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

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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

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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.

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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

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Class Format

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

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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

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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

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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

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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

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Drugs and Musculoskeletal Pain

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

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CHRONIC PAIN

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

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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.

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Traditional Orthopedic Approach

• Isolated joint kinematics
• Uniplanar
• Isolated muscle strength
• Morphologically oriented

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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

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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

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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

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Optimal Neuromuscular Control

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

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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

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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

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Functional Muscle Division

• Stabilization Group
• Movement Group

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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

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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

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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

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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

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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

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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

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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

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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

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Pathogenesis

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

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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

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Classification of Trigger Points

• Satellite
• Attachment
• Active
• Limit ROM
• Weakness
• Local Referred pain
• Latent
• Limit ROM
• Weakness
• Pain only with compression

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Classification of Trigger points

• Active TP
• Limit ROM
• Weakness
• Local Referred
• Pain
• Latent TP
• Limit ROM
• Weakness
• Pain only with compression

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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

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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

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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

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Cumulative Injury Cycle
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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

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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

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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

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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

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Patient 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

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Patient 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

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Posture

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

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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

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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

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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

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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 paine.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

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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

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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

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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

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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

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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

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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

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SPECIAL 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)

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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

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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

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Clinical Use

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

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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

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Use of Eye Movement and Breathing

• Contraction- inhale-hold and look up
• Relaxation- Exhale-hold and look down

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Joint Mobilization

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

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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

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Subluxation Complex(Chiropractic)

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

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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

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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

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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

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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

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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

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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

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Segmental Motion

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

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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

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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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111
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

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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