tendon tightness that they starting toe-walking! In some cases, the decreased activity was enough to cause enough Achilles tendon tightness to result in toe-walking!


Children with Sensory Integration Disorder can be “sensory-defensive” or “sensory-seeking,” both of which can cause toe-walking. That’s a bit confusing because sensory-defensive and sensory-seeking appear to be opposites! Sensory-defensive kids toe-walking because they are adverse to the feeling of the floor on the bottom of their feet. They rise up on their toes to minimize the contact of the very sensitive soles of their feet and the ground, especially on cold or rough surfaces. Kids who are sensory-seeking rise up on their toes to increase sensory input from the various sensors in the muscles of the feet and legs. These include position, stretch vibration, and other sensors. By rising up on their toes, they put themselves in an unstable position where the body needs more input from these sensors to balance and stay stable. They may even have a little bounce in their steps to increase this sensory input. This increased sensory input feeds their sensory-seeking needs. Toe-walking is more common in children with Autism than in children without Autism. Most children with Autism who are toe-walkers do so for sensory reasons.


“Idiopathic” refers to conditions where the cause is not known. It is often a diagnosis of exclusion where all other causes are “ruled out.” Though the kids with idiopathic toe-walking, don’t have a neuromuscular, orthopedic, or sensory cause of their toe-walking, it is not unusual to have relatives who are also toe-walkers, suggesting a  genetic cause.

Most kids with idiopathic toe-walking start walking on their toes as soon as they learn to walk. Most of them stop toe-walking after a few years without any specific treatment. However, some kids with idiopathic toe-walking become adults who walk on their toes. Often, this happens because that individual would have stopped toe-walking at some point during childhood; but, they couldn’t because they had already developed Achilles tendon contracture, resulting in this physical barrier to the stopping of the toe-walking. For this reason, even though idiopathic toe walking isn’t due to an underlying medical cause, and most idiopathic toe-walkers stop on their own, treatment may still be needed.


There are numerous treatments for toe-walking. But, for success, the correct combination of treatments for each individual needs to be established. I’ll touch upon some of them here.

Braces (Orthoses)

The most common brace used to treat toe-walking is the ankle-foot-orthosis (AFO). AFO’s are plastic (or sometimes carbon fiber), custom-molded braces that extend from the feet to the upper calf. For toe-walking, they should almost always have a hinge at the ankle that allows for the foot to dorsiflex (point up), but prevents the foot from plantar-flexing (point down) past neutral. AFOs help in a couple of ways. By preventing the foot from plantar-flexing past neutral, it mechanically prevents that child from toe-walking. By preventing toe-walking, the AFOs can help that child to “internalize” a regular heel-toe walking pattern. They also help by preventing or slowing down the worsening of the Achilles tendon tightness.

Nighttime dorsiflexion splints can also help to maintain the flexibility at the ankle. When we sleep, whether we do so on our backs, sides, or belly, our ankles are almost always in a toe-down position. Being in this position for the several hours of sleep results in worsening of the ankle tightness. By using a nighttime splint, similar to an AFO, worsening tightness can be prevented or slowed. Of course, this requires a child to be a pretty sound sleeper! If wearing nighttime splints prevents the child from getting a good night’s sleep, they aren’t worth it!


Both physical and occupational therapy can be helpful. A physical therapist can help to teach some toe-walking children to walk in a more heel-toe pattern. They can also help to stretch the tight muscles as well as teach the child and/or family members to stretch at home. Physical therapy homework is very important! A physical therapist may also be trained in other techniques that may be helpful such as Kinesiotaping. I’ll have to cover the topic of Kinesiotaping in another post. It’s a big one! In the situation of toe-walking caused by a neuromuscular or orthopedic cause, the physical therapist would treat the toe-walking in the context of the comprehensive physical therapy treatment of the underlying condition.

For kids who toe-walk for sensory reasons, occupational therapists are often an essential component of the team. Toe-walking due to sensory reasons is extremely difficult to stop while the sensory integration issues are still impacting that child.

Serial Casting

Serial casting is a technique that is very helpful for stretching tight muscles. It is most often provided by specially-trained physical therapists. Sometimes pediatric orthopedic surgeons perform it. In serial casting for tight Achilles tendons, therapist of orthopedist stretches the ankle in the up-position and applies a lightweight cast, similar to one that would be used for a broken bone. That child would then keep the cast on for one to two weeks, carrying on as usual. Walking is encouraged during this time. After one to two weeks, the cast is removed and the ankle is stretched further. With each cast, the ankle joint should get more flexible. These steps are repeated until the goal range is reached or the casts aren’t resulting in increased range-of-motion. Most kids tolerate the casts better than expected. But, warm weather, especially if a child enjoys swimming, is not a great time to serial cast since the casts cannot get wet.

Botulinum Toxin (Botox) Injections and Alcohol/Phenol Nerve Blocks

Botox and nerve blocks are injection procedures that reduce the “hyperactivity” of muscles by blocking some of the signals traveling between the muscle and the nerve that “controls” it. In kids who toe-walk due to “spasticity” from an injury to the brain or spinal cord, these injections can be very effective in reducing the involuntary contraction of these muscles that is causing the toe-walking. For these kids, the injections need careful planning in a comprehensive way that takes into account all of the other neuromuscular effects of that medical condition. These injections can also be helpful for idiopathic and sensory-based toe-walkers by weakening the calf muscles so it is more difficult for those children to rise up on their toes. During the period of time that the injections are in effect, the flatter walking pattern can be better “internalized” and worsening of the contractures can be prevented.

One of the most commonly mentioned disadvantages of Botox and nerve blocks is that they are temporary. Botox typically lasts for three to six months. Nerve blocks typically last six months or more. However, one of the major advantages of these injections is that they are temporary! Since kids are changing so quickly during growth and development, the factors causing their toe-walking are also changing. A temporary treatment like Botox and nerve blocks allow for better tailoring and adjusting of the treatment to meet the needs of each individual over time.

Botox injections and nerve blocks are most commonly performed by Pediatric Physiatrists (physicians who specialized in Physical Medicine and Rehabilitation Medicine). Neurologists and orthopedists also sometimes perform them.

Orthopedic Surgery

If an Achilles tendon gets too tight, serial casting and other more conservative treatments may not be enough. An orthopedic surgeon can lengthen a tendon using several different surgical techniques. The recovery time as well as how much flexibility can be gained varies with the different techniques. For this type of surgery to be successful (and not cause worsening of the walking), it should be performed by a pediatric orthopedic surgeon experienced in these techniques, with planning and decision-making performed together with the patient, family, and entire treatment team.


There are a lot of kids out there walking on their toes. Most will do just fine and will stop toe-walking on their own. But, since there are some scarier causes of toe-walking, an evaluation by a Pediatric Physiatrist should certainly be considered. And, even if the toe-walking is idiopathic, treatment is sometimes still needed for those kids who get tight at a young age or continue to toe-walk past the toddler years.

Never Let Your Guard Down Around Spasticity

Spasticity is a type of muscle tightness and hyperactivity that occurs when there is an injury to or malformation of the brain or spinal cord. It is commonly seen in conditions such as cerebral palsy, spinal cord injury, and traumatic brain injury. It can also be seen in many genetic conditions. Spasticity can be challenging in many ways:

  1. Function: Spasticity can cause impairment in function. When performing fine and gross motor tasks, muscles need to contract at the right time and in the right amount. Other muscles also need to relax at the right time.  For example, when getting up off the ground, the muscles that straighten the knee need to fire while the muscles that bend the knee need to relax. When there is spasticity, all those muscles fire at the same time, essentially working against each other. A lot of energy is expended; but most of that energy is wasted.
  2. Orthopedic Deformity: Bones grow based on the forces applied to them. Therefore, muscle balance is critical for optimal bone development. Spastic muscles pull when they aren’t supposed to, and they often do so with excessive force. Over time, joints can be pulled out of sockets, and bones can be twisted. The greatest damage occurs when an individual is still growing. When bones are growing, if muscles are not in balance, the bones will grow crooked. Scoliosis is a way-to-common example.
  3. Ease of Care: When spasticity pulls, it can prevent a caregiver from being able to move a part of the body. As a result, it can take much more time to perform hygiene and dressing tasks. And, if the spasticity prevents adequate hygiene, skin can break down resulting in infection and severe illness.
  4. Pain: Spasticity can cause pain in several ways. Most commonly, the spasticity can cause pulling on a “pain generator” such as a dislocated hip or an inflamed tendon. Sometimes the spasticity, itself, can be painful.  In addition, if the spasticity pulling on parts of the body prevents that individual from sitting or lying evenly and comfortably, pain can occur. It is common for spasticity to pull an individual to one side or the other, which then results in too much pressure concentrated on a bony part of the body.

For all these reasons, it is essential that spasticity be treated early, consistently, and aggressively. 

Hip Dysplasia…Explained (Part 1)

At the shoulder, flexibility is key. We depend on that flexibility to be able to scratch an itch on our back or toss a Frisbee to a buddy. At the hip, it’s stability that counts. We depend on our hip joints to support our weight, especially while standing. As a result, the human hip joint has evolved into a ball-and-socket joint. Its needed stability comes from the tight interface between the head of the femur and the socket of the pelvis.

Bone grows based on the forces placed on it. When a child stands, her weight causes the head of the femur to push into the socket. As a result, the socket grows deeper and deeper, and the hip joint becomes more and more stable. Of course, the opposite happens when there are not enough forces pushing the head of the femur into the socket.

The other factor is the direction of forces, which needs to be in the direction of the socket. When there is muscle imbalance around the hip joint, it becomes more difficult for the hip joint to stay secure. For individuals with Cerebral Palsy, Traumatic Brain Injury and other similar conditions that cause muscle tightness, the muscles that pull the legs in towards each other (adduction) tend to be tighter than the ones pulling the legs apart (abduction). Similarly, the muscles that twist the legs inward (internal rotation) so the knees are facing each other are tighter than the ones that twist the legs outward (external rotation). These forces torque the head of the femur out of the socket.

Its all about forces on the hip joint.

These two factors combined can be a recipe for disaster. The lack of adequate pressure pushing into the socket results in a socket that is more saucer-like than cup-like.



Over time, the shallow socket and the twisting/pulling forces result in the head of the femur moving out of the socket (dislocation).

Why is dislocation bad? Sometimes it is not. Some individuals can sit comfortably and stand on dislocated hips. Many have no pain at all. But, many lose the ability to walk, and do have pain. If only one hip dislocates, that person may not be able to sit evenly. This uneven sitting can cause pain, skin breakdown, and even cause scoliosis to develop or worsen. These, in my opinion, are very important reasons to keep hips as healthy and stable as possible.

Coming Soon…How Do We Keep the Hips Healthy?

Focus is the Key – Focal Vibration Therapy on a Budget

A few weeks ago, I wrote about whole body vibration. I’m going to shake things up a bit (pun intended, sorry) and write about Focal Vibration Therapy.

Focal Vibration Therapy has been shown to be an effective tool in neurological rehabilitation. For spasticity management, I believe it holds incredible potential. It may even play a role in the treatment of sialorrhea (excessive drooling). I’ve been exploring ways to make Focal Vibration Therapy accessible and affordable since therapy-grade vibration devices can run well over $1000. That’s just not within reach of most families, nor do I think it is necessary. More about devices later…

Over the past ten years, there have been a handful of research studies looking at the effectiveness of focal vibration for the treatment of spasticity (muscle tightness/hyperactivity due to an injury to the brain or spinal cord).  Focal vibration is a fascinating option because the standard treatments of spasticity include oral medications, injection therapies, and orthopedic & neurological surgery.

Well, what is focal vibration therapy anyway? Focal vibration is simply using a device to administer high frequency vibration to a specific body part. The vibration does not have to be strong; but, it does need to be applied to the right area, for the optimal amount of time, at the best frequency.

One theory of how focal vibration works to reduce spasticity is by triggering the Tonic Vibration Reflex (TVR).  What happens is the vibration stimulation activates sensors in the muscle (step 1). When these sensors detect the vibration, it sends a signal to the spinal cord through a sensory nerve (step 2). Then, the spinal cord has a control center (3) that turns down the volume on the opposite muscle group by sending a signal down a nerve to those muscles (step 4). This is a regular, very helpful reflex. It makes sure that when we are using a muscle or group of muscles to perform a motion, it is very helpful to “turn off” the opposite muscles so they don’t “fight” the ones trying to do a job. We are using this reflex to “turn off” or at least “turn down the volume” of the spastic muscle by stimulating the opposite ones with the vibration. Ta-da…less spasticity with no real side effects!

Now, in all fairness, focal vibration can’t eliminate the need for other spasticity treatments such as medications, injections, or surgeries. There is a good amount of research supporting the use of focal vibration; but more research is still needed to determine the best location to apply the stimulation, how strong the vibration should be, and at what frequency. Also, how long the spasticity reduction lasts varies quite a bit from study-to-study, minutes to days.

Now, without further delay, how do we do it?

As a mentioned above, vibration devices can be quite expensive. But, I believe I have found a couple of options that are much more affordable. The most versatile is the PADO CM-07 Dual Motor Percussion & Vibration Therapy Massager for Back & Sports Pain, Sciatica, Neck, Leg, FootPADO CM-07 Dual Motor Percussion & Vibration Therapy Massager.

It is unique because it has both vibration and percussion heads. When the head of the device moves towards-and-away from the body, that’s percussion. Percussion is the most common type of massage device. They are really all the rage for those overworked, sore muscles. When the head of the device moves side-to-side across the body, that’s vibration. Vibration tends to be subtler. It’s more of that gentle rub as opposed to that vigorous soft-tissue massage. The studies I reviewed all utilized vibration. But, I’ve been wondering if percussion can be beneficial or even superior. If I reason it out, each time the percussion pushes on a muscle/tendon, it would apply a stretch to that structure, similar to when your doctor checks your reflexes by tapping on your knee with a reflex hammer. But, this would be like Tommy Lee, drummer for Mötley Crüe, playing drums on your knee with a pair of reflex hammers. This type of stretch triggers the Muscle-Stretch Reflex which should elicit a similar inhibitory reflex to opposite muscles just like the Tonic Vibration Reflex. Since I haven’t found any studies investigating the use of percussion instead of vibration, what I’m saying here is all speculation. I think it is worth a try since there are so many percussion massage devices out on the market right now and many are quite affordable such as the Wahl Delux Deep Tissue Percussion Therapeutic Handheld Massager which provides only percussion but its highest setting is quite strong.

Also, like the Pado, the intensity is adjusted using a continuous dial as opposed to a push-button that selects between a few different settings. I find the continuous dial very helpful in finding just the right amount of percussion/vibration based on effect and patient’s tolerance (most find it quite tolerable or even enjoyable!). I’ve started giving it a go. I’ll chime back in down the line after I’ve had more experiences!

Now, the technique is quite straightforward. The vibration should be applied to the musculotendinous junction, the area where muscle becomes tendon. A good rule of thumb is the musculotendinous junction is about two-thirds the way down the length of the muscle. Find that spot and place the vibration head there.

As an example, to relax the calf muscle, apply the vibration to the Tibialis Anterior, the muscle in front, just to the outside of the shin bone. Hold steady for about three minutes. 

For spastic hamstring muscles, apply the vibration to the front on the thigh a bit above the knee cap.

I’m hoping that future research will give us more guidance in the type of vibration/percussion, the location, and “dose” that will give the most spasticity reduction. For now, I think the current body of evidence is compelling enough to give focal vibration a go.

Murillo N, Valls-Sole J, Vidal J, Opisso E, Medina J, Kumru H. Focal vibration in neurorehabilitation. Eur J Phys Rehabil Med. 2014 Apr;50(2):231-42.

Celletti C, Camerota F. Preliminary evidence of focal muscle vibration effects on spasticity due to cerebral palsy in a small sample of Italian children. Clin Ter. 2011;162(5).

Russo EF, Calabrò RS, Sale P, Vergura F, De Cola MC, Militi A, Bramanti P, Portaro S, Filoni S. Can muscle vibration be the future in the treatment of cerebral palsy-related drooling? A feasibility study. Int J Med Sci. 2019 Sep 20;16(11):1447-1452.

Then and Now

Sometimes tidying up the house yields some lost little treasures. During my first year of medical school, I wrote an article for “Plexus,” our medical school newsletter, about some themes that were important to me. Re-reading it was a stroll down Memory Lane. And, it reminded me of what an incredible journey it has been. I feel that I’ve traveled so far…changed so much; yet, in some ways, I’m the same.

Lessons From the Rock

(Plexus, Vol. 17, No. 17, February 20, 1996)

I said good-bye to some really good friends a few months ago. These were friends I trusted with my life…literally. Rock climbing is something you don’t do alone. Well some people do, but for me, the best part would be missing.

It was only eight months ago that I was sitting in a creek that runs through Owens River Gorge. Six hundred feet below the high desert of the Eastern Sierras, “the Gorge” seemed a million miles from alarm clocks, traffic jams, and florescent lights. We were living out of King’s truck, and surviving largely on the case of fifty Powerbars Chris won at a local climbing competition. We climbed every day, taking turns holding the rope for the other, in case one fell.

Climbing out of “The Gorge.”

You meet all types in the rock gym and at the crags, which would explain how I ended up on a climbing road trip with King, a forty-year-old high school math teacher, and Chris, a fourteen-year-old, well…kid. It was easy to understand the perplexed looks on the faces of people we met along the way. They would naturally, but erroneously, assume Chris was King’s son, but weren’t all too sure how I fit into the picture. But, to our good friends, there was no question. We shared a passion for climbing.

Getting to the rocks usually meant living conditions were going to fall somewhat short of luxurious. Climbing, itself, doesn’t seem to naturally fall into the same sentence as “fun.” It’s definitely not relaxing. Then again, we never seemed to mind as long as we were suffering together. Maybe it was because misery loves company, but I think there was more to it than that.

Living out of King’s truck.

When I met Soledad, she was just learning to walk with cuff-crutches, recently having undergone a series of operations that would hopefully allow her to leave her wheelchair behind. I was working as a volunteer instructor with Project Climb, an organization that taught climbing to “at-risk” youth. Soledad, who was ten years old, would come into the climbing gym in Santa Cruz once every few weeks with her sisters, Maria and Andrea. Their mom always followed, greeting us with a big smile. Maria was eight years old and had the energy to prove it. Andrea, being four, made the forty-foot walls of the gym look like a hundred. Not to be left behind by her sisters though, Andrea would scurry up the walls too. She was such a joy that I didn’t even mind climbing up to carry her down when she realized that climbing up was much more fun than coming down.

Soledad has Cerebral Palsy. That made no difference to her…she wanted to climb. And she did. The lower-angled wall was her favorite. After putting on a harness and tying into the rope, Soledad would grab two handholds. She would move her legs, gradually, until they touched some footholds. Pushing up a few inches, she would then grab some higher handholds. Some twenty minutes later, after reaching the top, Soledad would smile, wave, and signal us to lower her back to the ground. Exhausted, but always smiling, she would thank us and tell us how much fun the route was that she had just climbed.

Project Climb was established to build trust, self-esteem and courage; but Soledad has taught me much more than I could ever hope to have given to her. Success is not measured absolutely. We all have our own challenges in our lives, and it is how we each fact them that will determine what we take away from the experience. John Long, a famous climber, once said, “The summit meant nothing; the climb, everything.” Soledad may never summit Everest but I believe that she derives just as much, or even more, from climbing than any world-class alpinist.

This may somewhat explain what King, Chris, and I were doing in “the Gorge.” By climbing, we put ourselves in a situation that challenges us physically, mentally, and emotionally. We all climb at different levels with different natural abilities; but the challenges are real for each of us. Overcoming the challenges on the rock carries much further than just the cliffs. And the fact that we help each other in each of our pursuits doesn’t detract from the accomplishments. Rather, it allows us to push past our perceived limitations, thereby accentuating the rewards.

Chris climbing something hard in “The Gorge.”

Well, let’s see. Chris is now Junior World Champion for his age group and ranks amongst the top five competition climbers in the country. He continues to fire up the hardest climbs in the States. King, still pulling down hard in the gym, on the rock, and in his classroom, is getting stronger by the day. Soledad, no doubt, is walking and climbing better than ever, and is brightening up the day for everyone she meets. As for me, I’m in medical school now. Traded my ropes, carabiners, canned chilli, and calluses on my fingers for books, scalpels, cafeteria burgers, and a rear end permanently molded to the histo-lab seats (ok, at least the quality of my diet hasn’t changed much). It was really tough for a while, but I do realize one thing. The faces of companions are new and today’s adventures may be different, but you never ever truly lose your old friends or the adventures you shared together. They are who you are, as new friends will take part in forming who you will become tomorrow. There are new challenges every day, but I know that this trip will continue to yield rewards. Over these first few months of medical school, I have met some wonderful people. And, things aren’t that scary anymore now that I know friends are once again holding the other end of the rope. 

To Improve Balance, Wobble – Slackline Training Therapy


Life is all about balance. Sour Patch Kids accomplished the perfect balance of sweet and sour. SCUBA diving bliss happens when one is neutrally buoyant, just the right amount of floating and sinking.  Mobility is dependent on optimal balance, too. A little too much of left or a little too much of right, and…well, you know. 

Optimal balance requires a few “senses” feeding information: vision to give orientation in space, information about the position of a body part relative to others (proprioception), and the control center in the brain to process all of the information (cerebellum). It is important to note that if you are missing one of these senses (such as vision), one can still maintain balance; but, the rest of the components need to work that much harder. The brain and spinal cord process all of this data and then controls one’s muscles to maintain a position or make some moves. Therefore, strength is just as important as the other components when it comes to posture and movement. 

For individuals with Cerebral Palsy, there may be impairments in some or all of these important components. Physical therapy is often focused on addressing these particular impairments. That’s why I got so excited when I came across this research study by Lucia Gonzalez and her colleagues. In their study, they randomized twenty-seven children and adolescents with Spastic Cerebral Palsy into two groups. One group received traditional physical therapy while the other group received slackline training. Both groups trained three times a week for 6 weeks. Both groups improved in their postural control and motor skills with greater improvement in the slackline training group for several measures. In addition, the slackline training was rated as requiring only light exertion. Now, I love slacklining. But, for me, I would definitely NOT rate it as light exertion!

González L, Argüelles J, González V, Winge K, Iscar M, Olmedillas H, Blanco M, Valenzuela PL, Lucia A, Federolf PA, Santos L. Slackline Training in Children with Spastic Cerebral Palsy: A Randomized Clinical Trial. Int J Environ Res Public Health. 2020 Nov 21;17(22):8649.


Slacklining is a sport (or sometimes an obsession) where a person balances on a strip of nylon webbing that is attached to two stable structures. Unlike tightrope walking, a slackline is not strongly tensioned. Instead, it kinda sags. And, it’s that sag that adds to the challenge!

Generally, a slackline is attached between two trees. With the growing popularity of slacklining over the past few years, there are several commercially available “kits” that make it easy to set one up. Works great when you have two solid trees hanging around at just the right distance apart without a swamp with crocodiles or a garden of pricker-filled bushes between them. But, when that isn’t the case, Gibbon, one of the most well-known slackline equipment companies, came up with this free-standing slackline!

The SlackRack lets you set up a slackline anywhere, including indoors. It may be the only safe and practical way of slacklining in the comfort of your living room! And, for physical therapy gyms, it is a no-brainer. It is very light making moving it a snap. Slide it between parallel bars, add a well-adjusted walker, or a pair of Loftstrand crutches and slacklining becomes accessible to even more people!

The SlackRack comes in 2 models, the Classic and the Fitness. Gibbon recommends the Classic for families and the Fitness for balance and coordination training. Hmmm, what if your family wants to train balance and coordination? Then, which one? We bought the Fitness model to check out so I haven’t tried the Classic. You probably can’t go wrong with either one.

Both models are eight feet long. If you are short on space, the SlackRack can be set up as a four-footer. Add the optional extension and you can cruise along for twelve feet. Remember, the longer the slackline, the more it will wobble and swing.

I’ve been dropping hints at our hospital to add a few SlackRacks to our therapy gym. I’m all for the therapeutic benefits of fun stuff. And, I think slacklining can be tons of fun. We just need a few more research studies to help us to optimize our prescriptions for therapeutic slackline training!

Have you slacklined before? Do you think it can be used as therapy?

Shake, Rattle & Roll – Whole Body Vibration Training On A Budget

One can build strength by resistive exercises, which can come in two general forms: high resistance-low repetition and low resistance-high repetition. Bulking up? Go with high resistance-low repetition. Toning and building endurance? Go with low resistance-high repetition. These conventions, of course, are general and there are many exceptions. But, I’m all for “simple.” I think of Whole Body Vibration Training (WBVT) as low resistance-high repetition to the extreme! With each vibration, the body’s posture is perturbed necessitating small muscle contractions throughout the entire body to stabilize itself. These are small contractions but they are happening hundreds to thousands of times a minute. They all add up to a training effect.


WBVT refers to the transmission of vibrations to the human body for the purpose of eliciting some type of benefit. This is most commonly accomplished with a device called a vibration plate. Or, you can take a bus ride along a remote Nepalese road to Katmandu! WBVT is nothing new. But, over the past few years, there has been much more interest in the medical research community. We now have more evidence supporting its use in the treatment of neuromuscular and orthopedic conditions.

Vibration comes in a few flavors: vertical vibration, horizontal vibration, and oscillation (think teeter-totter). The most common way of using a vibration plate is to stand on it. Simply standing on it for ten minutes has been shown to be beneficial. To step it up, one can lift weights, use resistance bands, throw and catch medicine balls, or practice yoga poses. If you are a master-planker, planking on a vibration plate can be a game-changer. Same goes for push-ups. For individuals who are unable to stand, kneeling and sitting can be effective even if support is needed. Adjust a walker or gait trainer a little bit taller and use it together with the vibration plate. I’ve seen Rehab Technology Therapists make engineering magic happen by attaching vibration plates to the footplates of standers. Sky’s the limit when you knowledge meets imagination!

A walker or gait-trainer can be placed over a vibration plate.


My interest in WBVT stated about five years ago when a few research studies showed that this intervention could possibly reduce spasticity. 10 minutes on a vibration plate can reduce spasticity for about 45 minutes to a couple of hours. 

Things got even more exciting when some studies showed potential strengthening effects for individuals with stroke, the elderly, and children with Cerebral Palsy. Building strength is one of the most effective ways of improving function and mobility in individuals with neuromuscular conditions. It is also one of the most challenging. If one does not have adequate strength and motor control to perform resistive exercises, options for strengthening become very limited. This is where WBVT may be the key. Things were already looking great. Then, WBVT “doubled-down” by showing potential ability to improve balance and bone mineral density. I’m betting that it can improve bowel motility and reduce constipation. The studies haven’t been done yet; but, I wouldn’t be surprised if it does. The research continues and the future looks bright! 


Just a few years ago, one would potentially have to “mortgage the farm” to pay for the $3K to $7K, therapy-grade vibration plate. Luckily, the fitness industry has embraced and adopted WBVT as a way to “super-charge” workouts. As a result, there are dozens of affordable home vibration plates, some under $100. From what I have seen, you don’t need to be at $7K; but, you probably don’t want to be at under $100. The “sweet spot” seems to be in the $200 to $400 price point. Since there are so many options now, it’s important to take a good look at the specifications of each vibration plate.

Rumblex Vibration Plate
The LifePro Rumblex 4D is my favorite home vibration plate. It can provide horizontal, vertical, and oscillation vibration or any combination of the three. It has some pretty powerful motors capable of frequencies of 4hz-40hz and oscillation excursion of 1cm-12cm.

The LifePro Rumblex 4D is my favorite home vibration plate. It can provide horizontal, vertical, and oscillation vibration or any combination of the three. It has some pretty powerful motors capable of frequencies of 4hz-40hz and oscillation excursion of 1cm-12cm.

The LifePro Waiver Mini is only 23.6 inches long, 13.8 inches wide, and 4.7 inches tall, making it a great choice to integrate with a stander. At 4hz-10hz, it isn’t as powerful as its siblings; but, it should be plenty when used with a stander.

Right between the Rumblex and the Waiver Mini is the LifePro Hovert 3D in power and types of vibration. It is slightly smaller and lighter than the Rumblex 4D (30.5 x 15.3 x 5.8 inches, 35 lb). It has oscillation and horizontal vibration modes but not vertical. For spasticity-reduction, strengthening, balance, and bone mineral density, the vertical vibration mode is the least useful.

I’m hoping to see more studies that will guide us in the optimal “dosing” of this intervention. We need to know how hard, how fast, and for how long to shake, rattle, and roll. And, it would be very helpful to see more studies done with these affordable home fitness vibration plates.

WBVT, I believe, holds great potential. But, it isn’t a good fit for everyone. If you have epilepsy, your neurologist should be part of the discussion regarding the appropriateness of WBVT for you. In general, as for all types of exercise and therapies, I would recommend that you have a chat with your medical team before rockin’ it with WBVT.

Have you tried WBVT as exercise or therapy? Please share your thoughts and experiences!


It has been a long journey; ten years of medical education and training, followed by fifteen years of practice. it has been a tough road. But, there have been so many individuals along the way who have propped me up when I was falling over. So many have extended a supportive hand when I had already fallen. Many have offered a generous seat at their dinner table when I needed nourishment. And, so many have shouldered the burden to allow me to rest for a while. And, so I realized that this journey has not been undertaken alone; and, it continues as a team…a family.

Much of the knowledge I possess and use in everyday practice has not come from textbooks, lectures, and research publications. So much of what I have learned, I learned from personal trainers, rock climbers, SCUBA divers, martial artists, dancers, fencers, and chess players. And, my patients, their families, and our community have taught me so much about both treatment options, and the Art of Living, alike.

With these writings, I hope to add a new facet to this incredible journey. Life is full of challenges; and, each person’s journey is unique. I am grateful that our paths as passengers on this same wondrous, blue, planet cross often. And, I hope we can all continue to share, teach, and learn from one another. My goal for this forum is that it be a conversation as I selfishly hope to continue to learn from you. Thank you. We are on our way…