CCE5_LTR_PPT

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Low Tech Rehabilitation

Basic Protocols for Immediate Use

Low Tech RehabPost Graduate ProgramsMark Hartsuyker, D.C.

Some Background……

• 2 year degree/training as PTA• Graduated 1980 from LACC• 18 years practice Ithaca, NY• 3 years practice Boston, MA

– Private Practice– Ergonomic Consultant

• October, 2002 - Logan Clinical Faculty

Structure of Content

• Theory and Background• Functional Anatomy • Testing, Analysis & Diagnosis• Hands-on practical experience

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Overview of Weekend• Introduction & Testing

– Basic Concepts & Foot Evaluation– Manual Muscle Testing & Flexibility

• Core Stability – Neck Flexors and Neck Stability– Swiss Ball

• Posture & Knee – Postural Awareness & Anterior Pelvic Tilt – Knee Rehab. & Rocker/Wobble Boards– Case Study

• Upper Body– Shoulder Rehabilitation– Upper Extremity Rehabilitation

Assumptions

• Detailed History including:– Nature of Chief Complaint– Past Personal History & Review of Systems– Past Family History

• Appropriate Orthopedic, Physical, Neurological & Chiropractic Exams

• Differential Diagnosis

Special Tools of Assessment

• Full sized pain drawing with five types of discomfort

• Analog Pain scale• Oswestry Quality of Life Index

– Neck– Low Back

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Role of Manipulation

• Direct experience that….– Spinal manipulation is potent– Chiropractic adjustment is central

• Active management compliments• Exercise programs do not replace the

importance of manipulation

Low-Tech Rehab• What – Low cost tools for

rehabilitation• Why – Pain management,

myofascial pain & long term fitness

• Who - Nearly all your patients• How – Selective techniques

geared to individual need, dependent upon place in the treatment cycle

Philosophical Perspective• Passive vs. active management• Part of problem or part of the solution• Not dependent but empowered patients• Differentiate & build your practice• Give patients something to look forward to• It’s fun to teach!

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Managed Care

• Carriers are expecting active treatment protocols

• Continued reimbursement based upon outcomes

• Appreciable improvement when active management has been instituted

Getting Paid

• 97110 “Rehab/Exercise”• 97112 “Neuromuscular Re-Education”• One unit = 8 to 25 minutes• One unit = $45

The Terrible Triad• Pain interferes with patient’s

ADL’s• Decreased mobility causes

segmental dysfunction• Decreased function causes

muscle atrophy• Lack of motion allows patient

to fixate on pain• Sleeplessness does not allow

muscles to relax• Hopelessness sets in,

reinforcing cycle

Pain

ImmobilityDysfunction

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Neurological Basis - Pathways

• Primary sensory afferents - to spinal cord• Ascending relay neurons - spinal cord to brain

stem / thalamus• Thalamocortical projections• Modulation: Nociceptive transmission is modified• Perception: Transduction, transmission,

modulation interact to create subjective emotional experience of pain

Neurological Basis - Pathways

Afferents

Ascending pathways

Dorsal horn

Neurological Basis• Large scale motor activity

given preference• Low grade pain perceived in

absence of large scale motor activity

• Chronic pain associated with aberrant changes in dorsal horn organization

• Prompt action necessary to avoid these changes!

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Interlocking Systems

Cognitive

Perceptual

Limbic

EmotionalMotor

Codependency of major CNS systems & environment

Testing - Biomechanical Analysis

• Leg length discrepancies– Functional or anatomical

• Muscle strength deficiency• Muscle tension,

hypertonicity or shortening• Foot dysfunction• Recurrent patterns of

segmental dysfunction• Ergonomic factors

When do you start?• Active management

– Immediately– Gauged to patients abilities or

level of function• Rehabilitation

– When most acute phase has passed

– Pain present so keeps patient interested

– Before “auto discharge” occurs

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Goals of Rehabilitation• Decreasing pain• Take away the fear of movement• Decreasing mechanical stress on spinal

structures• Strengthening weak muscles• Stabilizing hypermobile segments• Improved mobility• Improved posture• Improved fitness levels to prevent injury

Increasing Compliance

• Partnership with patient• Have you engaged the patient?

– Why am I doing this exercise?– How does it relate to my diagnosis?

• Post-instructional Check– Check patient’s technique within 1-3 day– Are they doing the exercise(s) correctly?– Are they doing them at the recommended

frequency?– Document compliance in SOAP

Documentation

• Note the time rehabilitation started and ended in date area.

• Briefly describe type of exercise, program, tool and why.

• Describe patient’s immediate understanding• Note frequency, duration, weight used and

how many times per day• List any handouts given to the patient

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Patient Handouts

• Ease of Creation

• Individualized

• Covers various rehab tools

• Covers documentation

• Reasonably priced

Tools of the Trade

• Swiss ball• Foam rolls• Wobble & rocker board• Soft kickball• Elastic bands• Kinesiotape• Hand & wrist devices

Swiss Ball

• Trunk Strengthening• Targeting of select muscle groups• Enhanced Proprioception• Mimics Real Activities & Demands• FUN!

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Foam Rolls

• Compliments Swiss ball type activities• Trunk stability• Balance and coordination

Wobble & Rocker Board

• Ankle stability• Knee stability• Post ankle sprain rehabilitation• Functional challenge to area• Re-establishes proprioception

Soft Kickball

• Resistance exercises – neck flexors• Post-MVA rehabilitation• Headaches• Extensor & SCM myofascial pain• Loss of cervical lordosis

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Elastic Bands

• Strengthening for all extremities• Graded resistance activities • Easy to target selective groups• Functional activities can be mimicked

Kinesiotaping

• Provides “touch” to area of chief complaint

• Lifts skin to open lymphatic channels

• Increased mechanoreceptor stimulation

Wrist & Hand Devices

• Selective stability across wrist• Strengthening of forearm muscles• Used when acute phase has passed• Tools:

– Dynaflex balls– Wristiciser– Handmaster

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Summary of Process• Examination/Analysis• Diagnosis

– Understand contributing factors– Patient seen in wholestic manner

• Formulate a treatment plan– Short term goals– Long term goals

• Reassess at appropriate intervals

Evaluation of Foot Biomechanics

• Evaluation• Biomechanics• Proprioception


Foot Evaluation – Why?• Foundational when considering:

– Biomechanics/positioning– Proprioception to all postural

muscles

• Small change inferior = large change superior

• “Bed” of proprioceptors is rich given role of feet in standing and locomotion

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Foot Dysfunction

• Foot dysfunction < > foot pain• Recurrent dysfunction in:

– Ankle, knees, hip– Sacral-iliac joints, lumbar spine– Neck, headaches– Shoulder diagnosis

• Do symptoms increase with weight bearing activity?

Steps for Evaluation• Observe• Palpate• Heel Strike Test• Recommendation

Leg Length Discrepancies• Functional

– Pelvic unleveling– Pronation– Supination

• Measurement – Pelvic Influence– Fixed to non-fixed measurement– Patient lies supine with legs in neutral position– Measure both legs from umbilicus to medial malleolus– Unequal measurement suggests functional shortening– Radiographic methods

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Leg Length Discrepancies• Structural

– Growth plate injury

– Trauma - Fracture– Infection– Poliomyelitis– Cerebral Palsy

Observe• Hip Height Difference• Achilles Tendon Deviation• Medial Malleolus• Hallux Valgus Deviation

Palpate

• Inform the patient of your intentions• Hold the ankle with one hand• Firmly palpate the longitudinal arch

– Taut– Loss of height– Pes Planus– Tender

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Mechanism of Heel Strike

• Phases of gait:– Heel strike Stance Toe-off Swing

• Heel strike moment facilitation of quadriceps group

• Loss of strength at this moment = inhibition at moment weight shifts to limb in stance

• Patient prone, hip at 45 degrees• Show patient direction of travel• Test muscle strength• Inform patient of procedure• Do a “dry run”• Heel strike, withdrawal & test

Heel Strike Muscle Testing

• Is there a loss of strength?• Double strapping across arch & ankle• Retest strength• Proprioception is aberrant


• No loss of strength?• Biomechanics alone a factor• Consider orthotics on other factors

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• With strapping – no change in quadriceps?

• Consider joint dysfunction along kinetic chain:– Ankle– Knee– Hip– SI joint

Aberrant Heel Strike Effects

• Loss of stability across the knee– 60% muscular & 40%

ligamentous– Recurrent knee pain with weight

bearing activities• Loss of anterior stability to the

ilium– Chronic recurrent SI joint

instability– Compensatory muscle tightening

Gait Cycle Revisited

• Heel Strike• Stance Phase• Toe-Off• Swing

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Proprioceptors

• Golgi tendon organs (GTO) activated• Spindle cell receptors in longitudinal arch• Between each bone – capsular receptors• Mechanoreceptors in longitudinal ligament

Heel Strike through Toe-Off

Neurological Basis• GTO signals to anterior horn

of spinal cord• Type 1B afferents signal

inhibition• Possible nocioception below

threshold for perception• Upon taping, possible

unloading of mechanoreceptors in the plantar fascia

Proprioception & Postural Muscles

• Test latissimus dorsi or neck flexors seated

• Test standing with & without taping

• More then heel strike perception may be dysfunctional

• Correlate findings to patient’s symptoms

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Recommendation

• Do not need to have positive heel strike to recommend orthotics

• Pronation alone adequate indicator• Common bilateral equal pronation off

the shelf device may suffice• Marked deviation with chronic foot pain

podiatrist referral may be indicated

Supinated Feet

• High arch = rigid arch• Inflexible• Poor shock absorption• Tendency towards heel pain

Types of Orthotics

• Casting weight bearing• Casting non-weight bearing• Hard vs. “soft”

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Documentation• S: The patient states that her symptoms of headaches/shoulder pain/low back pain is/are worse after

long period of standing at work, although she does not complain of foot pain.O: While weight bearing there is a deviation of the Achilles tendon bilaterally with the right greater then the left. This deviation on the right appears to be approximately 15 degrees with the medial malleolus also more prominent on the right towards the midline. Palpation with light/moderate/deep pressure of the mid longitudinal arch while weight bearing elicited marked/moderate/mild tenderness and there was mild/moderate/marked tonicity of the plantar musculature. The strength of the quadriceps muscle was bilaterally +5. When heel strike was mimiced the strength of the quadriceps bilaterally/right/left was inhibited to +4. Taping of the ankle into neutral position and elevation of the arch with two closely set bands was performed. After this procedure the heel strike response was retested with the quadriceps strength returning to +5.A: Bilateral pronation, right > left with proprioception loss during gait contributing to biomechanical problems of the ankle/knee/hip sacral iliac joint(s)/lumbar spine/shoulder/cervical spine. It is my opinion that P: Cast the patient for ___________ orthotics, dispense and monitor for improvement in the biomechanical dysfunction of ___________ (named regions). It may also be valuable to provide manipulation for the intrinsic foot bones to aid the patient's adaptation to the orthotics.

Evaluation of Muscle Function

• Clinical Correlations• Documentation of Soft Tissue Findings• Testing Procedures

– Direct or Prime Groups– Antagonists


Stages of Assessment

• Do we have stability across the region?

• Is there flexibility in all muscles that cross the joint or that effect the region?

• Is there adequate range of motion– Segmental (vertebral)– Global

• Exercise or general fitness level

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Muscle Testing – Why?

• Assess stability• Identifying true weakness• Correlate with diagnosis• Measure effectiveness of manipulation• Know which muscles to rehabilitate• Objective measurement of outcomes• Measure patient compliance

Applied Kinesiology

• Prior to Goodheart muscle testing existed!

• Muscle testing will lead to various conclusions

• Emphasis-– Relation to vertebral subluxation– Weakness secondary to

biomechanical factors

Role of Manipulation

• Profound effects that are:– Direct – Corresponding to neurological level– Indirect – complex proprioception mechanisms

• If weakness persists– Are you adjusting all involved segments?– Is the muscle weak for another reason?

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Muscle Balance & Function

• Balance across structures• Considerations for all testing

– Hypertonicity– Postural shortening– Inhibition– Atrophy– Myofascial pain

Vladimir Janda on Joint Dysfunction

• Muscle spasm is always present in area of a painful lesion.

• Pressure of muscle in spasm increases the characteristic pain.

• Muscles & fascia are common to several spinal segments & if strained may restrict several contiguous segments.

• Muscle fatigue = predisposing factor that decreases the force available to meet demands.

• Muscle tightness may influence joint position stain of soft tissue & joints even within the normal ROM.

Janda on Chronic Pain

• Impaired CNS motor programming may be due to:– Stress & chronic fatigue– Constrained movements or posture

• Leads to:– Muscle imbalance– Overstress on structures of musculoskeletal

system

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Janda on Increased Muscle Tone

• May arise from:– Dysfunction of the limbic system– Impaired function at the segmental

(interneuronal) level– Impaired coordination of muscle contraction,

possibly due to trigger points– As a response to pain irritation

Myofascial Pain

Prime Mover - weak

Synergist - overworked

Antagonists – hypertonic

Active Trigger Point• Produces pain WITHOUT digital

compression• Very tender on palpation• Characteristic pain pattern for the

muscle (either with ischemic compression or without)

• Impedes muscular flexibility• Produces muscle weakness• May elicit a local twitch response with

compression (or needle stimulation)

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Latent Trigger Point• Usually silent – no spontaneous pain• Tender on palpation• Produces referred pain pattern only with

ischemic compression• Impedes muscle flexibility• Produces muscle weakness• May elicit a local twitch response with

compression (or needle stimulation)• Active TrP may become latent in a chronic

stage• May become active with

microinjury/microtrauma or macrotrauma

Muscles Prone to Tightness

• Gastrocnemius • Soleus • Tibialis Posterior • Short Hip Adductors • Hamstrings • Rectus Femoris• Iliopsoas • Tensor Fasciae Latae• Flexors of Upper Limb

•Piriformins•Erector Spinae•Quadratus Lumborum•Pectoralis Major •Upper Trapezius •Levator Scapulae •Sternocleidomastoid •Scaleni•Masticatories

Muscles Prone to WeaknessPeroneiTibialis Anterior Vastus Medialis &Lateralis Gluteus MaximusGluteus Medius &MinimusRectus AbdominisExtensors of Upper Limb

Serratus Anterior Rhomboids Middle and Lower Trapezius Deep Neck Flexors Digastricus

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Muscle Palpation-Described• Area being palpated?

– Example: Right pectoralis minor• Pressure of palpation used?

– Superficial, moderate, deep• What did you feel?

– Taut, band-like, nodule, involuntary twitch, diffuse

• What did the patient experience?– Discomfort, pain: mild, moderate, severe– Distribution of the pain

Art of Muscle Testing• Force aligned with muscle fibers• Force appropriate for length of lever arm• Force appropriate for frame size• Force appropriate for muscle size• Match strength to strength gradually• Is there a reserve after contraction against a

moderate graded force?• Are there fasciculations?• Is there an obvious effort or recruitment?

Muscle Strength Grading

• 0 – No contraction• 1 – Slight contraction, no movement• 2 – Full range of motion without gravity• 3 – Full range of motion with gravity• 4 – Full range of motion , some

resistance• 5 – Full range of motion, full resistance

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IliopsoasL2, 3

Rectus FemorisL2, 3, 4

Sartorius L2-L3

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Tensa Fascia LataL4, 5 S1

Hip AdductorsL2, 3

Quadratus LumboriumT12, L1-4

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Gluteus MediusL4, 5, S1

Gluteus MaximusL4, 5, S1

Piriformis L5, S1 & S2

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HamstringsL5, S1, 2

Rectus Abdominus

Caution: Not to be done with an acute or grossly unstable patient! Use the Swiss ball as a functional test.

Caution: Not to be done with an acute or grossly unstable patient! Use the Swiss ball as a functional test.

Oblique & Transverse Abdominals

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Gastrocnemius/Soleus

S1-S2

Latissimus DorsiThoracodorsal, C6, 7 & 8

Teres Minor & InfraspinatusC4, C5 & C6

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Pectoralis MajorClavicular Sternal

C5-C6C6-C7

DeltoidsAxillary, C5, 6

SupraspinatusSuprascapular, C5

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Infraspinatus C4, C5 & C6

SubscapularisC5-T1

Rhomboids & SubscapularisC5 C5-T1

Integrated or Functional Version

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Rhomboids

Palpate the inferior aspect of the scapula to feel if it remains fixed towards the spine.

C5

Lower Trapezius

Because of attachment of lower trapezius to inferior scapula, palpate for maintenance of scapula in a diagonal towards lower thoracic spine.

Mid-Trapezius

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Teres Major C6-C7

Upper Trapezius Accessory Nerve – Cranial XI (spinal portion)

Deep Neck Flexors & SCM

• Covered in a separate section• Very important in a variety of syndromes

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Antagonists or Reciprocal Testing

• Test one muscle rapidly followed by it’s antagonist

• Dampening is short lived unless first muscle tested is excessively tight

• Patient must be well coached prior to testing• Excellent patient education tool

– Found mostly in athletic patients– Stretching proven essential to outcome

Reciprocal Inhibition• Hamstring to Quadriceps (likely)• Quadriceps to Hamstrings (less

likely)• Adductors to Abductors (likely)• Abductors to Adductors (less likely)

Testing Reciprocal Inhibition

• Test the antagonistic muscles singly

• Train the patient for test– Positioning– Perform a “dry run”

• Quickly test one group• Rapidly switch to antagonist

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Summary

• Understand balance of function across joint• Analysis of various factors effecting muscle• Check if VSC is causing weakness• Disuse atrophy of select groups is common• Selective strengthening programs based

upon findings

Neck Flexors• Anatomy Review• Syndromes and Symptoms• Myofascial Pain Patterns• Observation & Testing• Strengthening• Expectations & Charting


Anatomy Review – Prime MoversLongus Capitis

Longus Colli

Scalaneus Anterior

Anterior rami C1-C3

Anterior rami C2-C6

Anterior rami C4-C6

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Anatomy Review – Prime Movers

Platysma

Anatomy Review – Synergists

Spinal portion of Accessory Nerve (Cranial XI) & Anterior rami C2-C3

Sternocleidomastoid

Anatomy Review – Synergists

Scalenes

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Anatomy Review - Antagonists

Suboccipitals


SemispinalisCapitis


Splenius Capitis

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Upper Trapezius


Temporalis

Spindle Cells• Rich endowment of spindle cells in:

– Neck flexors– Sub-occipital triangle– Longus colli

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Reciprocal Inhibition Cascade

Injury, posture, VSC

Facilitated neck extensors

Inhibited neck flexors

Time, adaptation &

postural changes

Neck flexor disuse atrophy

Pre-Disposing Factors

• History of a motor vehicle accident (or several) or other neck trauma, even if this event was many years ago

• Occupational – flexor dominant• Behavioral – slumped body posture

Syndromes• Loss of the cervical lordotic curve

visible on a lateral radiograph • Anterior head carriage • Hypertonicity of the sub-occipital

muscles, levator scapula, upper trapezius, SCM's and TMJ related muscles

• Headaches, especially those of myofascial origin (see muscles noted above)

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Syndromes

• TMJ dysfunction • Inability to maintain cervical

corrections • Chronic tension between the

shoulders

Myofascial Pain Principles

Prime Mover - weak



Myofascial Pain Patterns

Levator Scapula

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Splenius Capitus


SCM’s


Suboccipitals

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Temporalis

Postural Evaluation

•Forward head carriage

•Stooped posture

•Loss of curve on lateral cervical

Testing - Observation

• Translation or “chin jut”• Fasciculations• Chest raised• Arms brought forward• Terminal flexion or none

Instructions to patient:“Please lift your head

off the table.”

•Have table at horizontal neutral•Arms overhead decrease role of synergists

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Testing – Challenge•Chin tuck

•15-20 degrees of flexion

•Two finger or hand edge resistance

Further Testing - SCMSternocleidomastoid

Strengthening

•Guide patient to neutral head position

•Have the patient walk into the ball slowly.

•Avoid translation

•Instructions: “Keep ear over shoulder”

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Strengthening

•Hands on the wall to maintain the the chest-wall inter-space

•Keep just enough pressure to maintain the ball on the forehead

Strengthening

•With guidance have the patient perform a chin tuck

•Do they feel an increase in pressure on the forehead?

Strengthening

•Guidance can be given both during the chin tuck & flexion

•Always ask permission to touch

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Strengthening

•Have the patient complete flexion

•Repeat at least several times under observation to insure correct technique

Follow-up

• Insure compliance by having the patient return in 2-3 days for an exercise check

• Watch for lack of neutral start, translation or excessive pressure

Additional Care

• Regular manual manipulation • Coaching in proper

ergonomics and posture • Performance of gentle and

regular stretching of the cervical extensor groups

• Soft tissue release techniques

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Expectations for Outcome• Observation = nearly full

translation• Testing elicits fasciculations• Testing = +4 or less strength• 4-6 weeks of rehabilitation may

be necessary

• Observation = flexion occurs early during motion• Testing = +4 or better strength• 7-10 days may show good results

Factors Effecting Outcomes• Inhibition secondary to segmental dysfunction of the

cervical spine • Inhibition secondary to excessive overuse of neck

extensors from poor ergonomics or posture • Loss of neuromuscular higher level integration from

disuse • Atrophy secondary to long-term inhibition • Atrophy secondary to cervical trauma (both short-

term and long-term) • Applied Kinesiology factors (a separate study not

within the scope of this presentation) • Pathological factors possibly not uncovered during

the history

Charting• Objective:

• What was observed?• What was the results of testing?

• Assessment:• Loss of deep neck flexor strength

• Plan:• Strengthen with soft ball 10x twice per day• Recheck patient’s compliance and technique

within three days

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Muscle Flexibility

• Testing of Key Groups


Vladimir Janda

• Czech doctor of neurology & physical medicine

• Extensive contribution to understanding muscle function

Upper Cross Syndrome

• Tightness of:– Upper Trapezius– Pectoralis Major– Levator Scapulae

• Weakness of: – Rhomboids– Serratus Anterior– Middle and Lower

trapezius– Deep neck flexors,

especially the scalene muscles.

FROM: J Manipulative Physiol Ther 2004 (Jul); 27 (6): 414—420

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Upper Cross Syndrome• This syndrome produces:

– Elevation & protraction-shoulders– Winging of the scapula– Protraction of the head

• Overstress of:– Cervical cranial junction

• C4-5 and T4 segments– Shoulder due to altered motion of the

glenohumeral joint

Lower Cross Syndrome

• Tightened Muscles:– Gastrocnemius– Soleus– Hamstrings– Adductors– Hip flexors (i.e. iliopsoas, rectus femoris,

tensor fascia latae– Erector spinae


• Weakened/Inhibited Muscles:– Posterior & anterior tibialis– Gluteus maximus– Gluteus medius– Transverse abdominus– Internal oblique– Multifidus

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• Common Joint Dysfunctions:– Subtalar joint– Proximal tibio-fibular joint– Tibio-femoral joint– Iliofemoral joint– Sacroiliac joint– Lumbar facet joints


• Common Movement Dysfunctions:• Excessive lumbar lordosis during

movements such as squatting, lunging, and overhead pressing

• The result of:– Tight hip flexors– Erector spinae, – From weakness/inhibition of the inner unit (i.e.

the transverse abdominus and multifidus).


• Common/Predictable Injuries: – Low back pain– Anterior knee pain– Hamstring injuries

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Evaluation Muscle Length

• Accurate positioning of the joints– Insure maximum lengthening of origin &

insertion• Adequately stabilization of one end• Smooth motion during stretch, especially at

end range• Patient’s perception of tightness not a

reliable guide• Rely on maintaining positional stability &

doctor’s assessment of end feel

Modified Thomas Test

• Support the patient on the edge of the table

Thomas Test – Lay Back

• Help the patient lay back flat on table

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Assess Resting Length

• To what degree does the thigh go into hip extension?

Additional Flexibility - Iliopsoas

• Can the thigh be extended another 10-15 degrees?

Movement should occur without loss of lumbar or pelvic stabilization.

Flexibility – Rectus Femoris

• While still in modified Thomas test position flex the knee

Observe for patellar position: Is it superior?

Is there an indentation superior to the patella?

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Flexibility – Rectus Femoris Prone

• Use Nachlas Test: patient prone and flex the knee by bringing the knee to the buttock

Hamstring Assessment

• Opposite knee bent• Support the heel in a bent elbow• Apply pressure to anterior tibia

Hamstring Assessment

• Palpate at ASIS for pelvis movement

• >70 degrees flexion = marked loss of length

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Hip Adductors• Move the non-testing

leg approximately 15 degrees into abduction

• Cradle the leg as in assessment of the hamstrings

• Slowly abduct the leg, palpating for when pelvic movement sets in

Hip Adductors

• Leg should be abduct to 45 degrees without pelvic movement

• Flexing the knee eliminates the hamstrings as a source of restriction

Assessment - Piriformis

• Flex the leg to no more than 60 degrees• Provide compression along the axis of the

femur• Adduct the thigh• Internally rotate

the femur• Feel for smooth

movement with no restriction

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Palpation - Piriformis

• Mentally draw a line between the PSIS and the greater trochanter

• The second line is from the ischial tuberosity to the ASIS

Palpation - Piriformis

• Palpation where these two lines cross • Palpation is conducted with one hand

reinforcing the other and is very deep

Gastrocnemius & Soleus

• Patient is supine, distal one-third of the tibia/fibula not supported by the table

• Distract the calcaneus caudally then raise the foot into dorsiflexion

• It should be able to flex to 90 degrees

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Gastrocnemius & Soleus

• To eliminate the soleus and isolate the gastrocnemius

• Flex the knee while maintaining the calcaneal distraction

• If the ROM increase the gastrocnemius is the tight muscle

Pectoralis Major

• Patient supine close to the edge of the examination table

• Stabilization of the trunk is essential

• Place the arm in slight external rotation at 120 degrees of abduction

• Palpate the muscle for tenderness while detecting the length

Upper Trapezius

• Patient supine, stand at the head of the table• Use your right hand on top of the right

shoulder to assess elevation• Use the left hand to flex the head fully, followed by lateral flexion

• Head rotation is to the ipsilateral side. Traction the shoulder girdle inferior

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Levator Scapulae• With the patient supine, stand

at the head of the table• Flex the head while

maintaining downward pressure on the shoulder

• Head is rotated contralateralto the side being held

• Depress the shoulder girdle and assess the quality of the end feel, comparing left and right sides

• Also palpate the insertion of the levator scapulae at the superior angle of the scapula

Active Care – Patient Self Stretches

• Upper trapezius• Levator scapulae• Iliopsoas• Piriformis• Pectoralis group

Basic Instructions

• Move into stretch position slowly • Setting the intensity (just right 4-6)

– Fine tune the position• 10-12 Breaths per position (audible)• Notice softening or increased ease• Release the pose carefully• Repeat the position of challenge

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Stretch - Upper trapezius

Stretch - Upper trapezius

• With less stretch

Stretch - Levator scapulae

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Stretch - Iliopsoas

Stretch - Iliopsoas

Stretch - Iliopsoas

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Stretch – Iliopsoas (supine)

Stretch - Piriformis

Stretch - Piriformis

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Stretch - Pectoralis group

Stretch - Pectoralis group

Resource

• “Stretching” by Bob Anderson

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Introduction to Swiss Ball & Foam Roll Exercises


Swiss ball offers:

• Trunk Strengthening• Enhanced Proprioception• Mimics Real Activities & Demands• FUN!

Ball Diameter User Height

• 75 cm. ball (29 inches) >6 ft. 0 in. tall• 65 cm. ball (25 inches) 5 ft. 5 in. to 5 ft.

11in. tall• 53 cm. ball (21 inches) 4 ft. 11 in. to 5 ft. 4 in. tall• 42 cm. ball (16 inches) <4 ft. 10in. tall• 30 cm. ball (14 inches) children 1-2 years old• 20-25 cm. ball (8-10 inches) for non-sitting

exercises requiring a small ball

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Swiss Ball Safety

• Padded floor – foam mats• No furniture in fall zone• Mounting - Hand & eye on the

Swiss ball • Patient and doctor face each other • May require safety belt around

mid-section• Assistant as spotter

Global Evaluation

• Relative function of muscle groups• Weakness or hypertonicity• Compensatory mechanisms• Neurological deficit• Synergetic movement• Lack of balance

General Indications

• Decreased range of motion• Decreased strength• Decreased balance reactions• Decreased coordination• Decreased endurance• Decreased proprioception

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Patient Population – Entry Level

• Chronic low back pain (if not in acute phase)• Deconditioned• Increased pain with ADL’s• Instability – i.e.: “I just stepped off the curb

and my low back went out.”

Contra-Indications

• Profound balance problems• Acute pain• Distress with sitting• Increase in pain during exercises• Ringing in the ears• Ball frightens patient

Signs of Sensory Overload

• Pupil dilation• Sweaty palms• Changes in respiration rate• Flushing or pallor• Complaints of dizziness

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Primitive People & Abs

Misconceptions

• “Definition” < > Toned Abdominal Muscles

• Raw Strength vs. True Functional Tone

Reminders to Patients

• Exercises take concentration• Safety zone if they fall• Perform exercises slowly (generally)• Any exercise can be “backed down”

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Reminder to Doctor

• Doctor - No “hard”agenda on a given visit

• Observe• Guide and encourage• Advance program only

when appropriate

Circles & Figures of Eight

• Sit on ball• Hands on inguinal

fold region• Feet apart• Eventual trunk &

head move contra to hips

• Doctor Observes:• How steady• Fasciculations• Flattening of pattern• Hip movement

matched by contralateral torso

Abdominal Sit-Back

• Feet spread apart• Roll hip forward• Slowly lean straight

back• Lean back to point

can still maintain mobility

• Doctor Observes:• How steady?• Fasciculations• Maintaining

balance• Anterior vs.

posterior pelvic tilt

65

Diagonal Sit-Back

• Feet spread apart• Roll hip forward• Slowly lean back

diagonal• Lean back to point

can still maintain mobility

• Doctor Observes:• How steady?• Fasciculations• Maintaining

balance• Anterior vs.

posterior pelvic tilt

One Leg Lift• Can the patient keep

balance?• Is there excessive

torso shift or does one hip hike up?– Transverse obliques– Quadratus

lumborium

Contralateral Puppet

• Do not advance if the “one leg lift” is poor!

• Lift leg and arm at the same time

• Keep torso even and balanced

66

Quadratus Lumborium• Hip pointed at ceiling• Bring hip to shoulder,

shoulder to hip• Not a lateral leg lift alone

Bridged Supine

• Lay over the ball• Feet spread apart at first• Arms out for stability• Start with ball under mid back• Slowly roll out to ball across upper

shoulders• Maintain flat abdominal platform

Full-Spine Roll-Out• Start seated & slowly roll out• Feet wide apart• Slowly stretch torso over ball• Place arms at 45 degrees

overhead• Lay back and let neck relax• Coming up – start with neck

curl

•Contraindications:

•Neck pain

•Poor stability on less advanced exercises

67

Full-Spine Roll-Out - 1



68


Gluteus Medius

• Lay on side over the ball• Bend bottom leg

underneath• Keep hip pointed at the

ceiling• Lift high leg towards

ceiling

Gluteus Maximus

• Lay prone over the ball on knees

• With knee bent, lift one leg

• Keep torso flat with no torque

• Do not want lumbar extensor activation

69

Increasing the Challenge

• Further COG is away from ball• Further away extremities from ball• Bouncing• Closing the eyes• Providing external manual

resistance

Swiss Ball and Athletes

• Activate a myriad of motor recruitment patterns, as the ball is unstable. It never moves the same way twice in a row!

• Enhance both spinal and peripheral joint stability, which help to prevent injury

• Swiss Balls are also effective stretching aids and can be used to develop strength in both open and closed chain environments.

Swiss Ball and Athletes

• High levels of nervous system activation, = greater neurological capacity in the playing environment

• Reduces the incidence of injury• Athletes who predominately use

machine training have a difficult time transferring their strength and power to the playing environment.

70

Progressive Push-Ups

• Lay prone over the ball• Have ball hit across hips• Keeping back stable perform push-up• Slowly walk out to knees• Eventually walk out to ankle• Always maintain flat back platform with no

dipping

Progressive Push-Ups - 1


71


Rhomboids

• Face down – kneeling• Arm out at 45 degree to

head/neck• Thumb up• Attempt to lift arm• Doctor observe/palpate for

scapular control

Rhomboids 2

72

Subscapularis & Rhomboid Dips

• Assume “progressive push-up” position• Extend out only to knees – esp. beginning• Drop chest/upper torso through scapula• Doctor directs by placing hand on sternum

and/or mid thoracic spine

Subscapularis & Rhomboid Dips

Balancing Bear

• Kneel on all fours on ball• Maintain position• Don’t fall off

73

Kneeling on Ball

• From “Balancing Bear” advance• Kneeling on ball• From arms outstretched to resting on hips• Great for knee stability from trunk

Foam Rolls

• Beginners Position– Sit back on the foam roll

placed vertically under the full length of your back

– Have your head and neck supported on the foam roll

– Bend your knees with your feet on the floor

Foam Roll - Stretch position:• Start with your arms at your side and then

raise one, then both of them overhead • Hold for 20-30 seconds

74

Foam Rolls - Prone

Have Fun!

Shoulder Rehabilitation

•Anatomy Review•Muscle Testing Review•Common Problems•Treatment

75

Anatomy Review - Shoulder

• Pectoralis minor– Common TOS

provoker– Tension rolls gleno-

humeral joint anterior– Tightness common

with forward rolled posture


• Latissimus dorsi– Inhibited by: thoracic

fixations & C1– Major posterior postural

stabilizer– Readily inhibited by foot

dysfunction– Weakness allows anterior

glenohumeraldisplacement


• Infraspinatus & Teres minor – Inhibited by

fixation in lower cervical spine

76


• Deltoid– Anterior– Middle– Posterior

• Fixation mid to lower cervicals will inhibit


• Rhomboids– Inhibited by both

lower cervical & thoracic fixations

– Inhibited by excessive flexor tone

– Under used by most patients


• Supraspinatus– Inhibited by

mid to lower cervical fixations

77


• Subscapularis– Tendon easily

entrapped as it passes through the gleno-humeral joint

– Increased wear & tear with advancing age

Evaluation

• History• Orthopedic, neurological &

physical– Remember probing palpation of

soft tissue structures to patient tolerance

• Radiographic• Chiropractic spinal analysis• Selective muscle testing

Radiographic

Osteonecrosis, both humeral heads, due to steroids used to treat this patient's chronic leukemia

78

Tendonitis, Capsulitis & Bursitis

• Uneven balance of forces across a joint• Impingement of soft tissues

– Tendons, bursa & joint capsule– Vascular components (TOS)– Neurological entrapment

• Improper coupled motions across joint• Excessive wear and tear of soft tissues

Myofascial Pain

Prime Mover - weak



Myofascial Pain - Triggers• Pressure – direct contact by leaning• Stretching – passively while sleeping or indirectly

during activity• Use – contraction, especially with considerable

resistance or posturally

• Pressure – ischemic compression• Stretching – gentle, slowly, regularly• Use – low resistance, aerobic style

Myofascial Pain - Treatments

79

Trigger Points

• Latissimus Dorsi– Mid-thoracic– Posterior scapula– Anterior shoulder– Entire arm to hand

Trigger Points

• Subscapularis– “Frozen Shoulder”– Posterior shoulder– Arm– Wrist

Trigger Points• Teres major

– Similar to latissimus dorsi

– Deltoid & arm pain

80

Trigger Points • Deltoid– Local pain at shoulder

Trigger Points • Coracobrachialis– Similar to deltoid– Arm, forearm &

wrist

Trigger Points • Biceps brachii– Pain lateral

shoulder– Pain anterior elbow

81

Trigger Points • Supraspinatus– Mimics subdeltoid bursitis– Elbow, arm & forearm

Treatment Steps

• Pain relief– Ice, modalities (electrical stimulation,

ultrasound)– Possible start trigger point release work

• Passive motion• Manipulation when applicable• Gentle resistance within non-painful

range• Gradual increase in range and resistance

Passive Motion• Pendulums or Codman’s arm swing

82

• Wall walking

Passive Motion

Resistance Exercises

• Internal Rotation– Pectoralis major– Subscapularis


• External Rotation– Teres minor

83


• Abduction– Supraspinatus– Deltoid


• Scapular Retraction– Rhomboids– Trapezius

• Scapular “Fixing”– Subscapularis

Knee Rehabilitation

Wobble Board

Resistance Bands

Stretching


84

Overview

• Anatomy Review• Syndromes and Symptoms• Myofascial Pain Patterns• Observation & Testing• Strengthening• Expectations & Charting

Assumptions – Prior to Treatment

• Detailed History of Chief Complaint• Full Regional Work-up of the Knee

– Standard Orthopedic Testing• What do we know?

– Rule out primary pathologies– Diagnosis – do we treat, co-manage or

refer?

Anatomy Review

• Quadriceps

85

Anatomy Review

• Adductors• Adductors

Anatomy Review

• Tensa Fascia Lata

Anatomy Review

• Gluteus Medius

86

Anatomy Review

• Hamstrings

Anatomy Review• Gastrocnemius

• Soleus

Myofascial Pain - Knee

• Rectus Femoris

87


• Vastus Intermedialis


• Vastus Lateralis


• Vastus Medialis

88

Feet Biomechanics

• Pronation causes angular forces• Supination causes contralateral stresses• Poor proprioception causes abherrent

muscle firing during the gait cycle

Ankle Stability & Proprioception• History of repeated

ankle sprains

Rocker Board

• Renewal of proprioception

• Progression– Two feet – AP motion with

control– One foot - maintaining

control• No looking at the feet!

89

Wobble Board

• Two feet – AP rocking with control

• Two feet – lateral stability• One foot – four point

motion• One foot – slow circles

without touching floor

Trunk Stability & Proprioception

• An unstable pelvis causes– Angular forces from superior to inferior– Greater stress across the knee

Muscular Tension

• Hamstrings• Quadriceps Group• Calf Group (soleus &

gastrocnemius)• Adductors• Abductors• Gluteal group

90

Stretching

• Hamstrings

Stretching• Calf Group

Gastrocnemius

Soleus

• Quadriceps femoris

Stretching

91

Reciprocal Inhibition

• Hamstring to Quadriceps (likely)• Quadriceps to Hamstrings (less

likely)• Adductors to Abductors (likely)• Abductors to Adductors (less likely)

Testing Reciprocal Inhibition

• Test the antagonistic muscles singly

• Train the patient for test– Positioning– Perform a “dry run”

• Quickly test one group• Rapidly switch to antagonist

Strengthening

• Quadriceps

92

Strengthening

• Gluteus medius

Strengthening• Adductors

Adductors & Gluteals

Strengthening• Abductors

93

Postural Awareness &Anterior Pelvic Tilt

McKenzie's –Back

Extension Exercises


Syndromes- Indicators

• Facet syndrome• Excessive lumbar lordosis• Poor abdominal control/positioning• Chronic low back pain with weight bearing• Poor standing posture• Runner’s posture

Assessment• Lateral lumbar radiographs• Standing postural analysis• Muscle testing for facetal

jamming

94

Radiographic Analysis

• George’s weight-bearing line

• Sacral base angle• Spondylolisthesis

Muscle Testing – Facetal “Jamming”

• Patient prone• Test the hamstring strength• Careful instruction performing a “press-up”

– Keep the hips on the table– Use arm strength only– Extend to 2/3 to ¾ of full extension range– Respect painful limit of ROM

• Hamstring inhibition present?

Anterior Pelvic Tilt• Engage the patient

– Explain diagnosis– Explain progression– Give demonstration

• Progression– Prone position & strengthening– Standing wall tilts– Standing, walking & running

95

Exercise Progression - Prone• Patient on a firm, comfortable

surface• Patient contacts pubic bone• Place small firm object under

lumbar spine• Instruct them to roll pelvic so

that pubic bone “rolls” towards the nose

• Hold for 3-5 count and relax

One-Third Curl• Patient can perform a good anterior pelvic

tilt• Cross arms over chest or behind the head• Set a pelvic tilt• Slowly curl 1/3 towards full sit-up• Hold for a slow count of 3-5• Slowly roll back down while maintaining

the pelvic tilt throughout

Wall-Tilt• If the patient shows good

control during pelvic tilts and 1/3 curls

• Start in a low squat and perform tilt against the wall

• Slowly move up the wall, performing a tilt at each level

• If shoulders start to roll forward then patient to perform exercise at last correct level

96

Standing Tilt• If the patient can work their

way up the wall to nearly standing

• One hand low on the anterior pelvic area

• One hand in the lumbar lordosis

• Perform a pelvic tilt without shoulders rolling forward

• Imagine a “sky hook” lifting head towards the ceiling

• All postural changes occur from the pelvis up

• “Goldielocks Principle” for degree of tilt

Integration into ADL’s

• If good control with standing• Patient can assume posture

– Walking– Running– Sitting

• Visual cues in regular activities as triggers

McKenzie Method

• Comprehensive assessment• Positions that centralize pain• Committed to either flexion or extension • Performance independently at home• Neutral spine and dynamic muscle

support of their spine

97

Observation/Assessment

• Patient's response to repeated, near end-range spinal motions

• Patients are diagnosed with either postural, dysfunction or derangement

• Derangement = alteration in the structure and mechanics of the intervertebral disc

Prime Patient for Extension

• 65-70% require extension*• Maintaining extension during all ADL’s• Non-weight bearing extension• Standing extension• Repeated throughout the day

* Stats put forth by McKenzie practitioners

Low Tech RehabArm

WristHand


98

Introduction

• Biomechanics are considered• Touch on carpel tunnel syndrome• Complete work-up including:

– Metabolic– Cervical Disc– Tumors especially apical lung– Orthopedic & Neurological

Anatomy Review

• Pronator Quadratus– Approximates ulna &

radius– Inhibited by injury

• Extension of wrist

– Origin-insertion STM helpful

Anatomy Review

• Flexor digitorium profundus– Hypertonicity leads to

medial epicondylitis

99

Anatomy Review

• Extensor digitorium communus– Hypertonicity leads to

lateral epicondylitis– Frequent source of

myofascial pain syndrome

Anatomy Review

• Pronator teres– Consider involvement

when pronation causes pain

Anatomy Review

• Median nerve

• Ulnar nerve

100

Myofascial Pain

• Latissimus dorsi• Pain in the arm,

forearm & hand

Myofascial Pain

• Scalenes• Pain along entire upper

extremity to wrist & hand

• Associated chest pain• Post MVA

Myofascial Pain

• Extensors• “Wrist pain”• Pseudo-carpal tunnel• “Painful weak grip”• Frequently associated

with lateral epicondylitis

101

Myofascial Pain

• Finger Flexors• “Stiff fingers”• Pseudo-carpal tunnel• Frequently

associated with medial epicondylitis

• Wrist & finger pain

Myofascial Pain

• Palmaris longus• Hand pain• Associated with

“Dupuytren’sContracture”

Myofascial Pain

• Opponens Pollicis• Thumb pain

102

Other Sources – TP’s

• Scalenes

Other Sources – TP’s

• Latissimus Dorsi

Carpel Tunnel Syndrome• Is the presentation “classic”

– Frequent burning, tingling, or itching numbness in the palm of the hand and the fingers, especially the thumb and the index and middle fingers

– Some carpal tunnel sufferers say their fingers feel useless and swollen, even though little or no swelling is apparent

103

Carpel Tunnel Syndrome

• Not all wrist or hand pain is CTS• Causes of pain

– TP’s of flexor or extensor muscles– TP’s of latissimus dorsi– TP’s of the scalenes– Median nerve entrapment at the elbow– TOS from the pectoralis minor

Carpel Tunnel Syndrome

• Screen the patient for true CTS• Mixed or multiple diagnosis is possible• Each component of pain production must be

addressed• Trace the entire path of both nerve and

referred pain patterning

Treatments - Passive

• Spinal manipulation• Extremity manipulation• Ischemic compression• Kinesiotaping• Gentle stretching

104

Manipulation - Rationale

• Spinal: Consider levels of innervations to injured area

• Primary problem = extremity• Reflex arcs will spinal

segmental dysfunction• Marked reduction in healing time

gained

Extremity Manipulation

• Is there joint instability?– Yes: may be contraindicated– No: proceed as indicated

• Lateral & medial radius/ulnar displacement– Analysis: tenderness of origin & insertion of

pronator quadratus– Spongy springiness upon medial squeeze

Ischemic compression• In belly of muscle palpate for

area of:– Taut– Tenderness– Nodularity– Possible fasciculation or

involuntary twitch• Steady pressure to patient

tolerance• Patient takes slow deep breaths• Cannot breath through pain, too

much

105

Kinesiotaping

• Provides “touch” to area of chief complaint

• Lifts skin to open lymphatic channels

• Increased mechanoreceptor stimulation

Active Care: Stretching

• Comparative body awareness– Sitting, close the eyes– Tune into how the arms feel

• Perform the stretches unilaterally• Compare left to right arms

– Lighter, at ease, increased sense of energy• Goal: increased compliance

Active Care: Stretching• Three basic stretches:

– Extensors– Flexors– Thenar

• Held for ten slow deep breaths• Patient to pace themselves• Can be done with elbow bent• Excellent injury prevention for

patients who use their hands a lot

106

Forearm - Flexors

• Outstretched arm• Reach across fingers• Gently pull back• Can be performed with

elbow bent• Hold for ten slow deep

breaths

Hand Stretch - Thenar

• Keep hand in “stop”position

• Gently pull the thumb down towards the beltline

• Hold for ten slow deep breaths

Forearm - Extensors

• Outstretched arm• Reach across back of

knuckles• Gently pull back• Can be performed with

elbow bent• Hold for ten slow deep

breaths

107

Compare Extremities• Kinesthetic feedback• How does the stretched side compare to the

unstretched side?– Lighter– Warmer– More at ease

• Reinforces value of stretch• Now stretch the opposite extremity

Dyna-Flex• Gyroscopic action

provides resistance• Full circle of strength

training• Enhanced stability

across wrist

Handmaster Plus

• Open

• Closed

108

Wristiciser

• Go through all principle diagnosis

Summary

• Multifactorial nature of hand, wrist and arm pain

• CTS may be present yet with other contributors

• LTR instituted only when:• Through understanding of diagnosis has

been reached• Acute phase has passed

Knee Pain Patient

Problem Centered Orthopedic Tests and

Functional Muscle Testing


109

Pain Presentation• Bilateral anterior-medial knee pain with left side

more troubled then the right• Aggravated by squatting, prolonged sitting and

extending the leg into extension• “Feels like the knee is going to lock” when the

knee is in flexion• 3 months prior had a couple of acute episodes

during a long inventory inspection, which called for repeated squatting & kneeling, with pain so intense the patient could not arise.

• Within an hour of aggravation, the knees felt fine

Pain Drawing

• Primary pain quality = “achy”

History - Activity

• 50 year old male• Recreational bicyclist 3-

4X/wk for 45 minutes per session on X-country ski simulator (Nordic-Trak)

110

History - Occupational

• Occupation – warehouse inspection, calling for sitting at a computer, repeated kneeling and squatting and standing on hard concrete floors

• Medical history unremarkable• No trauma to the area of

involvement

History - Podiatrist

• Pronation corrected many years ago by orthotics

Physical Examination

• Visual inspection unremarkable with no edema• Q angle normal• Knee ROM full & without pain• Motion palpation detects a definite eccentric glide

of the patella bilaterally as patient extends the knee

• Pain upon palpation at lateral aspects of knee, left > right

111

Q-Angle (Reference)• The Q-angle (or "quadriceps angle) is formed in the frontal plane by two

line segments: – from tibial tubercle to the middle of the patella – from the middle of the patella to the ASIS

• The q-angle in adults is typically 15 degrees. Increases or decreases in the q-angles are associated in cadaver models with increased peak patellofemoral contact pressures (Huberti & Hayes, 1984). Insall, Falvo, & Wise (1976) implicated increased q-angle, along with patella alta, in a prospective study of patellofemoral pain.

• Increases in q-angle are associated with: – femoral anteversion– external tibial torsion – laterally displaced tibial tubercle – genu valgus

References: • Huberti, H.H., & Hayes, W.C. (1984). Patellofemoral contact pressures:

The influence of Q-angle and tendofemoral contact. Journal of Bone and Joint Surgery, 66A, 715-724.

• Insall, J., Falvo, K.A., & Wise, D.W. (1976). Chondromalacia patellae: A prospective study. Journal of Bone and Joint Surgery, 58A, 1-8.

Orthopedic Evaluation

• Thomas Test - indicative of a flexion contracture involving the iliopsoas musculature

Positive


• Marked tenderness of the entire iliotibial band, especially near the distal portion when mild to moderate pressure was applied

• No obvious muscle atrophy• Circumference of thighs was

symmetrical

112


“Latent” trigger point of vastus medialis

Orthopedic Evaluation• Abduction Stress Test (valgus)

Indicative of a medial collateral ligament injury

Negative

Orthopedic Evaluation• Adduction Stress (varus)

Lateral collateral ligament damage

Negative

113


• Apley’s Compression

Negative

Meniscus Injury


• Clarke’s SignIndicative of patellar chondromalaciaMildly Positive

Orthopedic Evaluation• Trendelenburg’s Test

Suggestive of insufficiency of the hip abductor system

Mildly positive

114

Muscle Testing• +5 bilateral quadriceps

Muscle Testing

• Hamstrings +5 bilaterally

Muscle Testing• +4 Hip Adductors bilaterally

115

Muscle Testing

• +4 gluteus medius bilaterally

Muscle Testing

• Poor core stability

Poor Flexibility

• Hamstrings• Calf musculature

116

Chiropractic Findings

• Gillet’s Test• Motion Palpation L/S spine• Mild extension fixation – right ilium• Conclusion: not a significant contributor to

patient’s symptoms• Possibly compensatory to knee pain

Your clinical impression…..?

• IDKInternal Derangement of the Knee

I don’t know!

Condromalacia PatellaFunctional Muscle Imbalance

Myofascial Pain of Vastus Medialis

Iliotibial Band Syndrome

Treatment

• Soft tissue release of ITB• Deep pressure to tolerance for

vastus medialis trigger point

117

Treatment

• Strengthening of:– Adductors– Gluteus Medius

Treatment• Core stability strengthening• Progressive Swiss Ball routines

Treatment of Trigger Point“Application of slowly increasing, non-

painful pressure over a trigger point until a barrier of tissue resistance is encountered. Contact is then maintained until the tissue barrier releases, and pressure is increased to reach a new barrier to eliminate the trigger point tension and tenderness.”

Travell & Simons’ Myofascial Pain and Dysfunction - 2nd edition

118

Treatment

• Stretching :– Iliopsoas– Calf group– Hamstrings

Conclusions

• Orthopedic testing is valuable yet has limits• In the face of hard orthopedic findings,

functional testing may lead to actual conservative therapy applied

• Multiple diagnosis may exist and all may need to be pursued

• Use your knowledge to understand

Documents

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