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Title: A Kinetic Chain Approach to Musculo-Skeletal Pain Combining Manual Therapies, Nutrition and Corrective Exercise.


1
A Kinetic Chain Approach to Musculo-Skeletal Pain
Combining Manual Therapies, Nutrition and
Corrective Exercise.
  • GEOFF LECOVIN DC ND L.Ac CSCS
  • ADAM RINDE, N.D., ASCM-HFI., CES

2
Integrative Approaches to Pain
  • This class is a synthesis of cutting-edge
    chiropractic, osteopathic, naturopathic, massage,
    nutrition and dry needling techniques and
    principles.
  • Practitioners and students will learn the
    different phases of pain and how to effectively
    assess and manage each phase with physical
    medicine, exercise, nutrition and prescription
    drugs.
  • Participants will refine their skills in soft
    tissue and joint manipulative therapy and get
    exposure to dry needling. They will be able to
    effectively manage the most common orthopedic and
    sports medicine problems seen in private
    practice.

3
Course Objectives
  • Understand the different phases of pain
  • Differentiate between an orthopedic approach and
    Integrative approach to musculoskeletal pain
  • Understand the significance in assessing the
    kinetic chain
  • Learn about common distortion patterns
  • Understand the role of trigger points
  • Understand the significance of perpetuating
    factors
  • Learn how to assess musculoskeletal conditions
  • Learn how to decide which manual therapy or
    modality is indicated
  • Understand the role of corrective exercise as
    part of the treatment plan and prevention

4
Class Format
  • Lecture on theory, rational and approach
  • Hands-on application- evaluation and treatment

5
PAIN
  • An unpleasant sensory and emotional
    experience associated with actual or potential
    tissue damage, or described by the patient in
    terms of such damage.
  • International Association for the Study of
    Pain

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3 PHASES OF PAIN
  • 1. Immediate/Nociceptive
  • 2. Acute/Inflammation
  • 3. Chronic

8
IMMEDIATE /NOCICEPTIVE PAIN
  • Induced by extrinsic factors where there could be
    a threat of tissue damage
  • Acute onset e.g. cut, burn, slap
  • Over 90 will recover within a few weeks
  • Pain messages are carried by A-Delta and C Fibers
  • Good prognosis

9
ACUTE INFLAMMATION
  • Actual tissue damage e.g. strain/sprain
  • Recognized by signs of inflammation- redness,
    increased local temperature, and swelling
  • Occurs as a result of substances released by
    damaged tissue cells (which are necessary for
    repair)
  • Pain messages are carried by C-fibers
  • Self limiting
  • Responds to Naturopathic therapies or NSAIDS,
    analgesics and rest

10
Biochemical Causes of Acute Pain (Inflammation)
  • Vasoactive amines- histamine, serotonin
  • Bradykinin
  • Prostaglandins
  • Leukotrienes
  • Thromboxanes
  • Cytokines- interleukins and tumor necrosis factor
  • Lactic Acid
  • Potassium ions
  • Irritate nociceptors
  • Usually self-limiting

11
Drugs and Musculoskeletal Pain
  • Always check your patients medications for
    possible musculoskeletal side effects e.g.
    Statins, anti-hypertensive drugs etc.

12
CHRONIC PAIN
  • Ongoing nociception or inflammation
  • Psychological
  • 3. Neuropathic- functional and structural
    alterations within the Neuromusculoskeletal
    system

13
Structure vs Function
  • Structure (orthopedic approach)- focuses on the
    pathology of static structures emphasizes
    diagnosis based on localized evaluation and
    special tests.
  • Function- recognizes the function of all
    processes and systems within the body, rather
    than focusing on a single site of pathology.
  • The structural approach is necessary and
    valuable for acute injury or exacerbation, the
    functional approach is preferable when addressing
    chronic musculoskeletal pain.

14
Traditional Orthopedic Approach
  • Isolated joint kinematics
  • Uniplanar
  • Isolated muscle strength
  • Morphologically oriented

15
Integrative Functional Approach
  • Focuses on all kinetic chain components
    (muscular, articular, neural)
  • Optimum acceleration, deceleration and dynamic
    stabilization in multiplanar (saggital, frontal,
    transverse) movements
  • Enables synergistic production and reduction of
    force and dynamic stabilization
  • Maintains optimum length-tension and force-couple
    relationships of agonists and antagonists
  • Allows optimum joint arthrokinematics and
    neuromuscular efficiency

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Regional Interdependence
  • Seemingly unrelated impairments in a remote
    anatomical region may contribute to, or be
    associated with, the patients primary complaint
  • Wainner et al JOSPT 2007

19
Optimum Alignment
  • Alignment of the musculoskeletal system allowing
    posture to be balanced with center of gravity
  • Ability of the neuromuscular system to perform
    functional tasks with the least amount of energy
    and stress on the kinetic chain
  • Optimum muscle length-tension relationships at
    which a muscles are capable of developing maximal
    tension

20
KINETIC CHAIN CONCEPTS
  • Proprioception- the cumulative neural input to
    the CNS from mechanoreceptors (specialized neural
    structures that convert mechanical information
    into electrical information that is relayed to
    the CNS)
  • Length-Tension Relationship- the optimal length
    at which a muscle can produce the greatest force
  • Force-Couple Relationship- the synergistic action
    of muscles to produce movement around a joint
  • Arthrokinematics-The ability of a joint to move
    through its biomechanical range of motion

21
Optimal Neuromuscular Control
  • Normal length tension relationships
  • Normal force couple relationships
  • Normal arthrokinematics
  • Optimal sensorymotor integration
  • Optimal neuromuscular efficiency
  • Optimal tissue recovery

22
Example of Kinetic Chain Dysfunction and Pain
  • Excessive pronation- metatarsalgia, bunion, PF,
    neuroma
  • Excessive tension in tibialis posterior and
    peroneous longus- shin splints
  • Knee stress- tendonitis, injury susceptibility
  • Lateral thigh tension- tight hamstrings, ITB, TFL
    (e.g. PFS)
  • Abnormal L-P rhythm- anterior pelvis rotation
  • Increased lumbar lordosis- tight psoas, erector
    spinae and latissimus dorsi- Lumbago
  • Downward traction of the scapula with shoulder
    movement
  • Excessive tension in outer shoulder muscles
  • Neck and shoulder pain

23
MUSCLE ACTION CLASSIFICATIONS
  • Agonists- prime movers
  • Antagonists - act in direct opposition to prime
    movers
  • Synergists - assist prime movers during
    functional movement patterns.
  • Stabilizers- support or stabilize the body while
    the prime movers and the synergists perform the
    movement patterns
  • Neutralizers- muscles that counteract the
    unwanted action of other muscles

24
Functional Muscle Division
  • Stabilization Group
  • Movement Group

25
Stabilization Group (Local Muscles/Inner Unit)
  • Peroneals
  • Tibialis posterior/Anterior
  • VMO
  • Gluteus Medius
  • Pelvic floor muscles
  • Transverse Abdominus
  • Internal Oblique
  • Multifidus
  • Deep erector spinae
  • Transversospinalis group
  • Diaphragm
  • Serratus anterior
  • Middle/Lower Trapezius
  • Rhomboids
  • Teres Minor
  • Infraspinatus
  • Posterior deltoid
  • Lomgus Coli/Capitus
  • Deep cervical Stabilizers

26
Movement Group (Global/Outer Unit)
  • Gastocnemius/Soleus
  • Adductors
  • Hamstrings
  • Gluteus Maximus
  • Psoa
  • TFL
  • Rectus Femoris/Quadriceps
  • Piriformis
  • Erector Spinae
  • QL
  • Rectus abdominus
  • External oblique
  • Pectoralis Major/Minor
  • Latissimus Dorsi
  • Teres Major
  • Upper Trapezius
  • Levator Scapulae
  • SCM
  • Scalenes

27
FUNCTIONAL MOVEMENT DIVISION SUMMARY
  • Stabilization System (inner core)
  • ?? Local muscles for joint support and posture
  • ?? Being prone to weakness and inhibition
  • ?? Less activated in most functional movement
    patterns
  • ?? Fatigue easily during dynamic activities
  • ??Predominantly slow twitch
  • Movement System (outer core)
  • ?? Global muscles for movement
  • ?? Being prone to developing tightness
  • ?? Readily activated during most functional
    movements
  • ?? Overactive in fatigue situations or during new
    movement patterns
  • ?? Compensate (synergistic dominance) during
    fatigue states
  • ?? Predominantly fast twitch

28
Low Back Pain
  • Chronic low back pain represents 85-95 of the
    population
  • Lack of appropriate neuromuscular response of the
    muscles stabilizing the LPHC
  • Patients unable to preferentially recruit the
    inner unit musculature of the LPHC
  • Recruitment of motor units from the outer unit
    leading to synergistic dominance, altered normal
    force couple relationships, length-tension
    relationships, joint kinematics and neuromuscular
    control

29
CAUSES OF MUSCLE IMBALANCES
  • Pattern overload
  • Aging
  • Decreased recovery and regeneration following an
    activity
  • Repetitive movement
  • Lack of core strength
  • Immobilization
  • Cumulative trauma
  • Lack of neuromuscular control
  • Postural stress

30
Postural Distortion Patterns
  • Altered Reciprocal Inhibition- The process
    whereby a tight or overactive agonist inhibits
    its functional antagonist. This results in
    altered force couple relationships and
    synergistic dominance and leads to the
    development of faulty movement patterns and poor
    neuromuscular control.
  • Synergistic Dominance-The process whereby
    synergists compensate for a weak or inhibited
    prime mover in attempts to maintain force
    production and functional movement patterns. This
    causes faulty movement patterns, which leads to
    tissue overload, decreased neuromuscular
    efficiency and injury.
  • Arthrokinetic Dysfunction- A biomechanical
    dysfunction in two articular partners, resulting
    in abnormal joint movement (arthrokinematics),
    muscle inhibition and proprioception disturbance.
  • Myofascial dysfunction (trigger points)
  • CNS changes

31
MYOFASCIAL PAIN SYNDROMES
  • A myofascial trigger point is a highly localized
    and hyperirritable spot in a palpable taut band
    of skeletal muscle fibers.
  • Travell and Simons

32
TRIGGER POINT SYMPTOMS
  • 1. Onset after micro or macro trauma
  • 2. Local or referred pain (RPP)
  • 3. Pain with muscle contraction
  • 4. Muscle stiffness and restricted joint motion
  • 5. Muscle weakness
  • 6. Paresthesia and numbness
  • 7. Proprioceptive disturbance- dizzy, lack of
    balance
  • 8. Autonomic dysfunction- pilomotor reflex
  • 9. Edema and celllulite- decreased circulation
    and waste accumulation
  • 10. Sleep disturbance

33
Pathogenesis
  • Over stretching/over shortening
  • Overloading of tissue
  • Micro-trauma
  • Destruction of sarcoplasmic reticulum
  • Release of calcium
  • Sustained muscle contraction

34
Physical Findings of MTrPs
  • Taut band
  • Tender and painful nodule to palpation
  • Patient pain recognition
  • Local twitch response
  • Limited range of motion
  • Muscle weakness
  • Positive stretch sign- pain of mechanical or
    neural origin exhibited during myofascial
    stretching that can be improved with trigger
    point therapy to the muscle

35
Classification of Trigger Points
  • Satellite
  • Attachment
  • Active
  • Limit ROM
  • Weakness
  • Local Referred pain
  • Latent
  • Limit ROM
  • Weakness
  • Pain only with compression

36
Classification of Trigger points
  • Active TP
  • Limit ROM
  • Weakness
  • Local Referred
  • Pain
  • Latent TP
  • Limit ROM
  • Weakness
  • Pain only with compression

37
TRIGGER POINTS ARE KNOWN TO CAUSE
  • Headaches
  • Neck and jaw pain
  • Low back pain
  • Carpal tunnel syndrome
  • Joint pain (arthritis, tendonitis, bursitis,
    ligament injury)
  • Tennis elbow
  • Contributing cause of scoliosis
  • Earaches
  • Dizziness
  • Nausea
  • Heartburn
  • False heart pain
  • Arrhythmia
  • Genital pain
  • Sinus pain/congestion
  • Colic and bed wetting
  • Depression, CFS, lowered resistance to infection

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Trigger Point Evaluation
  • History
  • Establish biomechanics of injury
  • Identify RPP
  • Evaluate ROM limitation
  • Check for weakness
  • Palpate for local tenderness
  • Look for possible LTR
  • Applicable orthopedic/neurologic tests
  • Identify perpetuating factors
  • Establish myofascial diagnosis

46
Motor Programs (CNS Changes)
  • Blue prints of movement stored in memory much
    like a computer program
  • Initiated in higher brain centers (cerebral
    cortex) and carried out by lower centers (brain
    stem, cerebellum, Basal Ganglia) in the form of
    muscle synergies

47
Kinetic Chain Imbalances
  • Imbalances in muscle length
  • Altered normal length-tension relationships
  • Abnormal force-couple relationships
  • Altered reciprocal inhibition of the functional
    antagonist
  • Synergistic dominance
  • Faulty movement patterns
  • Initiation of the cumulative injury cycle

48
Cumulative Injury Cycle
49
Postural Distortion Patterns
  • When a chain reaction evolves in which some
    muscles shorten and others weaken, in
    predictable patterns of imbalance
  • Janda
  • Upper crossed syndrome
  • Lower crossed syndrome

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UPPER-EXTREMITY POSTURAL DISTORTION
  • Characterized by Rounded shoulders and a forward
    head posture. This pattern is common in
    individuals who sit a lot or who develop pattern
    overload from uni-dimensional exercise
  • Shortened Muscles Pectoralis major and minor,
    Latissimus dorsi, teres major, upper trapezius,
    levator scapulae, sternocleidomastoid, scalenes
  • Lengthened Muscles Lower and Middle trapezius,
    serratus anterior, rhomboids, teres minor,
    infraspinatus, posterior deltoid, deep cervical
    flexors
  • Common injuries Rotator cuff impingement,
    shoulder instability, biceps tendonitis, thoracic
    outlet syndrome, headaches

52
LUMBO-PELVIC-HIP POSTURAL DISTORTION
  • Characterized by Increased lumbar lordosis and
    an anterior pelvic tilt
  • Shortened Muscles Iliopsoas, rectus femoris,
    tensor fascia latae, piriformis, adductors,
    hamstrings, erector spinae, gastocnemius, soleus
  • Lengthened Muscles Gluteus maximus, gluteus
    maximus, gluteus medius, VMO, transversus
    abdominus, multifidus, internal oblique, anterior
    and posterior tibialis
  • Common injuries Hamstring strains, anterior knee
    pain, low back pain

53
LOWER-EXTREMITY POSTURAL DISTORTION
  • Characterized by Excessive foot pronation, genu
    valgus and poor ankle flexibility
  • Shortened Muscles Peroneals, gastrocnemius,
    soleus iliotibial band, hamstrings, adductors,
    iliopsoas
  • Lengthened Muscles Posterior tibialis, flexor
    digitorum longus, flexor hallicus longus,
    anterior tibialis, posterior tibialis, vastus
    medialis, gluteus medius, gluteus maximus
  • Common Injury Patterns Plantar fasciitis,
    Posterior tibialis tendonitis (shin splints),
    anterior knee pain, low back pain

54
Looking at the Body joint-by-joint From the
Bottom Up
  • Ankle mobility (particularly sagittal)
  • Knee stability
  • Hip mobility (multi-planar)
  • Lumbar Spine stability
  • Thoracic Spine mobility
  • Gleno-humeral stability
  • (The joints alternate mobility and
    stability)
  • Injuries relate closely to proper joint function
  • Problems at one joint usually show up as pain in
    the joint above or below

55
Patient History OPQRST
  • O- Onset
  • P-palliative/provocative
  • Q-quality
  • R-radiation
  • S-severity
  • T-temporal factors
  • FAOMASH (family hx, accidents, other, meds,
    allergies, surgical history, hospitalizations)
  • The patient will tell you whats wrong if you
    know how to ask

56
Patient Examination IPPIRONEL
  • I-inspection
  • P-palpation
  • P-percussion
  • I-instrumentation
  • R-range of motion (active and passive)
  • O-orthopedic tests
  • N-neurological tests i.e. motor, sensory
  • E-extra tests e.g. x-ray, MRI, CT
  • L-lab

57
Posture
  • Dynamic
  • Structural efficiency
  • Neuromuscular efficiency
  • Balance and equilibrium
  • Functional strength

58
Static Posture Landmarks
Side An imaginary line should run slightly
anterior to the lateral malleolus, through the
middle of the femur, center of shoulder and
middle of the ear Posterior An imaginary line
should run from between the medial malleoli, up
through the spine and center of the
head Anterior An imaginary line should run from
between the medial malleoli, up through the
sternum and center of the head

59
Common Dysfunctional Patterns
  • Ankle/Foot- Pronation/Turns out
  • Knee- Hyperextended/Moves in or out
  • Hip- Uneven
  • Lumbar/Pelvis/Hip- Lordosis/scoliosis
  • Thoracic- kyphosis/scoliosis
  • Scapulae- Uneven/abducted
  • Cervical- Lordosis/scoliosis
  • Head- Forward

60
Observing Dynamic Posture
  • Relates to the basic functions- squatting,
    pushing, pulling and balancing
  • Shows muscle and joint interplay
  • Can uncover postural distortions and imbalances
    in anatomy, physiology and biomechanics that can
    lead to injury

61
Movement assessment
  1. Identifies movements that consistently causes
    pain
  2. Identifies altered motor control, abnormal
    length-tension relationships, relative
    flexibility and faulty movement patterns  that
    can cause pain and can lead to pathology e.g.
    arthritis
  3. Movement impairment is classified by the
    direction of movement that causes pain e.g.
    movement classifications in the spine flexion,
    extension, rotation, flexion/rotation,
    extension/rotation
  4. Testing is performed sitting, standing,
    side-lying, prone, supine and in a quadruped
    position bilaterally and unilaterally
  5. Reproducing the pain is the key to both
    identifying the problem and effective treatment
    through therapy and corrective exercises/activitie
    s

62
Kinetic Chain Check Points (anterior/posterior/la
teral)
  • Foot/Ankle Straight ahead w/ neutral position at
    the ankle
  • Knee Straight ahead in line w/ 2nd and 3rd toes
  • Lumbo-Pelivic-Hip Complex Neutral spine with
    abdominals drawn in
  • Shoulder and cervical spine Neutral, center of
    shoulder in line with center of hip joint
  • Head Neutral, center of ear in line with center
    of shoulder

63
Dynamic Inspection (Overhead Squat)
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Abnormal Hip Extension Test
  • Patient prone and instructed to extend their hip
  • Doctor palpates erector spinae with thumb and
    index finger of one hand, while palpating the
    gluteus maximus and hamstring with the little
    finger and thumb of the opposite hand
  • Normal firing order- GM, contralateral ES,
    ipsilateral ES and hamstring

69
Altered Firing Pattern
  • Weak agonist- Gluteaus Maximus
  • Overactive antagonist- Psoas
  • Overactive stabilizer- Erector spinae
  • Overactive synergist- Hamstring
  • Symptoms- low back pain, buttock pain, recurrent
    hamstring strains

70
Abnormal Hip Abduction Test
  • Patient side lying/abducts hip. Doctor stands
    behind
  • Palpate QL with one hand and TFL and Gluteaus
    medius with the other hand
  • Normal firing order- Gluteaus Medius, TFL/QL

71
Altered Firing Pattern
  • Weak Agonist- Gluteus Medius
  • Overactive antagonist- Adductors
  • Overactive synergists- TFL
  • Overactive stabilizer- QL
  • Overactive neutralizer- piriformis
  • Symptoms- LBP, buttock pain, lateral knee pain,
    anterior knee pain, shin splints, plantar
    fasciitis

72
Trunk Flexion Test (abdominals and LPHC stability)
  • Patient is supine with knees and hips and 90
    degrees is instructed to perform a curl up
  • Normal firing pattern- ability to maintain a
    drawing-in maneuver
  • Altered firing pattern
  • Weak agonist- abdominal complex
  • Overactive antagonist- erector spinae
  • Overactive synergist- psoas
  • Symptoms- LBP. buttock pain, facet syndrome,
    facet instability

73
SPECIAL IMAGING Help or Hindrance?
  • Lumbar MRIs were done on 98 people with no hx of
    back or leg pain. 36 had normal discs at all
    levels, 52 had bulging discs at one or more
    levels, 27 had a disc protrusion and 1 had an
    extrusion.
  • The discovery by MRI of bulges or protrusions in
    people with low back pain may frequently be
    coincidental.(NEJM,1994)

74
GOAL OF TREATMENT
  1. Control the pain and break the pain cycle
  2. Break chemical and Mechanical feedback loop that
    maintains muscle contraction
  3. Increase circulation that has been restricted by
    contracted tissue
  4. Lengthen shortened muscles
  5. Reconditioning and strengthening weak muscles
  6. Correct movement patterns
  7. Prevention of recurrence through an appropriate
    exercise program

75
TREATMENT
  • Provocative
  • Active
  • Resisted
  • Functional
  • Proprioceptive

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Effective Treatment Options
  • Ischemic compression
  • Injection techniques
  • Dry needling
  • Soft tissue manipulation
  • Muscle energy technique (MET)
  • Joint manipulation
  • Friction massage
  • Ultrasound
  • Spray and Stretch
  • Contrast therapy
  • Corrective exercise
  • Supportive taping
  • Diet and nutrition to aid in repair

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Progressive Pressure Release Technique
  • Apply progressive pressure to point of tissue
    resistance for 45-60 seconds. Hold until
    resistance dissipates. Repeat procedure 3-4 times
    each time moving to a deeper barrier
  • Pressure is to patient tolerance
  • Have patient deep breathe
  • Release pressure quickly to produce vasodilation
    and elimination of the local ischemia
  • Identify and treat satellite trigger points
  • Follow by stretching (30 sec) and breathing
  • Post treatment heat or cold applications

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THE EFFECTS OF DRY NEEDLING
  • Provides Blood Growth Factors which can disrupt
    micro scars and promote tissue repair
  • Strengthen Tendons Ligaments by inducing local
    inflammatory reactions (PDGF, Fibroblasts,
    collagen)
  • Stimulates stretch sensitive GTO muscle
    spindles
  • Mechanical disruption
  • Treat Overactive Motor Points
  • Alters Neural Control via neurotransmitters,
    endorphins and inhibitory mechanisms
  • Stimulates Reflex Mechanisms e.g. spinal,
    sympathetic and circulatory

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SOFT TISSUE RELEASE TECHNIQUE (NMR- 97112)
  • Specific contact is made on the muscle
  • Traction is applied to the tissue in order to
    trap the lesion
  • The muscle is moved either actively or passively
    through the line of injury
  • The stretch is held for 1-2 seconds
  • Repetitions are done in different positions and
    planes of motion (8-10 times)

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EFFECTS OF SOFT TISSUE RELEASE
  • 1. STR stretches and softens scar
    tissue/adhesions
  • 2. Pain input messages to limbic system are
    reprogrammed
  • 3. Muscle length, flexability and memory are
    regained

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Muscle Energy Technique
  • A manual therapeutic procedure that involves
    contraction of a muscle in a controlled
    direction, at varying levels of intensity against
    a distinctly executed counter force applied by
    the therapist

83
Clinical Use
  • Lengthen a short muscle
  • Strengthen a weak muscle
  • Decrease local edema
  • Joint mobilization

84
Two Forms of MET
  • Post-Isometric relaxation (autogenic inhibition)
  • Contraction of agonist muscle
  • Relaxation of same muscle
  • Acute and chronic conditions
  • Reciprocal inhibition
  • Contraction of agonist
  • Relaxation of antagonist
  • Acute conditions

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The Barrier Concept
  • Beginning of range of motion
  • (Pathological barrier)
  • Physiological barrier- end of active ROM
  • Para-physiological space- between physiological
    barrier and anatomical barrier
  • Anatomical barrier- beyond which lyses of joint
    structures occurs

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MET
  1. Move to barrier and evaluate
  2. Position at barrier
  3. Isometric contraction (PIR or reciprocal
    inhibition)- 7-10 sec
  4. Patient relaxation
  5. Move to new barrier
  6. Repeat 3-4 times
  7. Re-evaluate
  8. Goal is to push pathological barrier to the
    physiological barrier

87
Use of Eye Movement and Breathing
  • Contraction- inhale-hold and look up
  • Relaxation- Exhale-hold and look down

88
Joint Mobilization
  • A set of passive motions with the purpose of
    improving mobility and function

89
Indications For Manipulation/Mobilization
  • Segmental dysfunction/hypomobile joints
  • Mechanical effects
  • Adhesions
  • Trigger points
  • Stimulation circulation, nervous system,
    lymphatic flow, joint receptors
  • Restore joint and muscle function
  • Psychological effects

90
Subluxation Complex (Chiropractic)
  • 1. Neurological
  • 2. Muscular
  • 3. Articular (joints)
  • 4. Histological (tissues)
  • 5. Biochemical- inflammation, nutrition
  • 6. Vascular-circulatory, lymphatic

91
Goal of Manipulation
  • Reduce pain (comparable sign- patient pain
    recognition)
  • Improve mobility/arthrokinematics (joint sign)
  • Decrease muscle guarding
  • Stretch and lengthen contractile and
    non-contractile tissues around the joint
  • Normalize nervous, circulatory and lymphatic flow
  • Improve muscle tone and stretch reflex
  • Break up adhesions
  • Improve joint proprioception and kinesthetic
    awareness- stimulates joint receptors

92
Therapeutic Effects of Manipulative Treatment
  • 1. Circulatory- move body fluids and provide
    tonic effect
  • 2. Neurological- modify reflexes
  • A. Somato-somatic
  • B. Somato-visceral
  • C. Viscero-somatic
  • D. Viscero-viscero
  • 3. Maintenance therapy for irreversible
    conditions

93
Definitions
  • Active Motion Voluntary movement of an
    articulation between physiological barriers
  • Anatomical barrier bone and soft tissue contour
    serving as the final limit to motion
  • Barrier factor restricting free movement
  • Elastic barrier the resistance felt at the end
    of passive ROM
  • Motion movement
  • Paraphysiological space that sensation of a
    sudden give beyond the elastic barrier usually
    accompanied by a cracking sound with a slight
    amount of movement beyond the usual physiological
    limit, but within the anatomical barrier
  • Passive motion induced at an articulation by the
    operator. Involuntary
  • Physiological barrier limits the voluntary
    motion of an articulation. Further motion towards
    the anatomical barrier can be induced passively
  • Restrictive barrier an obstacle to movement
    within the physiological limits of an
    articulation that reduces the active ROM

94
Grades of Manipulaton
  • Grade I- small amplitude movement and beginning
    of range. Used when pain and spasm limit ROM
  • Grade II- large amplitude movement at the
    beginning range. Used when pain and spasm limit
    ROM
  • Grade III- Large amplitude movement at mid range
    of movement. Used to reduce pain and increase
    periarticular extensibility, correct positional
    faults and release meniscoid tissue in the spine
  • Grade IV- Small amplitude movement at the mid
    range of movement. Used to reduce pain and
    increase periarticular extensibility, correct
    positional faults and release meniscoid tissue in
    the spine
  • Grade V- High velocity low amplitude to the
    anatomical end point of a joint. The pathological
    barrier is moved past the physiological barrier,
    into paraphysiological space

95
Resistance Concept
  • R1- beginning ROM (I and II go up to R1)
  • 50 between R1 and R2 (III and IV go to 50)
  • R2- Pathological barrier (V- path barrier an on)
  • Physiological barrier
  • Paraphysiological space
  • Anatomical barrier

96
Manipulation Considerations
  • Doctors position
  • Patients position
  • Doctors contact
  • Patients contact
  • Line of drive
  • Joint type and normal motion
  • Respiration
  • Patients eye position
  • Psycho-somatic influences
  • Distraction techniques

97
Segmental Motion
  • Forward bending
  • Backward bending
  • Side bending- right and left
  • Rotation- right and left
  • Coupled movements

98
Three Cardinal Rules For Effective Manual
Medicine Procedures
  1. Control- physicians body position, comfort of
    patient, extrinsic and intrinsic forces, and
    therapeutic intervention being employed
  2. Balance- physician and patient to ensure optimum
    comfort
  3. Localization- adequate engagement of the
    restrictive barrier in a pain free position,
    which will allow for optimum release

99
Three Most Common Errors of Palpation
  1. Lack of concentration
  2. Too much pressure
  3. Too much movement

100
Precautions To Manipulation
  1. Vertebral artery in the cervical spine
  2. Primary joint disease e.g. RA, AS, infectious
    arthritis
  3. Metabolic bone disease e.g. osteoporosis
  4. Primary or metastatic malignant bone disease
  5. Genetic disorders e.g. Downs syndrome,
    particularly in the cervical spine
  6. Hypermobility
  7. Acute fracture
  8. Acute inflammation

101
Mobilization MWM and SNAGS (Mulligan)
  • Identify signs loss of joint movement, pain
    associated with movement, or pain associated with
    specific functional activities
  • Apply Passive pain free joint mobilisation
    (i.e., parallel or perpendicular to the joint
    plane).
  • Investigate various combinations of parallel or
    perpendicular glides to find the correct
    treatment plane and grade of movement.
  • While sustaining the accessory glide, the patient
    is requested to perform movement, which should
    now be significantly improved (i.e. increased
    range of motion, and a decreased or, absence of
    the original pain).
  • Failure to improve indicates that the therapist
    has not found the correct contact point,
    treatment plane, grade or direction of
    mobilization, spinal segment or that the
    technique is not indicated.
  • The previously restricted and/or painful motion
    or activity is repeated by the patient while the
    therapist continues to maintain the appropriate
    accessory glide. Further gains are expected with
    repetition during a treatment session typically
    involving three sets of ten repetitions.
  • Further gains may be realized through the
    application of passive overpressure at the end of
    available range. It is expected that this
    overpressure is again, pain-free.
  •  

102
Beyond chiropractic help
103
ACTIVE ISOLATED STRETCHING (Mattes)
  • Myofascial stretching of isolated muscles
    which avoids activating the protective myotatic
    reflex contraction
  • Stretch through anatomical plane of attachments
  • Contract the antagonistic muscle to facilitate a
    release in the stretched muscle (reciprocal
    inhibition)
  • Ten repetitions for two seconds

104
Gua Sha (Tissue friction Massage)
  • A method in tradition Chinese medicine in which
    the skin on the back, limbs, and other parts of
    the body is lubricated and then pressured and
    scraped with a rounded object (e.g. a ceramic
    spoon). The method produces "sha" which are small
    red petechiae
  • Gua Sha creates a suction on the skin that pulls
    stagnant intercellular fluid to the surface,
    removing toxic debris, and replacing it with
    fresh oxygenated, nutrient rich fluid. This in
    turn accelerates regeneration and revitalizes
    diseased tissue.

105
Kinesiotaping
  • Applied unstretched to damaged muscles
  • Applied stretched to damaged joints or ligaments
  • Allows free range of motion to enable the bodys
    muscular system to heal itself biomechanically
  • Weak muscles- tape from O to I
  • Cramping/over contraction- tape I to O

106
Four Major Functions of Kinesiotaping
  1. Supports muscles
  2. Removes congestion to the flow of body fluids
  3. Activates endogenous analgesic systems
  4. Corrects joint problems

107
HYDRATION RESPIRATION
  • The connective tissue matrix is an important
    water storage compartment
  • Hydration promotes smooth, non-friction
    mechanical movement and effective nerve
    conduction
  • Respiration expedites water absorption

108
Respiration
  • Inspiration fixed (difficulty exhaling)
  • Expiration fixed (difficulty inhaling)

109
TREATING THE MINDBODY COMPONENT
  • Knowledge of the process and emotional sources
  • Experience vs. somatization of emotions
  • Breathing techniques
  • Tapping techniques using acupuncture points
  • EMDR
  • Systematic relaxation
  • Guided Imagery

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Self-myofascial Release
  • Autogenic inhibition- external pressure
    stimulates receptors (e.g. GTO, Ruffini endings)
    to override the dysfunctional yet protective
    mechanism caused by the cumulative injury cycle.

112
Tissue Pressure
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Lengthening
  • Stretching used to increase the extensibility of
    muscle and connective tissue, resulting in
    increased range of motion at a joint
  • Static- passive
  • Active- using agonists and synergists
  • Neuromuscular- PNF
  • Functional- using the bodys momentum
  • Neurodynamic- neural structures

115
Activate
  • Isolated (intramuscular) Strengthening Exercises
    used to isolate a particular muscle in order to
    increase the force production capabilities
    through concentric-eccentric muscle actions
    e.g. Scaption exercises
  • Strengthening exercises to start after a 70 of
    the normal range of motion has been achieved
    (empirical observation)

116
Integrate
  • Integration Techniques (Intermuscular)
  • Re-educating the nervous system on movement
    patterns and muscle synergies in a dynamic manner
    (eccentric, isometric, concentric)
  • e.g. Squat to row

117

118
Functional Exercise (NASM)
  • Multiplanar (sagittal, transverse, frontal)
  • Involves acceleration, deceleration and
    stabilization
  • Multiple speeds
  • Varying body positions
  • Optimum alignment
  • Periodization
  • Recovery and regeneration

119
Integrative Exercise (NASM)
  • Flexibility
  • Core stabilization
  • Balance
  • Speed and agility
  • Strength
  • Power
  • Cardio respiratory- stage train building up to
    intervals

120
PERPETUATING FACTORS
  1. Mechanical Stresses
  2. Nutritional/Dietary factors
  3. Metabolic and Endocrine Inadequacies
  4. Psychological factors
  5. Chronic Infection
  6. Other (allergy, sleep, improper breathing,
    dehydration, smoking, caffeine, medications,
    visceral disease)

121
MECHANICAL STRESS
  1. Structural- body asymmetry and disproportion e.g.
    leg length discrepancy, long second metatarsal
    and short first metatarsal
  2. Postural e.g. poor posture, poorly fitting
    furniture, poorly adjusted glasses, ergonomics
  3. Constriction of muscles e.g. poor fitting
    clothing
  4. Degenerative joint disease

122
NUTRITIONAL FACTORS (VITAMINS AND MINERALS)
  • Nutritional inadequacies cause impairment of
    energy, cell metabolism and function ,which
    reduces the ability of the muscle to meet extra
    demands and metabolic stress
  • Nutrients Play a role in the synthesis of
    neurotransmitters, protein, carbohydrate and fat
    metabolism, DNA synthesis, collagen synthesis and
    proper nerve and muscle function
  • Low levels should be treated as they may not be
    adequate for optimum health
  • Deficiency increases irritability of trigger
    points and nerves

123
NUTRITIONAL DEFICIENCY
  • B1- important for energy and synthesis of
    neurotransmitters. Potentiates the effectiveness
    of thyroid hormone
  • B6- important in lipid and protein metabolism and
    the synthesis of neurotransmitters
  • B12- essential for energy and DNA synthesis and
    in fat, carbohydrate and protein metabolism
  • Folic Acid- Important for synthesis of DNA, cell
    metabolism and for normal brain function and
    development
  • C- important in collagen synthesis and synthesis
    of serotonin and norepinephrine
  • Calcium, Magnesium, Potassium and Iron- Important
    in muscle contraction and function

124
Naturopathic Approaches to Inflammation
  • Antioxidants A, E, C, Se, Zn, CoQ10
  • C/Bioflavonoids- 1000mg 3x/day
  • Magnesium (citrate)- 300mg 2x/day
  • Fish Oil (18 EPA 12DHA)- 10g per day (at
    least 3g EPA)
  • Bromelain- 1000-2000 MCU 4x/day away from food
  • Quercetin- 500mg 3x/day
  • Boswellia- 400mg 3x/day
  • Glucosamine and Chondroitin Sulphate- 500mg of
    each 3x/day
  • Topical DMSO
  • Topical Biofreeze
  • Hydrotherapy
  • Guided imagery/systematic relaxation/hypsosis

125
Dietary Factors in Inflammation
  • Phytonutrients- vegetables and fruits
  • Green/Black tea
  • Garlic, Ginger, Turmeric, Cinnamon etc.
  • Consume low glycemic load carbohydrates (insulin
    connection)
  • Eat small frequent meals to ensure glycemic
    regulation
  • Omega 6Omega 3 should be lt41
  • Decrease meat, dairy, shellfish and refined
    carbohydrates/fats
  • Decrease caffeine and alcohol
  • Optimize digestion and bowel habits
  • Identify food reactions

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Healthy Plate
  • Red potatoes
  • Sweet potatoes
  • Pumpkin
  • Squash
  • (Brown/wild rice, oats, Quinoa)
  • Color
  • Broccoli
  • Cabbage
  • Carrots
  • Cauliflower
  • DGLV (e.g. Spinach, kale, chard, Brussels
    sprouts etc.)
  • Green beans
  • Onions
  • Peppers
  • Tomatoes
  • Herbs/spices
  • Beef (grass fed)
  • Poultry (w/o skin)
  • Wild game
  • Fish
  • Dairy (Yogurt)
  • Eggs
  • healthy fats, including
  • Avocado
  • XVOO
  • Raw nuts fruit for snacks
  • Drink water and green tea

128
METABOLIC AND ENDOCRINE
  • When energy metabolism of the muscle is
    compromised as a result of metabolic or endocrine
    imbalance it perpetuates trigger point activity
    e.g.
  • Hypoglycemia
  • Hypothyroid
  • Menopause
  • Hyperuricemia

129
Allergy/Infection
  • Can perpetuate trigger point activity, possibly
    due to histamine release

130
PSYCHOLOGICAL FACTORS
  • There is a decrease in brain serotonin which
    causes increased sensitivity and low oxygenation
    of the tissues e.g.
  • Stress
  • Depression
  • Anxiety
  • Insomnia
  • Fatigue

131
Tension Myositis Syndrome The mind body
connection
  • Conscious or Repressed Unconscious Emotions
  • Stress
  • Abnormal Autonomic Activity
  • Reduced Local Circulation of Blood
  • Mild Oxygen Deprivation
  • Muscle Pain
  • Nerve pain/Numbness/Tingling/Weakness
  • Tendon Pain

132
Hypnosis/Guided Imagery and Pain
  • Applied imagination
  • Hypnosis changes your expectations about how
    intense the pain will be
  • The process activates certain parts of the brain,
    including the portion that focuses attention. "By
    concentrating elsewhere, a person inhibits the
    pain from coming to conscious awareness
  • Reduced activity the primary sensory cortex and
    increased activity in other areas of the brain
  • increased activation in the left anterior
    cingulate cortex and the basal ganglia- part of
    an inhibition pathway that blocks the pain signal
    from reaching the higher cortical structures
    responsible for pain perception

133
Practical Applications
134
Evaluation and Treatment
  • Cervical spine
  • Thoracic spine
  • Lumbo-Pelvic-Hip complex
  • Upper ¼ - Shoulder, elbow, wrist, hand
  • Lower ¼ - knee, ankle, foot

135
Practical Format
  • Common patterns of dysfunction
  • Functional anatomy and biomechanics
  • Assessment/Examination
  • Treatment
  • Trigger point release
  • Muscle release therapy
  • Friction massage
  • Joint manipulation
  • Stretching
  • Corrective exercise (inhibit, lengthen, activate,
    integrate)

136
References
  • NASM
  • Leon Chaitow, ND., DC
  • Warren Hammer, DC
  • Vladimir Janda, MD
  • Craig Liebension, DC
  • Paul Chek
  • Shirley Sarhmann
  • Peter Levy, DC
  • Stuart Taws, LMP
  • SLACK Hands on seminars
  • Chan Gunn, MD
  • Stuart McGill
  • Gray Cook, PT
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