Title: A Kinetic Chain Approach to Musculo-Skeletal Pain Combining Manual Therapies, Nutrition and Corrective Exercise.
1A 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
2Integrative 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.
3Course 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
4Class Format
- Lecture on theory, rational and approach
- Hands-on application- evaluation and treatment
5PAIN
- 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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73 PHASES OF PAIN
- 1. Immediate/Nociceptive
- 2. Acute/Inflammation
- 3. Chronic
8IMMEDIATE /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
9ACUTE 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
10Biochemical 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
11Drugs and Musculoskeletal Pain
- Always check your patients medications for
possible musculoskeletal side effects e.g.
Statins, anti-hypertensive drugs etc.
12CHRONIC PAIN
- Ongoing nociception or inflammation
- Psychological
- 3. Neuropathic- functional and structural
alterations within the Neuromusculoskeletal
system -
13Structure 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.
14Traditional Orthopedic Approach
- Isolated joint kinematics
- Uniplanar
- Isolated muscle strength
- Morphologically oriented
15Integrative 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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18Regional 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
19Optimum 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
20KINETIC 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
21Optimal Neuromuscular Control
- Normal length tension relationships
- Normal force couple relationships
- Normal arthrokinematics
- Optimal sensorymotor integration
- Optimal neuromuscular efficiency
- Optimal tissue recovery
22Example 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
23MUSCLE 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
24Functional Muscle Division
- Stabilization Group
- Movement Group
25Stabilization 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
26Movement 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
27FUNCTIONAL 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
28Low 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
29CAUSES 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
30Postural 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
31MYOFASCIAL 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
32TRIGGER 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
33Pathogenesis
- Over stretching/over shortening
- Overloading of tissue
- Micro-trauma
- Destruction of sarcoplasmic reticulum
- Release of calcium
- Sustained muscle contraction
34Physical 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
35Classification of Trigger Points
- Satellite
- Attachment
- Active
- Limit ROM
- Weakness
- Local Referred pain
- Latent
- Limit ROM
- Weakness
- Pain only with compression
36Classification of Trigger points
- Active TP
- Limit ROM
- Weakness
- Local Referred
- Pain
- Latent TP
- Limit ROM
- Weakness
- Pain only with compression
37TRIGGER 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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45Trigger 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
46Motor 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
47Kinetic 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
48Cumulative Injury Cycle
49Postural 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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51UPPER-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
52LUMBO-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
53LOWER-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
54Looking 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
55Patient HistoryOPQRST
- 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
56Patient ExaminationIPPIRONEL
- 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
57Posture
- Dynamic
- Structural efficiency
- Neuromuscular efficiency
- Balance and equilibrium
- Functional strength
58Static 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
59Common 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
60Observing 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
61Movement assessment
- Identifies movements that consistently causes
pain - 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 - Movement impairment is classified by the
direction of movement that causes paine.g.
movement classifications in the spine flexion,
extension, rotation, flexion/rotation,
extension/rotation - Testing is performed sitting, standing,
side-lying, prone, supine and in a quadruped
position bilaterally and unilaterally - Reproducing the pain is the key to both
identifying the problem and effective treatment
through therapy and corrective exercises/activitie
s
62Kinetic 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
63Dynamic Inspection(Overhead Squat)
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68Abnormal 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
69Altered 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
70Abnormal 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
71Altered 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
72Trunk 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
73SPECIAL IMAGINGHelp 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)
74GOAL OF TREATMENT
- Control the pain and break the pain cycle
- Break chemical and Mechanical feedback loop that
maintains muscle contraction - Increase circulation that has been restricted by
contracted tissue - Lengthen shortened muscles
- Reconditioning and strengthening weak muscles
- Correct movement patterns
- Prevention of recurrence through an appropriate
exercise program
75TREATMENT
- Provocative
- Active
- Resisted
- Functional
- Proprioceptive
76Effective 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
77Progressive 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
78THE 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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80SOFT 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)
81EFFECTS 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
82Muscle 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
83Clinical Use
- Lengthen a short muscle
- Strengthen a weak muscle
- Decrease local edema
- Joint mobilization
84Two 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
85The 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
86MET
- Move to barrier and evaluate
- Position at barrier
- Isometric contraction (PIR or reciprocal
inhibition)- 7-10 sec - Patient relaxation
- Move to new barrier
- Repeat 3-4 times
- Re-evaluate
- Goal is to push pathological barrier to the
physiological barrier
87Use of Eye Movement and Breathing
- Contraction- inhale-hold and look up
- Relaxation- Exhale-hold and look down
88Joint Mobilization
- A set of passive motions with the purpose of
improving mobility and function
89Indications 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
90Subluxation Complex(Chiropractic)
- 1. Neurological
- 2. Muscular
- 3. Articular (joints)
- 4. Histological (tissues)
- 5. Biochemical- inflammation, nutrition
- 6. Vascular-circulatory, lymphatic
91Goal 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
92Therapeutic 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 -
93Definitions
- 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
94Grades 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
95Resistance 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
97Segmental Motion
- Forward bending
- Backward bending
- Side bending- right and left
- Rotation- right and left
- Coupled movements
98Three Cardinal Rules For Effective Manual
Medicine Procedures
- Control- physicians body position, comfort of
patient, extrinsic and intrinsic forces, and
therapeutic intervention being employed - Balance- physician and patient to ensure optimum
comfort - Localization- adequate engagement of the
restrictive barrier in a pain free position,
which will allow for optimum release
99Three Most Common Errors of Palpation
- Lack of concentration
- Too much pressure
- Too much movement
100Precautions To Manipulation
- Vertebral artery in the cervical spine
- Primary joint disease e.g. RA, AS, infectious
arthritis - Metabolic bone disease e.g. osteoporosis
- Primary or metastatic malignant bone disease
- Genetic disorders e.g. Downs syndrome,
particularly in the cervical spine - Hypermobility
- Acute fracture
- Acute inflammation
101Mobilization 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. -
102Beyond chiropractic help
103ACTIVE 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
104Gua 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.
105Kinesiotaping
- 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
106Four Major Functions of Kinesiotaping
- Supports muscles
- Removes congestion to the flow of body fluids
- Activates endogenous analgesic systems
- Corrects joint problems
107HYDRATION 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
108Respiration
- Inspiration fixed (difficulty exhaling)
- Expiration fixed (difficulty inhaling)
109TREATING 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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111Self-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.
112Tissue Pressure
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114Lengthening
- 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
115Activate
- 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)
116Integrate
- 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 118Functional 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
120PERPETUATING FACTORS
- Mechanical Stresses
- Nutritional/Dietary factors
- Metabolic and Endocrine Inadequacies
- Psychological factors
- Chronic Infection
- Other (allergy, sleep, improper breathing,
dehydration, smoking, caffeine, medications,
visceral disease)
121MECHANICAL STRESS
- Structural- body asymmetry and disproportion e.g.
leg length discrepancy, long second metatarsal
and short first metatarsal - Postural e.g. poor posture, poorly fitting
furniture, poorly adjusted glasses, ergonomics - Constriction of muscles e.g. poor fitting
clothing - Degenerative joint disease
122NUTRITIONAL 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
123NUTRITIONAL 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
124Naturopathic 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
125Dietary 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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127Healthy 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
128METABOLIC 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
129Allergy/Infection
- Can perpetuate trigger point activity, possibly
due to histamine release
130PSYCHOLOGICAL 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
131Tension 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
132Hypnosis/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
133Practical Applications
134Evaluation and Treatment
- Cervical spine
- Thoracic spine
- Lumbo-Pelvic-Hip complex
- Upper ¼ - Shoulder, elbow, wrist, hand
- Lower ¼ - knee, ankle, foot
135Practical 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)
136References
- 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