Archives for posts with tag: rehabilitation

Many clinicians are still focused on “stretching fascia”. Research shows that fascia requires up to 1997 N/cm2 of force (448.9 pounds of force) to stretch and deform it.(1) Not that clinicians would be able to deform it with manual techniques but the questions becomes if it should be deformed. When a structure or tissue is deformed, it loses its structural integrity. With connective tissues, muscle loses its ability to lengthen or contract due to tearing of the fibers where fascia loses its ability to dissipate electrical discharge to coordinate movement patterns.(2, 3) Our manual techniques do produce mechanical changes, it is on the abnormal collagen crosslinks that form during the inflammatory process that, hopefully, are still immature and malleable. However, there is also an effect via the nervous system provided by sensory input and muscle spindle stretch that can also be utilized to create functional changes and decreasing symptoms.

A review of myofascial grading system finds the range from I-V and encompasses both passive (grades I-III) and active (grades IV-V) techniques. With increases grades, many assume this corresponds with increasing pressure but that is an incorrect assumption; it corresponds with increased tissue tension. If there is significant pressure applied, the brain interprets it as a painful stimuli and will contract the tissues to protect the underlying structures. Even though the techniques are designed to be inhibitory, the patient may present as tighter after the techniques if the self-protection mechanisms have been activated via the nociceptor stimulation.

Here is a review of myofascial release techniques, their purpose and their mechanism of action:

Grade I

Rationale: to decrease pain after acute trauma or in instance of central sensitization (fibromyalgia, complex regional pain syndrome, reflex sympathetic disorder, thoracic outlet syndrome)

Technique: pressure is applied to tissue is passively placed in the position it assumes as it contracts

Mechanism: neurological: autogenic inhibition via decreased tension of the muscle spindle

Basis for: Jones Strain-Counterstrain (SCS), Positional Release Techniques (PRT)

Grade II

Rationale: to decrease pain after acute trauma or in instance of central sensitization (fibromyalgia, complex regional pain syndrome, reflex sympathetic disorder, thoracic outlet syndrome)

Technique: pressure is applied to tissue in a shortened positioned then moved to neutral

Mechanism: neurological: autogenic inhibition via decreased tension of the muscle spindle

Basis for: pin-and-stretch technique

Grade III

Rationale: to improve mobility in areas of myofascial adhesions and mechanical restrictions

Technique: pressure is applied to tissue in a shortened positioned then passively moved to a stretch

Mechanism: mechanical: stretching and shearing of abnormal collagen crosslinks

Basis for: pin-and-stretch technique, Active Release Techniques (ART)

Grade IV

Rationale: to improve mobility in areas of myofascial adhesions, mechanical restrictions or trigger points

Technique: pressure is applied to tissue in a shortened positioned then actively moved to a stretch

Mechanism:   mechanical: stretching and shearing of abnormal collagen crosslinks

Neurological: relaxation of the tissue via reciprocal inhibition

Basis for: pin-and-stretch technique, Active Release Techniques (ART)

Grade V

Rationale: to improve mobility in areas of myofascial adhesions and mechanical restrictions

Technique: pressure is applied to tissue in a lengthened positioned then concentrically contracted

Mechanism: mechanical: stretching and shearing of abnormal collagen crosslinks

Basis for: pin-and-stretch technique, Active Release Techniques (ART)

References

  1. Chaudhry H, Schleip R, et al. Three-dimensional model for deformation of human fasciae in manual therapy. 2008. Journal of the American Osteopathic Association. 108:379-390.
  2. Langevin HM. Connective tissue: a body-wide signaling network? 2006. Medical Hypothesis. 66(6):1074-77.
  3. Ingber DE. Tensegrity and mechanotransduction. 2008. Journal of Bodywork and Movement Therapies. 12(3):198-200.

POSE DESCRIPTION – see picture

Preparation:

standing with hips adducted and neutrally rotated

ankle is neutral

knees extended but soft

spine erect

Movement:

rotation occurs about the femoro-acetabular joint to produce hip flexion

ankle should remain neutral and not fall into plantarflexion

spine rounds slightly into flexion, curve should be evenly distributed

FUNCTIONAL MOVEMENT

relevant for bending and lifting, may replicate dressing (pulling on pants/shoes)

RELEVANT NEUROMYOFASCIA

Neural

mobilization of sciatic and tibial nerves

appropriate tone of all muscles involved

Muscle

concentric contraction of anterior chain

anterior tibialis – prevents ankle plantarflexion

rectus femoris – maintains knee extension, creates anterior pelvic rotation

rectus abdominis – provides trunk stability

eccentric contraction of posterior chain

plantar fascia/toe flexors – maintains neutral arch

triceps surae – maintains neutral ankle

hamstrings – control of knee extension and hip flexion

erector spinae – maintain spinal stability

Fascia

appropriate length of posterior chain

allows for neutral ankle, extended knee and flexed hip

PROGRESSION TO HOME PROGRAM

Patients can be instructed on more traditional stretches initially that breaks the movement into its individual parts: ankle/hip mobility and knee/trunk stability. Once appropriate mobility/stability of the impaired joint(s) has been achieved, the full hip hinge may be instituted back into the patient’s routine.

CLINICIAN EDUCATION:  dissociative movements

One of the primary causes of musculoskeletal pain outside of trauma is compensatory movement patterns. Individuals often lose the ability to perform a movement due to muscular tightness, joint/capsule restriction or muscular weakness. The brain automatically creates compensation to try to maintain movement homeostasis. This single segment hypomobility often creates dysfunction (hypermobility) and pain in the compensating structures. Often, the patients feel they have full range of motion due to the compensation but present clinically with abhorrent movement patterns. Appropriate treatment should emphasize not only stabilizing the hypermobility but finding and mobilizing the hypomobility.

Common movement compensations:
Trunk flexion for limited cervical flexion
Trunk rotation for limited cervical rotation.
Scapular elevation for limited shoulder flexion/abduction
Scapular protraction for limited shoulder IR
Scapular retraction for limited shoulder ER
Shoulder IR for limited radio-ulnar (elbow) pronation
Shoulder ER for limited radio-ulnar (elbow) supination
Trunk extension for limited shoulder flexion
Trunk extension for limited hip extension
Posterior pelvic tilt for limited hip flexion
Anterior pelvic tilt for limited hip extension
Increased knee flexion for limited hip flexion
Increased knee extension for limited hip extension
Increased knee flexion for limited ankle dorsiflexion
Increased tibial (knee) rotation for limited ankle inversion/eversion
Increased midtarsal supination for limited ankle inversion
Increased midtarsal pronation for limited ankle eversion

Look for upcoming posts on evaluation and treatment options for each dissociative pattern!

CLINICIAN EDUCATION: synaptic facilitation

 

Pavel Tsatsouline is a well known Russian strength coach known for his somewhat unorthodox approaches to training and conditioning. One of his well known approaches is referred to as “greasing the groove”. With this approach, he discusses practicing certain techniques to improve the ability to perform other, more complicated movements.

This can easily be applied to rehabilitation:

1. address soft tissue restrictions by performing post-isometric relaxation techniques (agonist-contract, contract-relax, contract-relax-agonist-contract) to the antagonist of the movement

2. apply proprioceptive neuromuscular facilitation to the agonist of the muscle to activate it from the movement’s synergists

3. have the person perform a set of 10 reps of active movement

CLINICAL EXAMPLE: decrease hip extension

1. ensure no restriction of mobility due to joint or capsule adhesions

2. with the patient prone, perform PIR to the hip flexors (rectus femoris, iliopsoas, tensor fascia latea, sartorius)

3. with the patent prone, perform PNF to the gluteus maximus and hamstrings (semi membranosus/ semitendinosis)

4. with the patent prone, have him/her perform active hip extension for 10 reps

CLINICIAN EDUCATION:  Thoracolumbar Fascia

There is much discussion as of late regarding the importance of the thoracolumbar fascia. Yet, few realize the importance of its role in both pain and movement dysfunctions.

ANATOMY
The thoracolumbar fascia (TLF) is a dense area of connective tissue and is the largest aponeurosis in the body. It spans from the sacrum, coccys and posterior spine of the ilium inferiorly to the iliac crest laterally. Its expanse has connections to each spinous process before ending superiorly as the nuchal fascia of the cervical spine.

It is comprised of 3 layers: anterior (thinnest), middle and posterior (thickest). The quadratus lumborum (QL) is located between the anterior and middle portions while the erector spinae are encapsulated between the middle and posterior sheets. The TLF continues to cover the paraspinal muscles in the thoracic region where it serves to separate them from the muscles that attach to and move the shoulder girdle complex.

The TLF is highly innervated with free nerve endings (nociceptors for pain transmission). These fibers are known to give sensory input and are highly responsive to both mechanical and noxious chemical stimulation. The TLF fibers also appear to be an extension of the dorsal horn neurons for innervation of the posterior trunk.

LUMBO-PELVIC FUNCTION – Protection
The TLF serves as an aponeurosis to protect the abdominal organs. While the bony thorax protects the organs of the thoracic cavity, the abdominal aponeurosis combines with the TLF to protect the small and large intestines. The TLF specifically serves to protect the lower portions of the kidney as well as the ureters in the retroperotineal space.

LUMBO-PELVIC FUNCTION – Mobility
The primary role of the TLF is to transmit forces between the upper and lower extremities. The transverse abdominis (TrA) is under somatic control and is designed to create trunk stability by tensioning the TLF. The tension of the TLF creates stable proximal attachments for the latissimus dorsi to create forceful shoulder extension and the gluteus maximus for hip extension. During ambulation, the TLF transfers force from the gluteus maximus to the contralateral latissimus dorsi (superficial posterior fascial line of Anatomy Trains) while the opposite limbs move into flexion (cross-crawl patterning).

As the TLF tensions, it pulls on the spinous process at each level and stiffens the spine. Once the lumbar spine is stable, the psoas has a firm proximal attachment to contract against to create a forceful hip flexion. Tensioning of the thoracic spine and rib cage creates stable proximal attachments for the rectus abominis and pectoralis major to contract against.

LUMBAR PAIN
Samples taken from individuals undergoing back surgery demonstrate numerous encapsulations of the free nerve endings that may be responsible for some of their pain. These encapsulations can occur from healing micro- or macro-traumas to the fascia that heals improperly.

Areas of adhesions in the TLF can create abnormal shearing forces on the spine itself. This can create a variety of tilts and rotations of the spinal vertebrae as they are pulled towards the areas of adhesion in the fascia. The TLF can create so much shearing force that it can actually fracture the spinous processes of the lumbar spine.

Other sources of lumbar pain are related to dysfunction of the TrA. If the TrA is not contracting or undergoes delayed contraction, the spine loses its stability. Furthermore, the extensors lose their proximal stability and are unable to appropriately contract leading to abnormal hip extension and arm swing during ambulation.

REHABILITATION
Appropriate medical care is needed to appropriate diagnose the source of low back pain. While low back pain can be an indicator a disease state (cancer, kidney stones, etc), it is primarily a musculoskeletal condition. Treatment should consist of manual therapy techniques to restore normal mobility to the TLF and the overlying skin to decrease shear on the spine and compression of nociceptors. Neuromuscular re-education techniques should be utilized to restore appropriate timing of TrA contraction.

REFERENCES
Barker PJ, Briggs CA, Bogeski G. Tensile transmission across the lumbar fasciae in unembalmed cadavers: effects of tension to various muscular attachments. Spine. 2004. 29:129-38.
Gracovetsky S. Is the lumbodorsal fascia necessary? J Bodywork Mvmnt Therap. 2008. 12:194-197.
Gray H. Gray’s Anatomy.
Langevin HM, et al. Reduced thoracolumbar fascia shear in human chronic low back pain. BMC Musculoskeletal Disorders. 2011. 12:203-15.
Tesarz J, Hoheisel U, Wiedenhofer B, Mense S. Sensory innervation of the thoracolumbar fascia in rats and humans. Neuroscience. 2011. 194:302-308.
Zorn A, et al. The spring-like function of the lumbar fascia in human walking. Journal of Bodywork and Movement Therapies. 2008. 4(23):261-3.
Schelip R, Klinger W. Chronic low back pain may originate from subfailure injuries in lumbar fasciae. Journal of Bodywork and Movement Therapies. 2008. 4(23):263.
Vleeming A, et al. The posterior layer of the thoracolumbar fascia: Its function in load transfer from spine to legs. Spine. 1995. 20:753-8.

I often joke that as we are becoming Doctors (of Physical Therapy, of Occupational Therapy, of Athletic training), we are becoming more like Doctors (of Medicine) in that many are taking a hands-off approach to patient care. Oddly, some chiropractors are taking a hands-off approach in using adjusting tools such as the Activator Methods International or computerized adjusting equipment from Sigma Instruments. (This is especially ironic since “chiro” is Latin for “of the hands”.)

While physical touch can have many positive influences from a rehabilitative stand point, it can also improve psychological and emotional well-being:

Manual therapies have been shown to decrease anxiety, tension and depression in active populations(1). The results have actually shown a greater reduction in psychological complaints than running. Improving psychological well-being may influence physical pain by decreasing central sensitivity or how the brain interprets peripheral input.

Massage may also create multi-system releases in tension. Interventions have been shown to decrease pulse rate which is under autonomic control(2). These individuals also reported decreased anxiety while demonstrating decreased output of cortisol in their urine and saliva (decreased adrenal activity).

Eating disorders such as bulimia are also psychological in nature. Manual therapy has been shown to be an effective intervention in decreasing anxiety and depression associated with disordered eating which can also help control the disorder eating itself(3).

On the opposite end of the spectrum are aggression issues. These may be hormonally or psychologically induced issues. Manual therapy has also been shown to decrease anxiety and aggression in adolescents via positive affects on mood(4).

Often, these results are thought to be associated with traditional massage therapy practice of 60 to 90-minute sessions. However, results can be seen with as little as 10-minutes(5). Elderly patients noted a psychological state of relaxation after the interventions of kneading from the occiput to the sacrum.

Even if manual therapy is not a strong suit, touch can be incorporated into treatment in several ways. Stabilizing touch during therapeutic exercises may have the same affect. Facilitating touch on the muscle that should be contracting is another approach.

REFERENCES
1. Weinberg R, Jackson A, Kolodny K, The relationship of massage and exercise to mood enhancement. Sports Psychologist 1988;2:202-211.
2. Field T, Grizzle N, Scafidi F, Schanberg S. Massage and relaxation therapies’ effects on depressed adolescent mothers. Adolescence 1996;31:903-911
3. Field T, Schanberg S, Kuhn C. Bulimic adolescents benefit from massage therapy. Adolescence 1998;33:555-563.
4. Diego MA, Field T, Hernandez-Reif M, et al. Aggressive adolescents benefit from massage therapy. Adolescence 2002;37:597-607.
5. Frazier J, Kerr J. Psychophysiological effect of back massage on elderly institutionalized patients, Journal of Advanced Nursing 1993;18:238-245

Myofascial Release

Did you know there are grades (degrees) of Myofascial release?

Grade I
Technique is applied with no tension through the tissue and it is on slack

Grade II
Technique is applied with minimal tension, typically with the tissue in neutral position

Grade III
Technique is applied with the tissue on stretch (passive)

Grade IV
Technique is applied as the tissue is stretch via a concentric contraction of the tissue’s antagonist (active)

Grade V
Technique is applied as the tissue concentrically contracts

[Image shows grade III MFR to cervico-pectoral fascia to improve left cervical rotation as well as right scapular depression/retraction]

Adventure Racing:  How runners should treat acute injuries

Runners traditionally suffer from chronic, overuse injuries from the mile after mile their bodies log on a weekly, monthly and yearly basis. However, with the popularity of adventure races such as Warrior Dash, Tough Mudder and Spartan Race that mix obstacles with distances up to15 miles, there has been a significant increase in the number of acute injuries that runners suffer.

Acute Injury

When an injury occurs, you can speed your recovery by working with your body’s natural healing process. Initially, your body will create swelling in the area. This serves several beneficial purposes:

Self bracing
Swelling provides immobilization of the body part by limiting its range of motion. This keeps from overstretching damaged tissue, which could lead to further injury.

Pain
Since most joints do not have additional space any amount of extra fluid will put pressure on the surrounding nerves creating pain. Pain is your body’s way of trying to keep you from using that area so that you do not worsen the injury. This also gives it a chance to heal.

Temperature Increase
The increase of blood to an injured area not only acts to stabilize it but also increases local metabolism. This raises the local temperature to kill any bacteria in the area. However, if the temperature increases too much, it can cause structural damage to the muscles in the area.

Immediate Care, 1-3 days

There are numerous acronyms for immediate care of an acute injury.
RICE – Rest, Ice, Compression, Elevation
PRICE – Protection, Rest, Ice, Compression, Elevation
PRINCE – Protection, Rest, Ice, NSAIDS, Compression, Elevation

However, this is not all accurate and guidelines should be followed.

Rest
Rest is designed to prevent further injury and to allow healing. Often, people, especially runners who do not like to miss a run, will try to train through an injury. They make the mistake of thinking the pain will “just go away”. However, the endorphins and adrenaline released during running can be powerful pain blockers. Furthermore, your brain will automatically change how you run to try to avoid stressing the injured area; this will eventually lead to pain in other areas of the body.

Active rest may be a better option, especially for runners due the fairly rapid decrease in cardiovascular fitness. Active rest should focus on training around the injured area. Non-weight bearing exercises such as swimming and cycling can keep your heart and lungs working while you heal.

Ice
Ice is the easiest way to treat a new injury. Ice decreases the blood flow to the area to limit both pain and swelling. Ice also decreases the actions of the nerves in the area to further help with pain relief. However, you should only ice an initial injury for 10-15 minutes every 2-3 hours. Icing for more than 15 minutes can invoke hunter’s response and actually increase blood flow to the area, which would worsen symptoms.

Compression and Elevation
These are both designed to limit the amount of swelling that can occur. Compression decreases the space the swelling can inhabit. Elevation uses gravity to drain swelling from the area.

What to Avoid

Stretching
A new injury typically is the result of tissues, either muscle or tendon or ligament, being overstretched or partially torn. Stretching may make the injury worse by causing more tearing of the injured fibers.

NSAIDs
Most people, even healthcare providers, think that anti-inflammatories should be started immediately after an injury. However, several research studies have found that taking anti-inflammatories (ibuprofen-Advil, naproxen-Aleve) can interfere with the body’s natural healing process; therefore they should be delayed by 7-10 days. Aspirin should also be avoided because, as a blood thinner, it may increase the amount of swelling. For initial relief, acetaminophen (Tylenol) would be the most appropriate for pain relief.

Pain
Pain is your body’s way of saying “stop” typically before an injury occurs or, if one is already present, before it can worsen. While we do have the ability to override our body’s signals, we put ourselves at great risk when we do so.

Post-Acute Care, 3-14 days

Stretching
At this point, the tissues are beginning to heal. Stretching can be beneficial to encourage the proper healing of the area and limit the amount of scar tissue.

Increasing blood flow
At this point, it becomes logical to increase blood flow to the area. The swelling has served its purpose and needs to be flushed out. Moist heat packs can be used to provide inactive increases or, if able to do so, light aerobic activity will help bring in new blood and the necessities for healing.

Protein
Most structures in the body are comprised of protein. By increasing protein consumption by 20-40 grams a day can supply the amino acids necessary for the repair of the muscles, tendons and ligaments.

Conclusion
Any time you do not feel that your injury is healing appropriately, it is best to follow-up with an appropriately trained healthcare provider. Certified athletic trainers (ATC) are trained to evaluate and treat most musculoskeletal injuries while understanding the demands of activity. Some physical therapists (PT) have advanced certifications in sports (SCS) or orthopedics (OCS). Also, some physicians have completed sports medicine fellowships, which allows them to understand and treat the demands of running as well.

Fascia

Fascia is like Saran-Wrap. For years, researchers thought it was merely something to help hold the body together. More research is coming out that discusses how it is an extension of the central nervous system and helps coordinate movements. Saran-wrap has a high tendency to stick to itself; once it is stuck, it becomes difficult to open back up. Similarly, through injury and overuse, fascia develops adhesions: it becomes sticky (thanks to its extracellular matrix) and adheres to itself as well as the muscles deep and the skin superficially. When this occurs, the tissues lose their ability to slide over one another. This greatly restricts movement. Any movement that does occur creates shearing of the tissues and subsequent pain.

Manual therapy techniques are not designed to ‘deform’ the fascia but merely restore the gliding properties.

Holistic Approach

Clinicians can become so embroiled in addressing a shoulder restriction or low back pain that they forget that it is a small part as opposed to the body as a whole. Often, they may refer to the person as “the shoulder patient” or “the low back patient”, especially if there is something unique to the case. This serves as a way of categorizing the patient when discussing the case while also staying within HIPAA guidelines.

The problem with this is that the patient as a person may be forgotten:

The shoulder or spine is attached to the rest of the body. The painful area may be the problem or it may be the compensation for a dysfunction elsewhere in the body. Many insurances will not pay for treatments outside of the area of subjective complaints even though documentation has been provided linking it to the symptoms. However, without addressing the other dysfunctions, the area of pain may never fully resolve.

The body is a fine instrument of movement capable, under the right circumstances, of healing itself. This requires the skilled interventions provided by a clinician but also encompasses other requirements such as nutrition. Several studies reference poor dietary habits with delayed healing time. Sprains and strains require extra protein to provide the amino acids necessary for recovery; something very difficult for many vegetarians or vegans. Other injury types may require an increase intake of different vitamins, such as vitamin C for collagenous injuries, or minerals, such as calcium in the presence of a fracture, to aid in recovery.

Moreover, by addressing just the body part, the patient’s mental state will be forgotten. Pain, especially chronic pain, can have drastic psychological implications including insomnia, anxiety and depression. A person’s mental state can have positive or negative impacts on their recovery from injury.

A true holistic approach should also encompass each of these aspects.

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