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2-Day Practical Training on Neuromuscular Stabilization prior to Symposium

Dynamic Neuromuscular Stabilization (DNS): According to Kolar A Developmental Kinesiology Approach

FIRST DNS “PA” COURSE EVER!!
Wyndham Lake Buena Vista Disney Springs Resort
1850 Hotel Plaza Blvd
Orlando, FL 32830
Introductory Course
Friday-Sunday, March 30-31, 2017
(8:00 – 6:00 Thu & 8:00 -12:00 Friday)
Instructor: Craig E. Morris, D.C.,
DACRB Questions?: rehaboc1958@hotmail.com
Register: => clinicalCE.org

“Practical Applications” Course Description

Dynamic Neuromuscular Stabilization (DNS) is a leading rehabilitation approach that has evolved from the world famous Prague School of Rehabilitation at Charles University, Prague, Czech Republic.

DNS has taken the rehab world by storm over the past decade!! DNS clinicians in all aspects of clinical and sports rehabilitation have taken courses all over the world and are applying DNS principles in every imaginable venue.

Dr. Craig Morris has studied at the Prague School for almost 25 years and is one of three original DNS international instructors since 2008. At the turn of the century, he would travel to Prague to study independently study with the Professors’ (the late) Karel Lewit, (The late) Vladimir Janda and Pavel Kolar. His 2004 Los Angeles area course introducing leading rehab clinicians to Professor Pavel Kolar provided a key boost for what would later be called “The DNS Movement”. He has utilized the brilliant work of Kolar on a daily basis for more than a decade, both in his clinic, in his DNS courses, and on professional athletes around the world.


But, DNS is very complex and understanding how to practically apply the theory and skills effectively eludes many, many clinicians. HOW DOES ONE:

  • ASSESS IT???
  • MAKE A CLINICAL PLAN???
  • ESTABLISH EXERCISES???
  • DETERMINE CLINICAL PROGRESSIONS???
  • CHART IT???
  • BILL IT???

Dr. Morris, a board certified chiropractic rehabilitation specialist, is offering the first ever Practical Skill Applications course to answer your questions and show you how it is done!!

* PREREQUISITE FOR THIS COURSE: DNS “A” OR EXERCISE 1 COURSE *

COURSE OBJECTIVES

  • Review understanding of the basic principles of developmental kinesiology and how they can be practically applied in assessment and therapy and exercises
  • Review the relationship between development during the first year of life and pathology of the locomotor system in adulthood. Posture will be discussed from a developmental point of view.
  • Evaluate and correct poor respiratory patterns
  • Practically integrate terminology such as functional joint ‘centration’ and ‘decentration’, stabilization,
    punctum fixum, punctum mobile and the integrated stabilizing system of the spine.
  • Demonstrate an understanding of the most important principles of ‘centrated’ developmental locomotor
    system movements.
  • Training of DNS “Flow Sequences” (transitioning from one ‘centrated’ position to another).
  • Refine manual skills to achieve joint centration
  • Demonstrate movement patterns and exercises as a customized progressive program for each patient.

Course Instructor

Craig E. Morris, D.C., DACRB – Senior DNS Instructor

Professor Morris is a 1981 graduate of Cleveland Chiropractic College, LA. He has practiced in Torrance, CA for 35 years, where he is the clinical director at the multidisciplinary (Chiropractic rehabilitation & Orthopedics) clinic, “F.I.R.S.T. Health”.

Dr. Morris is retired Professor of Clinical Sciences at Cleveland Chiropractic College, Los Angeles. He has lectured on all five continents on multiple occasions. He has also served as a post-graduate instructor at Southern California University of Health Sciences, Palmer Chiropractic College, the University of Southern Denmark, University of Johannesburg, Anglo-European, Canadian Memorial Chiropractic College and the School of Chiropractic at Anhembi Morumbi University in Sao Paulo, Brazil, Feevale University, Novo Hamburgo, Brazil, instructing various groups that included physicians, osteopaths, physical therapists, occupational therapists, athletic trainers and chiropractors.

Dr. Morris is the one of the original five clinicians from around the world, and the first doctor of Chiropractic in North America, to become an international certified instructor in Dynamic Neuromuscular Stabilization according to Kolar. He has studied with Associate Professor Pavel Kolar individually and in organized courses in Europe and North America for over a decade and utilizing these approaches in his clinic daily.
Dr. Morris was the first California Doctor of Chiropractic to successfully complete the three-year post-graduate specialty training and testing requirements to attain his Diplomate status of the American Chiropractic Rehabilitation Board (DACRB).

Dr. Morris has also studied extensively with the late Professor’s Karel Lewit and Vladimir Janda of the Department of Rehabilitation and Manual Medicine, Charles University, Prague, Czech Republic. He co- instructed many courses internationally with Professor Janda in North America and Europe. Dr. Morris was the first chiropractor ever invited to lecture at a Medical Conference in Eastern Europe. He has published several papers in peer-reviewed publications, such as SPINE, the Journal of Bodyworks and Movement Therapies (JBMT) & the Journal of Manipulative and Physiological Therapeutics (JMPT) and has served as a peer- reviewer for several scientific journals.

Dr. Morris is the founding President of the Slovak Chiropractic Association; a member nation of the World Federation of Chiropractic. He is a Fellow and 2-time Past President of the Academy of Forensic and Industrial Chiropractic Consultants. He is the Chairman of the Manual Medicine and Manipulation Committee of the American Back Society. He is a member of the California Chiropractic Association, the American Chiropractic Association, a former member of the California Society of Industrial Medicine and Surgery, and a former lecturer and Fellow of the American Back Society.

Dr. Morris is the editor of the text, “Back Syndromes, Integrated Clinical Management” (McGraw-Hill Publishers), a leading multidisciplinary text for the management of low back disorders that is available in hardcover and Kindle-ebook format at AMAZON.COM).

In the world of sports, Dr. Morris is a former Certified Strength and Conditioning Specialist (NSCA) and has remained active in the assessment and treatment of sports injuries for more than two decades. He has served as a member of the chiropractic staff at the 1984 Los Angeles Olympics, a medical board member for the International Powerlifting Federation, serving as the treating doctor for the World Junior Championships in Bratislava, Slovakia, a rehabilitation consultant for the National Hockey League Players’ Association (NHLPA), the director of rehabilitation for the Tampa Bay Lightning Ice Hockey Team (NHL) and a rehabilitation consultant for the Florida Panthers Ice Hockey Team (NHL). Dr. Morris served as a member of the Research Committee for the International Federation of Sports Chiropractic (FICS). He was director of Sports Rehabilitation for ProGolf Health, an international clinical sports management group for touring professional golfers on both the PGA and European tours.

REGISTRATION & FEES (This is a 2-Part Process):

Part 1: Register at clinicalCE.org (click DNS icon; Orlando March 2017 Course; Complete that.)

  • Licensed Clinician: $550
  • 2017 ACA Rehab Symposium Registrant $450
  • Student (MD, DC, PT, ATP Program) $400

Part 2: Register with the Prague School for course certification credit and emailed course notes. The link for this is: http://www.rehabps.cz/rehab/course.php?c_id=769
Prague School Fee: 80 Euros per registrant

Date: March 30-31, 2017 (Instructor Prof. Craig E. Morris)

Course Schedule/Hourly breakdown

Thursday March 30, 2017

8:00 – 8:50 Ontogenesis review with practical applications: postural, motor and sensory development from a developmental kinesiology model (This lecture will review how humans gain their motor control and establish their adult posture. It will emphasize key developmental milestones, which will be used later as part of the DNS functional assessment and as the basis for later determining therapeutic progress and progressions.)
8:50 – 9:00 Break
9.00 – 9:50 Practical Applications: Integrating the history from a DNS perspective
9:50 – 10:00 Break
10:00 – 10:50 Practical Applications: Integrating the examination with DNS Assessments
10:50 – 11:00 Break
11:00 – 11:50 Practical Applications: Integrating the examination with DNS Assessments (Cont.)
11:50 – 13:00 Lunch
13:00 – 13:50 Practical Applications: Establishing an integrated regular/DNS Treatment plan and Patient Education
13:50 – 14:00 Break
14:00- 14:50 Practical Applications: Establishing an integrated regular/DNS Treatment plan and Patient Education
14:50 – 15:00 Break
14:00- 14:50 Practical Applications: Establishing a CUSTOMIZED, INTEGRATED Exercise program
14.50 – 15:00 Break
15:00- 15:50 Practical Applications: Establishing an integrated exercise progression plan
15:50 – 16:00 Break
16:00 – 17:00 Practical Applications: Q&A with a sample case

Friday March 31, 2017

8:00 – 8:50 Review Day #1
8:50 – 9:00 Break
9:00 – 9:50 Practical Applications: Case examples with workshopping
9:50 – 10:00 Break
10:00 – 10:50 Practical Applications: Case examples with workshopping
10:50 – 11:00 Break
11:00 – 12:00 Summary: Q&A

QUESTIONS?? Contact Dr. Morris at email: rehabdoc1958@hotmail.com or Mobile Phone +1-310-480-7768

Chiropractic Rehabilitative Management of Complex Regional Pain Syndrome Secondary to Lumbar Intervertebral Disc Herniation

Peer Reviewed by the American Chiropractic Rehabilitation Board

By Dr. Jess T. Brower, DC
Introduction

This case study will provide information regarding the assessment, diagnosis, multi-disciplinary co- management, and successful treatment of a significant lumbar intervertebral disc herniation leading to radiculopathy accompanied by foot drop and secondary Chronic Regional Pain Syndrome (CRPS) involving the lower extremity.

Subject

The subject is a 44 year old caucasian female, who is married with two teenage children. She is fully employed performing childcare duties.

History

The patient reports that she awoke on April 1, 2015 with severe buttock and left lower extremity pain with no prior history. She was evaluated at a local emergency department and provided pain relieving medications. She had to return to an urgent care facility the following day for ongoing, unrelenting pain. She then followed up with her Primary Care Provider (PCP) soon thereafter for further management. After initial onset, she quickly developed a foot drop, and paresthesia and anesthesia over the left lateral leg, lateral and dorsal foot. Deviation from a neutral posture would cause severe pain in the lower extremity. She was referred to physical therapy where she obtained approximately 6 visits of care with little improvement. She reported that she gradually developed generalized swelling, redness, and discoloration of the left foot, when her PCP then obtained a left lower extremity vascular study where no abnormalities were found. She was last evaluated by her PCP on May 12. At that point, the treating physical therapist advised she obtain further assessment and care in the author’s office.

At the time of her initial visit on May 22 she was taking 100 mg of Neurontin, 3 times daily to no avail. This was the only medication she was taking at that time. Pain relieving medications and oral steroids all provided no relief of any significance during prior trials. Prior to the visit, the patient had prior pelvic and lower extremity vascular studies performed. The subject was complaining of pain, muscle cramps, and weakness in the left buttocks, thigh, lower leg, and foot without complaint of lower back pain. The pain in the buttocks, calf, and foot was rated 5 to 6 out of 10 on average. The quality of the complaint was described as burning, loss of sensation, stabbing, tension, and tingling. The location was solely as described previously. The prior symptoms were present 50 to 75% of the day, worsening and more specific to the afternoon and evening. The symptoms were reported to wake the subject at night, only providing some interference to Activities of Daily Living (ADL). Exercise, hobbies, household chores, and sleep are most affected, with intensity and interference varying from day to day. The only noted interventions and activities that provide relief were physical therapy, and only temporarily. Coughing, sneezing, forward bending, household chores, and reaching all worsened pain immediately.

No significant or related personal, social, or family history of trauma, disease, or disorders. Review of systems was unremarkable except for symptoms associated with presenting complaint. The patient did not drink alcohol or use tobacco and exercised at least 3 times per week.

Physical Examination

May 22

The patient had the following general appearance and characteristics: cooperative, maintained eye contact, mentally alert, no deformities, oriented x 3, and walked with a limp and obvious loss of left ankle dorsiflexion. The patient appeared to be in no apparent distress.

Height: 63” BMI: 23.7 BP: 135/89 SpO2: 98%
Weight: 133.4 lbs Aural Temp: 98.8 F Pulse: 93 BPM

The patient was unable to perform active dorsiflexion of the foot and ankle with gravity eliminated. Any deviation from neutral standing or sitting caused severe pain to radiate to left lower extremity. Patient unable to adopt any other postures. The seated and supine straight leg raise on the left was grossly positive for acute buttock and left lower extremity pain, with crossed straight leg raise overtly positive as well in both sitting and lying. Ankle jerk absent on the left, 2+ on the right. Patellar response 2+ bilaterally. Loss of sensation to both light and sharp touch over left lateral leg and dorsal foot, present on the right. Left foot and toes grossly and generally swollen, red, and considerably cool and moist to touch. Lower extremity pulses were full and palpable.

Diagnostic Testing

May 11

  • Venous Duplex Ultrasound
  • A left lower extremity venous duplex ultrasound was performed. No abnormal findings present.

May 14

  • Computed Tomography
  • A CT of of the abdomen and pelvis without contrast was performed. No abnormal findings present.
  • Computed Tomography Angiogram
  • A CT angiogram of the bilateral lower extremities was performed. No abnormal findings present.

May 22

  • Magnetic Resonance Imaging
  • An emergent MRI of the lumbar spine without contrast was performed on May 22 after initial assessment in the author’s office. The most significant finding was a 1.1 cm AP x 3 cm TR x 1.6 cm CC lobulated left posterior paracentral/foraminal/extraforaminal disc extrusion resulting in moderate central spinal stenosis, severe narrowing of the left lateral recess and neural foramen with impingement upon the left S1 descending, and foraminal and extraforaminal portion of the left L5 nerve root. In addition, a hematoma was also appreciated as a space occupying lesion. (Figures 1-3).

Figure 1. Sagittal T2 weighted lumbar MRI with disc herniation at L5/S1.

Figure 2. Close up of Sagittal T2 weighted lumbar MRI with disc herniation at L5/S1.

Figure 3. Axial T2 weighted lumbar MRI with disc herniation centrally and laterally.

May 22

  • Laboratory Studies
  • WBC – 7.4 K/uL
  • CRP – 5.7 mg/l
  • Sed Rate – 13 mm
  • All labs performed and found to be within normal limits, with no indication of systemic infectious or inflammatory process.

Assessment

Given the availability of prior imaging and testing at the time of the initial visit, the patient subjective history and objective physical examination findings, a lumbar intervertebral disc herniation leading to lumbar radiculopathy was strongly suspected, and this was confirmed via emergent MRI. Secondarily, the presence of pain, foot discoloration, swelling, diaphoresis, and coolness was uniquely indicative of CRPS given that no vascular claudication was present. Given the degree of symptom severity and loss of reflex activity and strength deficits in the left lower extremity, immediate surgical consultation was warranted.

Differential Diagnosis

When presenting with sudden onset of lower extremity pain without trauma, in a radicular pattern, including pain in the buttock with or without lower back pain, the most common suspicion is lumbar radiculopathy. The most common cause of lumbar radiculopathy is a herniated disc, though the differential may include non-neural lumbopelvic referred pain, lumbar spinal stenosis, lumbosacral plexopathy, and mononeuropathies of the of the leg of varying etiologies. Developing lower extremity weakness, loss of sensation, and paresthesia further confirms and supports neural involvement. When presenting with singular lower extremity pain, discoloration, cold skin, and swelling, the initial diagnostic reaction and differential is typically one of a vascular cause, most commonly a venous thrombosis, or secondarily an infection.

There was no presence of spinal or lumbar pain, nor was there any prior history of lower back pain leading up to April 1, and I believe this initially prevented more direct assessment of the lumbar spine as a cause of complaints. There was no family or personal history of cardiovascular or hematologic risk factors, history of chronic disease, nor any recent illness or surgical procedures, and no use of medications. This did not typically support the most common associated factors of a venous thrombosis. When all symptoms taken into context, with and without prior or current knowledge of advance imaging or laboratory testing, the constellation of symptoms supported the presence of a lumbar radiculopathy with secondary development of CRPS due to severity of neural compromise. This was further proven and supported via the testing as stated, both in the negative and positive examination findings. However, the presentation of both of these conditions at the same time is also unique and perplexing, as they share common and interrelated causation, as well as symptomatology.

Patient Management

After presenting on May 22, with severe radiculopathy, loss of strength, and signs strongly suggestive of CRPS, an immediate MRI of the lumbar spine was obtained on the same day. Following the discovery of a considerable lumbar intervertebral disc herniation, immediate contact with an orthopedic spinal surgeon was made, and subsequent patient follow up was scheduled for the same day. After orthopedic evaluation, surgery was scheduled for June 2. Upon the day of the operation, the patient’s status had not changed for better or worse. The surgical procedure consisted of a far lateral left L5/S1 microdiscectomy and a central L5/S1 left sided microdiscectomy. Two different surgical approaches were required given the nature of the disc herniation. A laminoforaminotomy was carried out and a complete hemilaminectomy was performed on the left side of L5. A large hematoma as well as a large disc extrusion were retrieved. During the procedure, a small dural rent was made, found, and repaired inter- operatively. Following the procedure, the patient was discharged on the same day.

Outcome of Care

On June 5, three days following the surgery, the patient presented to the operating orthopedist’s office complaining of positional, severe frontal headache, worse with standing and being upright, relief being obtained lying supine. The patient also noted on this visit that her left foot was dramatically improved in both strength, coloration, and comfort. Objective examination revealed that extensor hallucis longs (EHL) and ankle dorsiflexion strength were 4/5, whereas they were 0/5 pre-operatively. The patient was instructed to lie supine for 48 hours with only bathroom privileges to alleviate and address dural headache secondary to dural puncture. Upon further follow up on June 8, the patient reported that her headache had resolved and was not sensitive to postural position any longer. Was again evaluated on June 18 by the operating orthopedist, who noted continued patient improvement both objectively and subjectively. The final orthopedic follow up occurred on July 30, where the patient continued to report improved function and strength. Objective examination revealed 4+/5 strength of EHL and ankle dorsiflexion, with mild, ongoing discoloration and coolness over the left foot. She was released to full activity as of that date with instruction to consider further therapies or interventions to address ongoing CRPS symptoms.

History

September 14

The patient sought treatment, complaining of constant (75%-100%) dull, aching, sharp and shooting discomfort in the back of the left hip. She rated the intensity of discomfort, using a VAS, as a level 7 on a scale of 1 to 10 with 10 being the most severe. The discomfort was reported to increase with prolonged sitting.

The patient presented today to discuss ongoing pain across lower back, pain in left buttock, loss of function, left leg giving away. Stated that she had discectomy performed due to disc herniation earlier this summer after evaluation here for same. Stated that since that time, CRPS had improved in left lower extremity. Stated that sensation was dull, and that foot felt “asleep” mildly at all times. Stated that ankle strength had improved quite a bit, however, leg would give away at times without warning. Stated that she could no longer sit on the floor and play with children, nor care for them as needed due to pain in lower back and buttock. During discussion, she was in tears, as she was distraught, and concerned that she would never regain full function or her “life” back.

Physical Examination

September 14

Seated SLR and supine SLR on the left were acutely painful down posterior thigh to knee and in the left buttock. Patient could not extend lumbar spine without discomfort, and was severely limited from what she called a “block”. Forward bend was limited fingers to mid shin. Acute pain noted with palpation of left buttock and posterior hip. Left lower foot was very cool with mild perspiration and no noted color changes. Right lumbar paraspinal muscle spasm noted. Acute pain noted over L4 and L5. Heel and toe raise revealed normal strength bilaterally. Great toe dorsiflexion 4/5 on the left. Reflexes a little sluggish on the left as compared to right at S1. Sensation intact but decreased on the left across the foot as compared to right.

Subsequent examinations during further follow ups revealed the following findings, in no particular order or importance, each contributing to the entire presentation, with each finding being addressed specifically: hypertonic and/or overactive musculature, myofascial tissue dysfunction, inhibited and/or weak musculature, altered motor control upon movement pattern examination, pain in left buttock sitting cross legged, active, pain producing surgical scar; limited straight leg raise and active straight leg raise on the left with buttock pain, loss of passive spinal and extremity joint mobility, limited ability to forward bend or extend due to restriction and pain in lumbar spine, poor single leg balance and loss of intrinsic foot muscular activity on the left.

Assessment

I advised the patient, at length, that I felt she stood a great chance to return to all of her normal activities without pain or dysfunction. I advised her that she suffered from a rare disc herniation and sequelae. Additionally, she was not given and/or did not take the opportunity to have therapy immediately after surgery. Given those facts, warning was issued that progress may be slow, and the reason why she was still struggling with after effects of radiculopathy and CRPS. With much work and effort, I advised she could return to life fully.

Patient Management

The patient was tentatively scheduled 2 times per week for 5 weeks beginning September 14, with frequency depending upon her compliance with follow up visits and self-care strategies, and improvement and/or exacerbation of current condition. At that time, further care, discontinuation of care, or referral would be considered according to evaluation of condition. Re-evaluations were to be performed as needed according to changes in condition. Over the course of care and subsequent re-evaluation, additional treatment was prescribed, with episodes of care not exceeding 2 times per week, and then moving to 1 visit per week, with occasional weeks without care due to scheduling conflicts.

The goals of care were to improve the patient’s objective findings related to her subjective complaints and allow for the performance of caring for family, bending, most movements, sitting, and walking.

Additional short and long term goals included: decreased muscle spasm, decreased paresthesia, return of sensation, decreased pain, decreased restrictions on social life due to pain, improved ability to engage in personal care, improved tolerance to work duties, increased active range of motion, increased spinal stability and muscular endurance, increased ability to perform ADL, and increased function. Objective improvement would be monitored through the use of a pain scale, improved functional/orthopedic testing, and the ability to attain previously mentioned goals.
The goals were pursued through the use of education, chiropractic manipulation and mobilization, manual therapies, neuromuscular techniques, and rehabilitative exercise as indicated and deemed necessary by objective examination and clinical judgement at each visit to address the patient’s presenting complaints. The patient would be progressed as tolerated.

Chiropractic manipulative treatment and joint mobilizations were used to restore joint mobility, reduce pain, and reduce muscular tone. Manual therapies such as Active Release Technique (ART) and Graston Instrument Assisted Soft Tissue Mobilization were used to reduce myofascial restrictions and adhesions to restore related joint and/or soft tissue mobility and to reduce pain. Neuromuscular techniques were used to address re-education of movement, balance, coordination, posture, and proprioception accordingly. Rehabilitative and corrective exercises were used to develop appropriate strength, endurance, stability, and mobility where indicated.
At each visit, the timing, intensity, and location of symptoms were recorded, as were the aggravating and relieving factors. These were monitored using a scale of time of 1 to 100% of the day and the intensity on a Visual Analog Scale of 1 to 10.

Over the course of 18 visits from September 22 to January 4, the following strategies and techniques were performed as indicated and deemed necessary, varying in implementation and performance on given days of treatment.

Post-isometric relaxation was used to lengthen and reduce hypertonicity in the following muscle groups: left external hip rotators, left hamstring.

Graston Instrument Assisted Soft Tissue Mobilization was used to reduce myofascial adhesions and/or fibrosis in the following areas to improve mobility: left hamstring, left external hip rotators, lumbar spine surgical scar, left lumbar paraspinals, left lateral thigh.

Active Release Technique protocols were used to release myofascial restrictions/adhesions and improve mobility in the following areas: left external hip rotators, left gluteus maximus, left hamstring, left hip adductors, left plantar foot, left gluteus medius, left iliopsoas, and left tensor fasciae latae.

Chiropractic manipulative therapy was applied to reduce joint restriction and improve articular mobility in the following areas: left ankle mortise joint, left mid-tarsal shear, L3/L4 side posture extension, right sacroiliac joint prone drop, T10 prone extension, thoracolumbar junction supine extension, right sacroiliac joint side posture, T4 extension supine, thoracolumbar junction extension side posture, L5 side posture extension.

Dynamic Neuromuscular Stabilization was performed in varying developmental positions to facilitate agonist and antagonist muscular co-activation to achieve joint centration and stability, in addition to facilitation of inhibited musculature and a proper breathing pattern to reduce global muscular hypertonicity, resulting in coordinated and balanced movement patterns.

September 22

The following self-care strategies were demonstrated and assigned to Carol and were to be performed at home to tolerance as instructed to address objective examination findings and achieve stated goals:

  • Single Leg Standing in Bucket of Pea Gravel, 5 minutes, 2 sets, 1 to 2 times daily
  • Active Ankle ROM with Yellow Theraband, 10 reps each plane, 2 sets, 2 times daily
  • Seated Sciatic Nerve Mobilization, 10 reps, 2 sets, 2 times daily
  • Cat Camel, 10 reps, 2 sets, 2 times daily

October 21

Additional exercises were added to ongoing home exercise program:

  • Wall Bug, 10 reps, 2 sets, 2 times daily
  • Standing Forward Bend Progression, Hip Hinge Focus, 3 Variations, per Gray Cook, 10 reps each variation, 2 sets, 2 times daily

October 28

The following changes and additions were made to the home exercise program:

  • Eyes Closed, Single Leg Standing in Bucket of Pea Gravel, 5 minutes, 2 sets, 1 to 2 times daily
  • STOP – Seated Sciatic Nerve Mobilization, 10 reps, 2 sets, 2 times daily
  • STOP – Cat Camel, 10 reps, 2 sets, 2 times daily
  • Seated Left Piriformis Tri-Planar Stretch, 10 reps, 2 sets, 2 times daily

November 11

The following addition was made to the home exercise program:

  • Foam Roller Left Posterior Hip, 3 to 5 minutes per day, to tolerance

December 10

The following changes and additions were made to the home exercise program:

  • STOP – Active Ankle ROM with Yellow Theraband, 10 reps each plane, 2 sets, 2 times daily
  • STOP – Wall Bug, 10 reps, 2 sets, 2 times daily
  • STOP – Seated Left Piriformis Tri-Planar Stretch, 10 reps each plane, 2 sets, 2 times daily
  • Wall Slide Squat, 10 reps, 2 sets, 2 times daily
  • Supine, 3 Way Hamstring Mobilization with Band, 10 reps each plane, 2 sets, 2 times daily

January 4

The following changes and additions were made to the home exercise program:

  • STOP – Wall Slide Squat, 10 reps, 2 sets, 2 times daily
  • STOP – Supine, 3 Way Hamstring Mobilization with Band, 10 reps, 2 sets, each plane, 2 times daily
  • Long Sitting Reach with Adductor Activation, 10 reps, 2 sets, 2 times daily

Outcome of Care

Over the course of 18 treatment visits and strong adherence to the home exercise program, the patient was able to attain nearly all goals of care. The following improvements were reported by the patient and/ or objectively observed on given days of treatment. No episodes of significant regression were noted, with consistently trending positive progress, with intermittent days of decreasing return of symptoms. The following improvement progression was noted, in no particular order: foot was no longer cold, discolored; area of paresthesia consistently grew smaller and less frequent, was able to walk a 5K without symptoms or difficulty, able to jog upstairs, no longer had episodes of leg “giving away”, could sit cross legged in any orientation freely, fully, and pain free; straight leg raise was equal bilaterally to 90 degrees, as was active straight leg raise, each without pain; regained all ankle dorsiflexion and EHL strength, regained full forward bending ROM, able to reach toes easily with good movement patterning; able to perform lumbar extension without restriction, full long sitting reach without discomfort, overall considerable reduction in pain intensity levels. This was in addition to improvement of movement pattern quality, balance, strength, soft tissue quality, as well as joint mobility. On January 4, upon discussion, review of progress, and goal review, it was mutually decided to release the patient from further care, with instructions to continue home exercise program for the next several weeks. On the final visit, the patient reported occasional (1 to 25%) dull discomfort in the back of the left hip, rating the intensity of discomfort as a level 1 on a scale of 1 to 10, with 10 being the most severe. The discomfort was reported to increase with prolonged sitting on hard surfaces. The discomfort was reported to improve with movement. The patient also reported mild, recurrent episodes of paresthesia over the left lateral foot, but the frequency continued to reduce. This was a symptom that she was more than willing to live with. I advised that this had the potential to improve further, or may be a permanent issue given the severity of neural compromise in the past.

Review of Anatomy and Physiology

Per the patient presentation and imaging findings, dominant L5 radiculopathy, with lesser involvement of the S1 nerve root were present as a result of considerable compression by both an intervertebral disc herniation and an epidural hematoma, which developed as a result of the trauma sustained by the epidural venous plexus system due to discal compression. The patient suffered from loss of EHL strength with subsequent foot drop associated with L5 radiculopathy and typical dermatomal and dynatomal distributions of L5 and S1 patterns. A dynatome is the area of symptoms produced by an injured nerve root. This is in contrast to a dermatome, which is the peripheral distribution of symptoms as a function of conduction loss along the nerve root due to trauma and/or compression. Each can result in pain, paresthesias, and loss of sensation.

In 1995, the International Association for the Study of Pain, defined the term Complex Regional Pain Syndrome, better known as CRPS. CRPS is an orthopedic, neurological, and traumatological disease following trauma, surgery, fractures, and peripheral nerve damage. Typical symptoms include circulatory disorders, edema, skin changes, disproportionate pain, sudomotor changes, and loss of function in the extremities. CRPS seldom occurs in the absence of an identifiable trigger, and is much more common in women than in men. The exact etiology is unclear, where neuronal inflammation and maladaptive changes in the central nervous system are believed to be involved, leading to continuous sympathetic neural reaction as a result of continuous pain provocation by tissue damage. CRPS is primarily a clinical diagnosis. Early diagnosis and management of this disorder is key to prevent long term damage and suffering. Interventions typically include physical therapy and sympathetic nerve blocks, the latter of which was not utilized in this case. This was due to the fact that the acuity of the pain and symptoms improved significantly following surgical intervention, resulting in decompression if the involved nerve roots, and therefore alleviating the perpetuating factors.

Wolter T, Knoller SM, Rommel O. Complex Regional Pain Syndrome following Spine Surgery: Clinical and Prognostic Implications. Eur Neurol 2012;68:52-58.

Abdi S. Complex Regional Pain Syndrome in Adults: Pathogenesis, Clinical Manifestations, and Diagnosis. UpToDate. Retrieved from http://www.uptodate.com/home

Discussion

Overall, the patient was seen during the time period of September 14, 2015 through January 4, 2016 over the course of 19 visits after the initial evaluation on May 22 and subsequent recovery period post- operatively. From the time of onset, the patient had undergone approximately 9 months of care and recovery from an acute, unprovoked lumbar disc herniation leading to an epidural hematoma and resultant radiculopathy and secondary CRPS.

Ideally, the patient would have begun rehabilitative therapy immediately following surgical intervention, but was lost to further follow up until prompted to seek additional care for ongoing symptoms. Post- operative therapy was likely not pursued due to perception and belief that surgical intervention had and/or would resolve complaints. Potentially, an additional intervention to consider would have been mirror box therapy, as this is a novel approach to address the central nervous system component of CRPS and has shown promise for this condition. In addition, procedural sympathetic nerve blockage could have also been considered if progress was not being made, had stalled, or patient pain levels were too great.

Never the less, the patient still obtained an outstanding outcome given the degree and severity of presenting complaints. The successful outcome was due to several factors, of which included the presence and recognition of pathological “red flags” upon patient presentation, diagnostic triage, interdisciplinary communication and cooperation, appropriate and timely surgical intervention, and post- operative rehabilitation that included a variety of patient and condition specific interventions. Most importantly, an active, engaged, and motivated patient allowed for the plan of care to be carried through and completed.

As of February 29, 2016, per oral communication, the patient reported that she was doing very well, walking, playing with children on the floor, taking stairs, and performing all activities as she had before. She stated that she occasionally has very mild paresthesias over her left lateral foot and toes, and has an aching in left buttock if she sits for too long, but could be resolved with self-care strategies as assigned.

Crosstalk between Vitamins A, B12, D, K, C, and E Status and Arterial Stiffness

Mozos I1, Stoian D2, Luca CT3

1Department of Functional Sciences, Discipline of Pathophysiology, “Victor Babes” University of Medicine and Pharmacy, Timisoara, Romania.
22nd Department of Internal Medicine, “Victor Babes” University of Medicine and Pharmacy, Timisoara, Romania.
3Department of Cardiology, “Victor Babes” University of Medicine and Pharmacy, Timisoara, Romania.

Abstract
Arterial stiffness is associated with cardiovascular risk, morbidity, and mortality. The present paper reviews the main vitamins related to arterial stiffness and enabling destiffening, their mechanisms of action, providing a brief description of the latest studies in the area, and their implications for primary cardiovascular prevention, clinical practice, and therapy. Despite inconsistent evidence for destiffening induced by vitamin supplementation in several randomized clinical trials, positive results were obtained in specific populations. The main mechanisms are related to antiatherogenic effects, improvement of endothelial function (vitamins A, C, D, and E) and metabolic profile (vitamins A, B12, C, D, and K), inhibition of the renin-angiotensin-aldosterone system (vitamin D), anti-inflammatory (vitamins A, D, E, and K) and antioxidant effects (vitamins A, C, and E), decrease of homocysteine level (vitamin B12), and reversing calcification of arteries (vitamin K). Vitamins A, B12, C, D, E, and K status is important in evaluating cardiovascular risk, and vitamin supplementation may be an effective, individualized, and inexpensive destiffening therapy.

Read more…

Vitamin B12, Homocysteine and Carotid Plaque in the Era of Folic Acid Fortification of Enriched Cereal Grain Products

Robertson J1, Iemolo F, Stabler SP, Allen RH, Spence JD.

Abstract

BACKGROUND:
Carotid plaque area is a strong predictor of cardiovascular events. High homocysteine levels, which are associated with plaque formation, can result from inadequate intake of folate and vitamin B12. Now that folic acid fortification is widespread in North America, vitamin B12 has become an important determinant of homocysteine levels. We sought to determine the prevalence of low serum levels of vitamin B12, and their relation to homocysteine levels and carotid plaque area among patients referred for treatment of vascular disease since folic acid fortification of enriched grain products.

METHODS:
We evaluated 421 consecutive new patients with complete data whom we saw in our vascular disease prevention clinics between January 1998 and January 2002. We measured total carotid plaque area by ultrasound and determined homocysteine and serum vitamin B12 levels in all patients.

RESULTS:
The patients, 215 men and 206 women, ranged in age from 37 to 90 years (mean 66 years). Most were taking medications for hypertension (67%) and dyslipidemia (62%). Seventy-three patients (17%) had vitamin B12 deficiency (vitamin B12 level < 258 pmol/L with homocysteine level > 14 mumol/L or methylmalonic acid level > 271 nmol/L). The mean area of carotid plaque was significantly larger among the group of patients whose vitamin B12 level was below the median of 253 pmol/L than among those whose vitamin B12 level was above the median: 1.36 (standard deviation [SD] 1.27) cm2 v. 1.09 (SD 1.0) cm2; p = 0.016.

CONCLUSIONS:
Vitamin B12 deficiency is surprisingly common among patients with vascular disease, and, in the setting of folic acid fortification, low serum vitamin B12 levels are a major determinant of elevated homocysteine levels and increased carotid plaque area.

CMAJ. 2005 Jun 7;172(12):1569-73.

POLITE Method & Proprioception

Dr. Jeffrey Tucker
11620 Wilshire Blvd. #710
Los Angeles, CA 90025
310-444-9393

When the patient’s symptoms overwhelm me, I have a system I can count on. I use the acronym POLITE as a reminder of the things I may need to discuss, check or perform with my patient. The ‘P’ is Prevention, Plan, Posture, Proprioception. The ‘OL’ is Optimal Loading. The ‘I’ is Instrumentation, Ice. The ‘T’ is Taping, Technology. The ‘E’ is Education, Eating, Exercise, Ergonomics.

The majority of my practice is made up of patients with acute sports injuries and/or chronic pain. The chronic pain patients history usually reveals prior injuries, excess or prolonged sitting, poor postures, or repetitive movements over time that have led to movement inefficiency and dysfunction in natural movement patterns. Do these factors really relate to the current symptoms? I would say ‘yes’! It is known that previous injury in the same muscle does play a part in recurrent muscle injury (McCall).

My examination involves movement screens but the screen depends on the patient and their complaints. Movement analysis can inform us about the patient’s movement system. The only way I know if movement patterns are compromised (from the short term presence of pain or fatigue, or the longer term impact of muscle and joint restriction, chronic pain or the deficits left by previous injury) is to ask the patient to move. I observe if the patient can do what I ask – then I try to answer ‘Was there normal range of motion? Was there control of motion in the various planes (sagittal, frontal, transverse)?’ For example, when I ask a patient to perform a squat or a lunge, it’s no different than asking the patient a verbal question. I am questioning the patient’s pattern of movement under bodyweight load or with a load such as a band, free weight or kettlebell. I am looking for movement quality, synergies of muscle activation and co-ordination with other muscles. I am looking at proprioception (one of the P’s in POLITE). It’s about fluidity, balance, timing, symmetry or asymmetry of motion. This possess of asking the patient to perform a movement analysis (functional task) may provide greater insight as to why they were at risk to begin with.

Patients in pain, especially those with a history of an old injury often times don’t even realize that they have lost normal range of motion or a normal movement pattern. Others have obvious reduced ranged of motion or a pain with a certain movement that motivates them to come in to the office. Restoring pain free range of movement is a starting place for functional improvement in work, home, school, and recreational activities. Insurance companies are demanding we document this information. The treatment process often begins by 1) Discussing my plan and prevention strategies, making the patient aware of poor postures and showing or assisting them into full range of motion or correcting a dysfunctional movement pattern (proprioception) and 2) showing them how to resist the planes of motion in a variety of mediums (it’s easy for me to do this with Thera-Bands) to develop more integrated skills so that we change the brain’s perception of the movement system (OL – optimal loading) and 3) recommend ice, or heat, or other instruments (body composition, goniometers, etc) and 4) taping methods and technology (deep muscle stimulator, laser, shock wave, lymph drainage device, etc.) and 5) what can I do to improve the patients eating, exercise, ergonomics and of course all the while educating the patient.

A common objective finding we were taught is to evaluate range of movement – is it functional (full) or dysfunctional (not full or too much) and is it with pain or other sensation(s) or without pain or other sensation(s). With a full range of movement goal in mind, we can break down the steps to get there. I work to improve intermuscular coordination (more muscle, more nervous system involvement) to progressively stress the body greater than it had before without creating a flare up (which is not so easy sometimes). Some of the integrated variable approaches used to fix a ‘broken body’ include range of motion drills, learning to maintain ‘neutral’ spine or proper position during motion, varying the speed of motion, change the work done in a given amount of time (density), how much work is done overall (volume), working the planes of motion (sagittal, frontal, transverse), exercise or work activity, and the level of stability and the load applied. Static holds or dynamic movement can be used with all of the above. For example, simple observation of the ‘dead bug’ or ‘birddog’ can help us understand if the patient holds the spine still in the sagittal plane while moving an arm or a leg. Observe by looking at the static pose (patient on all fours with opposite arm and leg raised), progress to observation of watching repeated movement of the bird dog, establish if you have a patient that choses (unknowingly) a non-functional strategy of movement (loses neutral spine), and then address the problem. We are looking for dysfunctions that can arise during function.

I repeatedly educate patients that we have a concept of ‘neutral’ (especially the pelvis) posture, we have muscle/length tension relationships (muscle balance), and we have an ability to create and turn on and off ‘muscle stiffness’. You don’t just feel “tight” because some muscles got weak and long, and others got tight (short) and strong or weak. Prolonged repeated sitting causes muscle imbalance, but it also causes many of the deep core stabilizers to turn off because the body doesn’t have to use them from being supported by the chair itself. We need to reawaken or motor train these muscles to create proper stability within the musculo-skeletal system. If we can turn these deep core stabilizers back on our body will “release” many of these chronically tight structures to allow us to move better. Utilization of manipulation/adjustments and exercise movement therapy will improve flexibility, range of motion, strength, soft tissue ‘stuff’ and ultimately gait. But it just can’t be if we do everything, something will work approach.

One of the missing links in rehab treatment of movement control dysfunctions is proprioceptive training (e.g., wobble boards, roller boards, disks, physioballs). Proprioception identifies our sense of position, location, orientation, and movement of the body parts in relation to each other. It feels weight and tells us if we are stationary or moving, what direction we are moving, what range we are moving through and how fast we are travelling through it. Movement outcomes are determined by sensory input from mechanoreceptors, located in joints, tendons, muscles, and ligaments. These receptors provide the CNS with real time and constantly update the status of the body’s biomechanical and spatial properties. Other rehab programs that include multiple stimuli involve joint stability exercises (where agonist and antagonist muscles are co-contracting), balance training, plyometric (jump and/or explosive reaction) exercises, and skill-specific training. These will improve the body’s neuro-muscular control (Akuthota & Nadler 2004).  Past trauma and acute injuries to the body can cause an alteration in the muscles trying to support our body’s movement. Assessments of functional movements would show that the wrong structures are working, cutting down how well we move.

I’ll share an example of the POLITE method and how I use it in a 56 year old male entrepreneur who plays softball every Sunday. He presents with a chief complaint of a hamstrings injury. He has a history of on/off low back pain and previous same side hamstring injury. He had previous physical therapy including lumbar spine strengthening with a selection of different modalities, and injections into the low back. On top of softball he worked out another two days a week and said “I thought I was stretching properly”. He would continue to play with various tight areas especially the hips and shoulders, always feeling one sore and painful site and then the next.

I performed assessments that became exercises right away. I did manipulation and soft tissue therapy to his thoracic spine, hips and shoulders. I taught him proper breathing and posture (neutral) in sitting and standing. I educated him about the crucial need to get up and about more frequently to achieve the necessary flow of blood to the muscles that he has been sitting on. I taught him how to release his tight hip flexors related to his prolonged sitting. He learned a static stretch and progressed into a dynamic stretch. The primary hip flexors have a great deal of influence on the biomechanics of the hips, pelvis and lumbar spine. And their influence on these structures elicits responses up and down the kinetic chain. He had anterior rotation of the pelvis, increasing lumbar lordosis related to the bilateral tight hip flexors. Tight and posturally shortened hip flexors will also inhibit their antagonists – the gluteus maximus.
This correlated with his reduced hip extension (reduced from the tight hip flexors) which creates a need for the lumbar spine to contribute motion toward the hip extension requirement. This occurs as the proximal attachment of the psoas on the lumbar spine “gives” to the distal attachment on the femur by moving toward it through increased lordosis.

It was important stretch the hip flexors, reawaken the glutes, strengthen the muscle fatigue in the hamstrings, increase the range of motion noted in hip extension as well as internal and external rotation. For the hamstring, I had the patient prone lie, bringing his heel to his butt (no use of hands and maintaining neutral pelvis) performing isometric holds. We progressed to eccentric hamstring work. I taught him balance/proprioception exercise to improve the ankle-knee-hip-lumbopelvic chain.

My plan of corrective exercise (optimum loading) was a 6 week plan including manipulation and deep muscle stimulator. I gave him 2 weeks of several exercises and then moved into the next set of progressive exercises. Basically the plan encompassed teaching him to tape the hamstring, foam rolling, flexibility, ROM, activation, strength and an anti-inflammatory diet. Here is his entire exercise template:

  1. Foam roll hip flexors, adductors and thoracic spine
  2. Hip flexor stretches – standing and ½ kneeling
  3. Isometric hamstring contractions
  4. Glute bridging with CLX band arm resistance
  5. Dead bugs progressing to CLX band resistance
  6. Birddog progressing to Fire Hydrant Circles and CLX resistant bands
  7. Side planks
  8. Mountain Climbers
  9. ‘Groiners’ ending with deep squats that simulated his 3rd base position stance

I frequently use this progression in rehab for Glute med:

  • Clam progression
  • Bridge progression (Bridge up/down, bridge with toes raised, bridge with heels raised, bridge with ‘march’, single leg bridge holds, single leg bridge moving up & down)
  • Side lying against wall hip abduction
  • Band loop squat – side step walk or ‘Monster walk’

This is a typical Glute max progression I use:

  • Bridge progression
  • Leg lock bridge
  • Hip thrusts
  • Curtsy lunges
  • Squats (double leg)
  • Split squats
  • Single leg modified squats

My most recent email update from the patient after 4 weeks was “Just FYI, I hit two home runs on Sunday. Both required a lot of running.” If you are interested in learning current rehab methods please come and join the ACA Rehab Council in Orlando, FL March 30-April 2, 2017 for our annual symposium. Visit www.CCPTR.org for registration information.

Dr. Jeffrey Tucker is the current secretary-treasurer of the ACA Rehab Council.
References:

1) Akuthota et al. Core Strengthening Arch Phys Med Rehabilitation 2004 Mar; 85:S86-92
2) McCall et al. Injury risk factors, screening tests and preventative strategies: a systemic review of the evidence that underpins the perceptions and practices of 44 football (soccer) teams from various premier leagues.  British Journal of Sports Medicine 2013, 49:9 583-589
3) Worsley P et al. Motor control retraining exercises for shoulder impingement: effects on function, muscle activation, and biomechanics in young adults. Journal of Shoulder and Elbow Surgery 2013 Apr; 22(4):e11-19

Dynamic Neuromuscular Stabilization (DNS): The foundation for movement and a new opportunity for practical applications

Craig E. Morris, DC, DACRB 1, 2
Brett Winchester, DC 1, 3, 4
David Juehring, DC, DACRB 1, 5

1. Certified DNS Instructor
2. Retired Professor, Cleveland Chiropractic College, LA
3. Assistant Professor, Rehabilitation, Logan Chiropractic University
4. Instructor, Motion Palpation Institute
5. Professor, Palmer Chiropractic College

Dynamic Neuromuscular Stabilization largely originated during the last decade of the last century in the mind of Professor Pavel Kolar of the Rehabilitation Department, Motol Hospital, 3rd Medical School, Charles University. Since then, it has expanded dramatically in both principles and methods. Early courses were attempted in the United States around the beginning of the century, but the critical course that established a real foothold occurred in Redondo Beach, California in October 2004. The initial courses were simply called Developmental Kinesiology according to Kolar, until the official name of Dynamic Neuromuscular Stabilization was established in October 2008. With the combined teamwork of Professor Kolar, the organizational and supporting efforts of Assistant Professor Alena Kobesova, the Prague physiotherapists and the international instructors, DNS has grown over the past decade to become an internationally accepted rehabilitation approach taught in dozens of countries worldwide. Although DNS principles can be used for a variety of cases, professional athletes across all sports are reaping the benefits. Often used in the rehabilitation setting, athletes are now looking to DNS for athletic enhancement and movement preparation. “DNS concepts are reshaping how we evaluate and treat all aspects of sports medicine,” says Brett Winchester, DC, St. Louis Cardinals’ Team Chiropractor. “Indeed, I have used these methods both in practice and with professional athletes (NHL players, PGA players on tour, etc.) for over a decade, says Craig E. Morris, DC, DACRB.

DNS concepts are largely based on the genesis of “first generation” Prague School instructors, the late Professors’ Karel Lewit, Vladimir Janda and Frantisek Vojta. Professor Kolar ingeniously move the model forward with his critical understanding and skills utilizing the concepts of neurophysiologically-based developmental kinesiology (childhood movement development), muscle imbalance and postural dysfunction with a new neurophysiologically based functional assessment therapeutic protocols.

At its core, DNS is based upon the concepts of ontogenesis (the maturation of the human from point of conception until sexual maturity) to understand critical milestones in the locomotor system maturation to explain the processes of how newborns, without any conscious motor control, can establish postural stability needed to become bipedal after the first year. As Professor Janda had observed and reported consistent patterns of chronic pain syndromes postural dysfunctions and muscle imbalances (i.e. Upper Crossed Syndrome, Lower Crossed Syndrome, etc.), DNS demonstrates consistent patterns between faulty infantile postures and movement dysfunction and functional compromise (i.e. chronic pain, poor athletic performance, advanced degenerative changes, etc.).

“I have said for years now that DNS is foundational,” says Dr. Craig Morris, “in that it helps human to improve and stabilize the critical aspects underlying of human locomotion such as body awareness, posture and respiration. Furthermore, DNS is the universal clinical partner with all other clinical techniques, helping to improve their efficacy because of the stabilizing DNS effect. So, regardless of your assessment, manual techniques, counseling and exercises, the DNS approach will team together well with them.”

The principles and methods of DNS are somewhat challenging to learn. Part of this may be that developmental kinesiology milestones that form the DNS foundational principles are not regularly taught in Chiropractic schools. Also, the manual methods are complicated and can require additional therapeutic time in practice compared with the typical chiropractic visit time allotments. Finally, the PRACTICAL APPLICATION of DNS principles and methods into clinical practice and specific patient management is CHALLENGING. Several years of training and clinical application are required before a clinician has a solid understanding to of these principles and practices to qualifyto take the DNS final certification “D” course held at Motol Hospital Rehabilitation Department in Prague, Czech Republic. This course is provided under to supervision of Professor Kolar, Asst Professor Kobesova, the Prague School physiotherapists and the international instructors.

By analogy, just because a person memorizes thousands of Spanish words, it does not mean they can speak (or functionally effective) in that language. Grammatical application and practice is required to properly understand how to turn those words into a practical form of communication, resulting in fluency. In that same light, clinicians who have been taught DNS principles and clinical approaches can still be challenged on how to practically, functionally apply the DNS approach into their practices. “I think DNS is awesome and I know it is clinically important, but I can’t figure out how to apply it effectively in practice. I am not certain it is for me,” is a common theme that each of the authors have each heard repetitively from scores of DC’s.

There is Great NEWS for those many docs who have felt this frustration: The first ever “2-Day Practical DNS Application Course” has been devised by Professor Craig Morris and it will be held in association with, and just prior to, and in partnership with, the 2017 ACA Rehab Council’s Annual Convention!! This course will address practical issues like assessment, clinical planning, notes charting and even billing. Case studies will be provided and practical skills will be taught. Professor/Dr. Morris and Dr./Professor Winchester will be the instructor for this first course. There is a registration discount for convention attendees.

Health & Fitness Trends 2017

We really did sign up for a career of learning and development. Now that you have built a strong foundation of your manipulation skills, nutrition base, movement assessments and business knowledge, it’s time to keep up with the American College of Sports Medicine’s 2017 worldwide health and fitness trends. I’ve listed the top 10 out of the 20 picks with my comments as it relates to our profession.

Wearable technology was the leading trend for 2016 and remains there for 2017. Wearable tech includes fitness trackers, wearable cameras, smart watches, heart rate monitors, and GPS tracking devices. If your patient needs help remembering to exercise recommend they try a fitness and activity tracker like those from Jawbone and Fitbit. They’re designed to let you know how much activity you’ve had in your day and some even track how well you’re sleeping by monitoring sleep. Some have built-in heart rate monitors, while others can connect to a heart rate monitor. Most fitness trackers sync with your smartphone and computer to review your activity.

Body weight training is the most minimal approach to fitness and you’ll be surprised how effective bodyweight exercises can be for increasing and maintaining muscle and fitness. I live on the beach in the Santa Monica-Venice area and on any given Sunday you can see groups of young men and women that have the most fit, sculptured bodies working out only using bars and rings. The benefits of body weight training are that it’s free; it’s usually the first type of exercises I teach patients; it’s versatile, with many different variations; it can be done anywhere; it improves movement; it improves relative strength; it can improve reactive strength. My favorite bodyweight exercises are push ups, squats, lunges, pull ups, and ab roll outs.

High-intensity interval training (HIIT) describes any workout that alternates between intense bursts of activity and fixed periods of less-intense activity or even complete rest. For example, a good starter workout is warming up for a few minutes, then running as fast as you can for 1 minute and then walking for 2 minutes. Super-efficient HIIT is the ideal workout for a busy schedule—whether you want to squeeze in a workout during your lunch break or to get in shape for a fast-approaching event. You can achieve more progress in a mere 15 minutes of interval training (done three times a week) than the person jogging on the treadmill for an hour. It’s popular because in just 2 weeks of high-intensity intervals you’ll improve your aerobic capacity as much as 6 to 8 weeks of endurance training. HIIT workouts are efficient, you’ll burn more fat, its great cardio and you don’t need any equipment, you’ll lose weight and increase your metabolism, and you can make it as challenging as you want.

Educated, certified, and experienced fitness professionals. The ‘average Joe and Jane’ Chiropractor is good for the annual required license renewal credits. You will become more appealing to the public if you can pursue certifications and higher education that allows you to offer new services (rehab, exercise training, soft tissue, taping, functional nutrition coaching, etc). Look to your local Chiropractic College for Diplomate or certification programs. Performance Health is rolling out a new 36 hour certification course that has everything you need to know for the fitness minded practitioner and SCUHS is offering the Rehab Diplomate in 2017.

Strength training for my patients means they strive for strength, not size. Most men want a chiseled chest, big biceps, and 6 pack abs. But instead of training like a bodybuilder and relying on single-joint exercises designed to isolate specific muscles, I write programs that train like an athlete. For example, if you’re doing 25-pound biceps curls, you’ll probably be able to handle 50s for bent-over rows. You’ll build strength and burn more calories, and the extra weight will create added muscle stress and trigger more testosterone production. The result: Your biceps will grow faster than they would with simple curls. The chiropractic rehab model I use is “motor control” or “progressive overload” training. I am a movement system specialist which means I understand how to properly add more resistance and while spending more time in your weak zones, usually the glutes, lats and core. We have to be the ones encouraging our patients to perform more work in the gym or at home because the more they do, the more durable and injury resistant they become. I still recommend patients train for just 35 to 45 minutes a day at least 5 days a week, in the gym for only 30 to 40 minutes two or three times a week.

Group training is my favorite part of the week in my office. I originally started my in office exercise classes for clients that have low back pain and were afraid to go to a gym (they’d get reinjured easily, didn’t know what to do, etc). I started teaching classes more than 15 years ago with body weight exercises concentrating on very low load exercises. Some of the same people are still with me and we now work out with heavy Therabands and Kettlebells. You can start a kid’s only class, a women’s only class, a low back class, age 45-55 only class, etc. and charge appropriately for a ‘small group exercise class’.

Exercise is Medicine is my domain as a rehab specialist. We should own this category of care but unfortunately it’s already trademarked. I think it’s important to understand how to assess movement (function vs dysfunction), prescribe and help select the actual corrective exercise and when it should be stable or unstable, prescribe sets, reps, intensity – how much weight is being used or how much effort is being put forth relative to a maximal effort, tempo –speed of repetition, and rest.

Yoga just continues to expand and trend. I think it is a great in-office therapy to offer. At home I can look out my window and see 50 people gather on the beach every Saturday morning doing a large group low cost yoga session. The take home message is that you can do yoga and any class anywhere outdoors with enough space. Yoga is breath, flexibility, strength, metabolic, and group classes create community. I learned rhythmic flexibility and understand flow from my time spent in yoga classes.

Personal training is very much what we do as rehab specialist. If you don’t have the time, hire a qualified trainer and have them in your office. Selecting an exercise type or mode for patients is based on the person’s goals, functional capacity, interests, available equipment and time constraints. Have the ability to explain and get the patient to engage small and/or large muscle groups and create cardiorespiratory workouts. Once a core and cardiorespiratory base has been developed and a plateau has occurred, the exercise mode should be manipulated every two to three weeks in order to keep the patient from physiologically adapting. This helps to keep caloric expenditure high without adding time in to the workout.

Exercise and weight loss: Along with writing exercise programs, you’ll need to help patients navigate “super” foods like quinoa and kale, as well as supplement choices and meal plans like the Paleo diet, the Mediterranean diet, the Ketogenic diet and the vegetarian diet. We are still dealing with more than 30 percent of Americans being classified as obese. Again look at number 4 above. Look to your Colleges and local colleagues who are in this arena for help getting started.

Additional Health Trends not on the ACSM’s list but on the Dr. Jeffrey Tucker 2017 list is:
Cannabis: Patients are going to ask you about this as a source for pain relief for any and all conditions. Popular in several States are hemp seed or CBD creams, edibles with THC, and the actual weed to smoke. I was issued the first United States marijuana patent on a process to make CBD cream. Patients are going to have to try various creams to see if it does have an anti-inflammation effect on them. Note: While hemp is from the same plant as marijuana, it contains extremely low levels of THC, the substance that gives you a high.

Cleansing the kidneys, liver, and other organs is going to remain popular. Cleanses are not necessarily fasts, and cleanses are becoming more widely practiced and give the organs a rest while introducing more whole foods, organic foods, and non-processed health foods that contain high levels of vitamins, minerals, antioxidants, and immune-cancer-fighting substances. These cleanses give patients an opportunity to jump start weight loss, and help reduce inflammation in tough conditions. I have my patients drink shakes with supplement powders, fresh berries and fresh veggies, while eating a whole foods diet.

The term “functional medicine” has been around for years (the even newer term is Triage medicine) but is becoming more and more prevalent, especially marketed towards aging baby boomers. While going to your regular MD may help keep you out of trouble (or not), functional medicine practitioners blend intelligent modern medicine with alternative therapies. They focus on doing specialized blood work or other tests independently. Functional medicine is a compliment to your traditional medical practitioner yet may work together in tandem, incorporating optimizing and balancing hormones and vitamins. The practitioners who are practicing functional medicine are doing great work and I’m sure will continue to trend and grow. In my area one smart Chiropractor started a monthly functional medicine group made up of MD’s, DC’s, nutritionists, etc. Each month a different practitioner comes and talks to the group.

‘Innovation and technology’ that speaks to the movement toward ‘get me out of pain now’. Invest in new equipment such as lasers, vibration & percussion devices, Lymphatic drainage machines (Michael Phelps popularized this during the summer Olympics), Shockwave machines, SCENAR and even more. I continue to feel intense amounts of pressure to get them better faster and keep patients healthy. We are in a competitive market, and patients are less rigid about who they go to for pain relief as long as it is fast. It seems long term plans have peaked over the past few years. I hear shorter (30 day) cash (‘get me out of pain’) plans geared towards pain relief is going head to head with the ‘pay for the year care’ these days.

Vendors of supplements and equipment have a lot to say to us small business owners in Chiropractic. I recommend spending time each quarter with different vendors to learn about new products and supplements available. Vendors are committed to our professional growth, educational development, and well-being. If we do good, they do good! I think the new standard is laser, deep muscle stimulator, and shock wave therapy. These devices have a clean feel, and the modern aesthetic look of these devices is appealing. Selling supplements and other health related items in the office that makes it convenient for patients to purchase is appreciated. I was recently disappointed to see Metagenics on the shelves of a local health food store when they previously could only be purchased by doctors. There are many supplement companies marketed only to doctors for health or weight loss. I think this and private label products are a popular trend.

Low overhead by having shared space with multiple practitioners under one roof will remain the trend but you may need to spend money on new carpet and paint. It’s important to keep your office looking clean and fresh. In addition, I know spending money in this time of healthcare flux is scary but investing in new equipment like a Thera-Band Station, lymphatic stimulation device, shock wave therapy, laser, DMS devices, instrument tools, SCENAR, body composition machines, and posture/gait analysis equipment will expand your services and enhance patient care.

I honestly think it’s going to be one of Chiropractic’s best years ever. What do I think you can do to start making that happen? Start adding one or two of the top ten list to your office now. Get certified by Performance Health in their new 36 hour course or enroll in a Rehab, Sports or other Diplomate program. Become familiar with exercise, nutrition, taping and quality movement. Learn how to coach patients in diet, weight loss, and exercise therapy.

Everyone from chess players to the NFL are conscious about Chiropractic. Raise the bar for yourself, your practice and patients through exercise, fitness and diet.

Cheers to 2017 being a happy & healthy year to each of you and yours.
Jeffrey Tucker, DC, DACRB

 

Dr. Jeffrey Tucker
11620 Wilshire Blvd. #710
Los Angeles, CA 90025
310-444-9393

Conscious Core Stability For Low Back Pain Occurring Under Spinal Load: Queuing The Patient

Joseph W. Piwoszkin DC
Darien, IL
PEER REVIEWED BY THE AMERICAN CHIROPRACTIC REHABILITATION BOARD

Review of Anatomy and Physiology

The low back, or lumbar spine, consists of five lumbar vertebrae aptly referred to as L1, L2, L3, L4, and L5. The most inferior aspect of the lumbar spine, L5, connects to the sacrum; a large spade-shaped bone that connects the spine to the iliac bones of the hip.

The cervical spine and lumbar spine both consist of a lordotic curve with no supporting osseous structures. Unlike the thoracic spine, where each vertebra has a set of ribs attached (creating a supportive thoracic cage) the cervical spine and lumbar spine rely more heavily on muscular stability.

Due to the “upright” nature of mankind, axial loading of the spinal osseous structures is common. The job of the surrounding musculature is to resist buckling of the spine under the loads of activity. Anterior/abdominal muscles used for lumbar spine stability include the internal oblique, external oblique, transverse abdominus, and the rectus abdominus muscles. Posterior/back muscles used for lumbar spine stability include the multifidus, quadratus lumborum, lumbar erector spinae, and the thoracic erector spinae muscles. For the sake of this case study, these are the muscles being referenced when referring to core musculature (1).

Background Information

Low back pain patients requiring core rehabilitation can be defined in one of several groups: the deconditioned, imbalanced muscle development ratio, or the inability to maintain co-contraction (2). All have one common aspect to their rehabilitative care; they require education in creating a co-contraction of the core musculature. Currently, there are no outlined methods of checking for this stability pattern in patients during functional activities. Therefore, a high amount of responsibility is given to the patient’s kinesthetic awareness of functional bracing patterns. The responsibility of educating the patient in these patterns occurs during baseline rehabilitative care. When instructing the lay person on proper form and firing patterns with rehabilitative exercise, communication is key. Patients with low kinesthetic awareness at baseline (i.e. difficulty producing willful abdominal wall muscle contraction laying supine with knees at 45 degrees) should not progress to more active and functional exercise until this is mastered. If the practitioner cannot evoke abdominal wall musculature contraction in the patient, progression may be limited.

These are individuals who struggle with conscious core stability. Eliciting co-contraction in these individuals will rely heavily on the skill of the practitioner and their ability to kinesthetically educate or “queue” the patient into creating the desired outcome. A common difficulty with the aforementioned patient base is activating the abdominal wall muscles: especially internal/external oblique and transverse abdominus.

When performing an exercise used to target abdominal wall musculature, without proper queuing it is possible to continue to use poor firing patterns to execute the movements (overusing hip flexors, spinal erectors, quadratus lumborum). In the subacute or chronic patient, these “abdominal” exercises performed without proper abdominal wall contraction may continue to cause pain, but in the same patient with proper queuing, may not cause pain. Granata and Marras showed that co-contraction of the core musculature increases spinal stability by 36% to 64% (3). It may be considered that this considerable change in stability may affect whether or not the patient feels pain with rehabilitation, as well as activities involving spinal load.

Psoas major, part of the hip flexor group iliopsoas, originates at the lumbar spine. A compensatory pattern of overusing the hip flexors without dispersing force into the abdominal wall during stabilization may cause difficulty in maintaining a neutral spine. A lumbar hyperextension pattern is seen in hip flexor/erector spinae dominant stabilization patterns during exercise. According to McGill, a neutral lordosis in the lumbar spine during loaded activity has been shown to minimize risk of low back injury (4). Good queuing to correct these movement patterns in early rehabilitation may have a direct effect on outcomes.

History

Ruth, a 52-year-old female, presented to clinic for examination of low back pain. She rated the intensity of her pain on a scale of zero to ten, with zero being complete absence of symptoms and ten being very severe or unbearable pain, a seven. Pain was described with the following qualifiers: dull, sharp, deep, and stiffness. Upon questioning, Ruth stated her symptoms were aggravated by activities involving sitting, sleeping and bending. She stated that some relief was obtained when standing. Denied having, or ever having, any radicular symptoms into either legs. Ruth reported that about one and a half years ago she had a cyst removed from her right ovary. Roughly 6 weeks after surgery she woke up in the morning with extreme pain. The pain was located in the right lateral hip region. Reported pain was worse in the morning but decreased to “tolerable” levels after about 2 hours. Patient received a corticosteroid injection into the right hip that helped the pain, but since that time the pain has migrated to the low back. She reports still having occasional lateral hip pain if she moves incorrectly. Ruth has had x-rays and an arthrogram of the right hip. She reports having no known trauma in either the hip or low back areas. Previous relevant surgeries included two cesarean sections, a hysterectomy, and removal of the right ovary. Ruth also reports having undergone about one month of physical therapy, thirteen visits total, immediately previous to this examination. Ruth had another corticosteroid injection scheduled six days from our initial examination. Ruth works as a secretary. No red flags were found during the initial history.

Ruth’s previous rehabilitation did not involve any core stabilizing education. She stated that she did exercises for “her back muscles” and “leg exercises” as well. During her thirteen previous physical therapy visits at another institute she reported that her pain would decrease mildly followed by severe “flare-ups” of pain. This cycle continued throughout the thirteen visits.

Physical Evaluation

Active Lumbar Spine Range of Motion
Patient showed moderate-severe restriction in standing flexion, and moderate standing extension restriction. Both standing flexion and extension produced pain. Mild-moderate restrictions in left/right lateral flexion and left/right rotation without pain, but patient was hesitant to push these boundaries.

Palpation
With the patient prone, pain was noted with palpation over the posterior superior iliac spines bilaterally. Quadratus lumborum palpation revealed trigger points in the medial fibers near the origin along the upper lumbar spine with pain elicited. Gluteus maximus muscle origins on the right were hypertonic and tender. Middle and lower thoracic erector spinae musculature was overdeveloped comparatively with noted hypertonicity.

Motion palpation of the spine revealed restricted movement in the lower thoracic and upper lumbar spine. Counter nutation restriction of the sacrum.

Neurological Examination
Lower extremity muscle strength, pain/touch sensation, and reflexes were all within normal limits. No pathological reflexes were present.

Orthopedic Examination
Negative tests include: Straight leg raise, Bragard’s, Patrick-Fabere, and Kemp’s.
Positive Yoeman’s test bilaterally with pain in the respective sacroiliac areas and low back. Hibb’s positive on the right for pain in the right sacroiliac joint, negative on the left. Milgram’s positive for severe low back pain with the inability to hold the position for any amount of time.

Functional Examination
Squat test – Patient was asked to perform a squat with no previous queuing. While attempting to squat the patient used almost exclusively knee flexion with no hip hinging/flexion. Patient described having fear avoidance in “bending forward” because of back pain. Patient was placed supine with knees at 45 degrees and the examiner attempted to provoke an abdominal wall contraction from the patient. The patient showed complete inability to willingly produce any type of muscle contraction. When placed in a dead bug position (patient unable to raise her legs on her own due to pain) the patient described moderate low back pain, and light perturbation to the raised legs produced severe low back pain.

Imaging
X-ray and MRI arthrogram reports of the right hip were requested. X-rays were performed four months prior and the MRI arthrogram three months prior to the presenting examination. X-ray impressions stated “no evidence of acute bony abnormality” and the MRI arthrogram impressions were slight fraying of the acetabular labrum, strain of the gluteus medius at its insertion upon the greater trochanter with trochanteric bursitis, associated gluteus minimus insertional tendinosis, and no bony lesions demonstrated in the pelvis.

Differential Diagnosis

Acquired Sacroiliac and Lumbar Spine Instability and/or Sacroiliitis with Lumbar Spine Facet Syndrome.
Discogenic Pain of the Lumbar Spine

Rationale for the above diagnosis is severe pain and resulting fear avoidance behavior combined with the lack of ability to engage abdominal wall musculature. Correlation with tissue and spinal palpation, positive orthopedic tests, and functional testing support these diagnoses. Consideration of the multiple abdominal wall traumas from surgical intervention were made, however, good core stability patterns may not have been present prior to these interventions.

A compilation of information put together by Bogduk and Aprill supports the aforementioned structures as being valid sources of pain (5).

Patient Management/Intervention

These guidelines are not designed as a specific practice model. They may or may not be used, as deemed necessary by the practitioner, to help elicit abdominal wall muscle firing patterns. The “language” used is intended to be easily understood by the lay person.

  1. Screening & Queuing Co-contraction
    Patient began lying supine with knees flexed at 45 degrees, feet flat.
  2. Explain that you will be testing their ability to contract their “stomach muscles”
    1. An example of what a muscle contraction feels like can be easily made using the biceps muscle. Most patients will understand that when “flexing” the biceps the muscle should feel firm.
      1. “We want the same response in your stomach muscles”
  3. Press the pads of your second, third, and fourth fingers 2’ to 4” lateral of the umbilicus. Have the patient do the same with their own hand on the other side. Your pressure while pressing against their abdomen should be similar to the deep palpation pressure you would use during an abdominal exam.
  4. Ask the patient to “push your fingers away using their stomach”
    1. It is important at this point to correct any excessive lumbar extension in their attempt to contract the abdominal musculature. You may queue the patient by putting your other hand under their lumbar spine and telling them to either lightly press against it or to not let their back raise away from your bottom hand when attempting to contract.
  5. If the patient is able to achieve this, have them place both hands around their abdomen (level with the umbilicus) with their thumbs wrapping posteriorly and fingers anteriorly.
    1. Explain that when contracting, they should feel their hands being “pushed away in all directions” as if expanding their stomach 360 degrees.
  6. When the patient is able to achieve co-contraction at this level, progress them appropriately into your rehabilitative program. Explain that this is their foundation, and the importance of being able to consciously stabilize their core/spine.
    1. When performing core stability exercises (i.e. Dead/Dying Bugs or Plank/Bridge positions), make sure the patient is not falling back into lumbar hyperextension and a hip flexor/erector spinae dominant bracing pattern. Otherwise, you are continuing to train a dysfunctional pattern.
  7. If the patient is unable to comply with the above method, you may try the following:
    1. Remain in the above mentioned position with your hand and the patient’s hand on the abdomen. Ask the patient to give you a “fake cough” or a short fast exhale. You should note their abdomen pressing out against your hand during this. Ask the patient if they felt it as well. Make sure the patient is applying the appropriate amount of pressure onto their own abdomen.
      1. It may help to explain the muscles you are trying to contract attach the bottom of the ribs to the front of the pelvis, and that they should feel their ribs “being pulled down” or “dropping” when they cough or forcibly exhale.
      2. Another option is to press down on the bottom of the patient’s rib cage using the thumb and forefinger of one hand, pressing lightly into the intercostal spaces roughly even with the midclavicular line on each side. Have the patient continue with the above methods as you hold this position.
    2. Have the patient try to hold the contraction once they achieve it using the previous method. The patient may need to use this method multiple times. If so, allow the patient time to rest with a few normal cycles of respiration between multiple attempts.
    3. If the patient can maintain an abdominal wall brace with a normal breathing cycle pattern continue with number 5 listed above.
  8. Once the patient can consciously contract and hold their abdominal wall it is important to address an abdominal breathing pattern. If the patient cannot breathe during a held co-contraction, they should not be progressed into exercise involving core stability.

Patient Outcomes

Two visits were required before Ruth was able to create and maintain a co-contraction of core musculature while lying supine. By Ruth’s third visit she was able to progress to positioning herself and holding the dead bug position for 30 seconds without pain. Ruth presented on her fifth visit with a “flare-up” of pain. However, the pain was less than previous flare-ups and she was able to resume her previous level of rehabilitation on the next visit two days later. Ruth has continued to progress into exercises like straight leg raises, leg abductions, glute raises with feet on a BOSU, bridges/side bridges, prone hip extensions, dying bugs, standing chops, monster and crab walks. She performed the previously mentioned exercises without additional pain. By Ruth’s ninth visit she was having no morning pain, no pain with her current activities of daily living, and only “mild discomfort” while sitting in a car. Ruth also made a personal decision not to have the cortisone injection which was scheduled for six days after her presenting examination.

Discussion

Ruth was a superb example of having absolutely no conscious ability to stabilize and she required special attention to attain this firing pattern. Many patients can pick up this pattern quickly but are simply weak while others naturally create this pattern with no queuing at all.

The author would state that the importance of educating the patient of the dynamics of core exercise is equal to the ability to prescribe the appropriate rehabilitative program. It should be considered that exercise directed at the anterior abdominal wall can be ineffective if the patient is unable to use the correct muscle firing co-contraction patterns. When performing rehabilitative core exercise without first addressing how to properly stabilize the core, the risk of provoking the spine under a less than ideal stability pattern increases.

REFERENCES

  1. Liebenson, Craig. The Role of Muscles, Joints, and Nervous System in Painful Conditions of the Spine. Rehabilitation of the Spine: A Practitioner’s Manual. 2007; Chapter 2: 31-47.
  2. Osborne N, Cook J. Global Muscle Stabilization Training – Isotonic Protocols. Rehabilitation of the Spine: A Practitioner’s Manual. 2007; Chapter 27: 682-685.
  3. Granata KP, Marras WS. Cost-benefit of muscle cocontraction in protecting against spinal instability. Spine 2000;25: 1398 – 1404.
  4. McGill, Stuart M. Lumbar Spine Stability: Mechanism of Injury and Restabilization. Rehabilitation of the Spine: A Practitioner’s Manual. 2007; Chapter 5: 94-95.
  5. Bogduk N, Aprill C. The Sources of Back Pain. Rehabilitation of the Spine: A Practitioner’s Manual. 2007; Chapter 6: 113-119.

Rehab and Sports; A Winning Combination

That’s the theme for our 18th Annual Rehab Symposium scheduled to take place on March 31st – April 2nd, 2017 at the Wyndham Disney Springs Resort in Lake Buena Vista. The speakers are all under contract, the Wyndham is booked and our Rehab Council website is now ready to accept registrations at: http://www.ccptr.org/next-annual-symposium/ It’s time for all of us to make plans to attend. The Spring weather is delightful in Orlando and we’re working with the local Central Florida weatherman to assure plenty of sunshine.

Here’s the rundown. We will be offering 18 CEUs of (pending) credit through Palmer College of Chiropractic. And there is a possibility that we might even add two more CEUs of credit during a 2 hour breakout session on Sunday. The Symposium starts on Friday, March 31st, at 1:00 pm with Dr. David Seaman giving a 3 hour presentation on “How Low-grade Inflammation can disrupt Rehab”. After a half hour vendor break Drs. Alf Garbutt and Jerrold Simon will follow up at 4:30 pm with “Rehab of Military, MVA and Sports Concussions” which ends at 7:30 pm. The evening’s festivities are capped by a vendor and member social hour in Salon 1-2 at the Wyndham Hotel.

Saturday, April 1st, features four different speakers all speaking for 2 hours each and covering everything from postural restoration to low-level laser therapy. It all begins at 8:00 with Stephen Perle, DC, MS teaching “Spinal Rehabilitation Exercise Therapy”. At 10:30 am Dr. Skip George will instruct on how to utilize “Postural Restoration for Rehab and Performance.” After the Rehab and ACRB Board Meetings lunch will be served and will feature a luncheon speaker who will be named in the next few months. Just before lunch the 2017 Rehab Chiropractor of the Year will be announced. Any ideas who it may be? The afternoon will conclude with Jerome True, DC FIACN explaining the effectiveness of “Laser Therapy Treatment for Radiculopathy” followed by Perry Nickelston, DC, NKT demonstrating “Kinesiology Taping for Rehab and Sports.” As you can already tell, the Symposium is peppered with Rehab and Sports related subject matter.

Now don’t forget Sunday, April 2nd. Starting at 8:00 am, Ted Forcum, DACBSP will demonstrate the “Use of Instrument Assisted Soft Tissue Mobilization” and then Jonathan Puleio, M.Sc., CPE will conclude our Symposium at 10:30 am – 12:30 pm with the “Fundamentals of Office Ergonomics” for DCs. In addition, there will be vendor door prizes be given out during the 10:00 am vendor break. During all of our vendor breaks, snacks such as granola bars & fruit as well as juices, water and coffee with be available for any registered attendees who care to indulge.

Remember, registration is just a click away. Please log on to: http://www.ccptr.org/next-annual-symposium/ Looking forward to seeing everyone in Lake Buena Vista this coming Spring 2017.
Best regards,

Jerrold Simon, DC, DACRB President, ACA Rehab Council

Post Surgical Knee Rehab Study

Results and Analysis of Pilot Studies

conducted on the ROM3® Rehab System

About the ROM3 Rehab System

It has been observed that after a knee trauma, including injury or surgery, patients who undergo earlier movement, more movement, and more active movement of the joint tend to enjoy greater range of motion and better overall outcome than patients who perform less movement, delayed movement, or only passive movement of the joint.

matrix

The ROM3 Rehab System is an application of the above datum. A patented technology, it was designed to facilitate earlier movement and active movement of the affected joint, as well as more comfortable movement, consequently allowing and inviting more motion.

More information about the ROM3 technology, shown here, can be found at www.ROM3rehab.com.

Purpose of the Pilot Studies

Pilot studies are generally performed to assess the effectiveness of the materials, apparatus and procedures that will be used in larger-scale studies. The results gained from pilot studies help researchers determine the feasibility of engaging in additional work in the area and also helps researchers determine the most appropriate strategies to assess the data.

The information gained from pilot studies can also help to determine the value of continuing to explore the effectiveness of an invention, which is one of the primary purposes of the two pilot studies described below.

The two pilot results presented in this document concern the results from inpatient and outpatient rehabilitation protocols. Combined, the results strongly indicate that the ROM3 is usable immediately after surgery and is highly effective in assisting recovery after knee surgery by achieving more rapid Range of Motion.

The pilot studies were also useful in that the data collection protocols suggested that the instrument should be modified and streamlined so that the physical therapists will all be using the same metric and will not find the instrument to be cumbersome or burdensome. The results of the pilot studies have provided useful data and areas for modification so that imminent large- scale studies will yield the most informative data.

Inpatient Rehabilitation Pilot Study

Goals of the Study

Inpatient Rehabilitation Pilot Study

The three main goals of the study were:

  1. To explore the usability and safety of use of the ROM3 Rehab System immediately after TKA.
  2. To determine if use of the ROM3 Rehab System immediately after TKA has a significant effect on patients’ range of motion and speed of recovery.
  3. To determine if use of the ROM3 Rehab System immediately after TKA has a significant effect on lengths of stay and cost.

Description of Sample

The inpatient rehabilitation pilot study was conducted at Labette County Medical Center in Parsons, Kansas. The study consisted of 107 cases—13 cases in the ROM3 group (five male, eight female) and 94 in the comparison group.

Patients of both the ROM3 group and the comparison group were representative of all three surgeons at Labette County Medical Center. Twelve of the patients in the ROM3 group had a single total knee arthroplasty (TKA, i.e., total knee replacement) while one patient had TKA in both knees. Therefore, the total data set included 14 TKAs.

After surgery, each patient received standardized therapy per current rehabilitation protocols at Labette County Medical Center, where the data was collected.

Patients in the ROM3 group used the ROM3 Cycle in addition to the usual therapy protocol for a period of 7-15 minutes per day on each of post-op days #1-#4. All other therapy was kept the same for both groups.

Results & Analysis, Inpatient Rehabilitation Study

  1. Ability to safely use the ROM3 Cycle. The most important datum from the pilot study is that patients were able to safely use the ROM3 Cycle one day after surgery (1 day post-op).In actual fact, all of the cases in the ROM3 group were able to use the ROM3 Cycle for at least 8 minutes on each of the 4 days of the study.Twelve of the 13 cases in the ROM3 group were able to use the ROM3 Cycle immediately. One patient did not initially use it due to being admitted into the Intensive Care Unit (ICU) following surgery, and instead used the device later.Therefore, for those patients who were medically stable, 100% were able to use the device. There were no complications, worsened conditions, or cases in which a patient was medically stable but couldn’t use the ROM3 Cycle because its use extended beyond the patient’s ability—even post-op day #1.This is, itself, a very important finding since usability and safety by all patients is vital. It is commonly observed that a substantial percentage of TKA patients have severely limited range of motion after surgery. A device for the purpose of helping patients who have limited range of motion to recovery more quickly would be of little value if their limited range of motion prevented them from using it, or if its use worsened their condition.

    The findings indicate that the ROM3 Cycle may be used in the fashion that was intended, that is, immediately following surgery.

  2. Effect of the ROM3 Rehab System on range of motion and speed of recovery.It has been observed that 90° range of motion is an important milestone in recovery, since below 90° ROM, patients tend to struggle and experience discomfort and lack of functional mobility; above 90° ROM, patients demonstrate a greater level of functional independence and can better assume their own burden of care—a major goal of post-op therapy. Therefore 90° ROM was chosen as a key benchmark for this inpatient pilot study.All cases in the ROM3 group reached 90° range of motion in 4 days or less, except one patient (a patient with bilateral TKAs who reached 90o in only one knee within 4 days).There were three patients in the ROM3 group who reached 90° ROM on the first day after surgery. Each of these individuals continued to improve, and each reached an additional 4° – 5° or more using the ROM3 Cycle.Of the 94 patients in the comparison group, only 40.5% reached the critical 90° ROM benchmark within 4 days. Of the other 59.5%, most achieved 90° ROM in 5 to 10 days; and several with very stiff knees took longer than 10 days.

    Thus 100% of the ROM3 group reached the important milestone of 90° ROM between 1 and 6 days faster than the majority (59.5%) of the comparison group.

  3. Effect of the ROM3 Rehab System on length of stay and cost.Within the comparison group, the 40.5% that reached 90° ROM by post-op day #4 were discharged from the hospital in similar timeframes as the ROM3 group.For the 59.5% of the comparison group that took longer than 4 days to reach 90° ROM, hospital stays averaged 1.6 days longer than the ROM3 group.These additional 1.6 days of care, though relatively small, were quite expensive for the hospital, costing an average of $3,252.08 more per patient than the average cost per patient in the ROM3 group.Additionally, the maximum total cost for a longer stay patient in the comparison group was $10,211.19 more than the average cost per patient in the ROM3 group.

    Since hospitals receive flat rate reimbursements based on the diagnosis, regardless of the actual length of stay, the additional days of care are at the hospital’s expense—hospitals are not typically reimbursed for additional days of care. Thus hospitals have direct economic benefit from discharging patients as quickly as possible.

    Had the ROM3 technology and resultant savings been applied to the entire comparison group (assuming the results from the pilot study hold true across a larger scale), the savings would have been even more substantial:

    94 patients x 59.5% = 56 patients (whose hospital stay and cost could have been reduced)
    56 patients x $3,252.08 average extra cost = $182,116.48 (potential savings on 94 patients)

    From this projection, it can be extrapolated that use of the ROM3 Rehab System with TKA patients for just 4 days immediately after surgery would generate an average cost savings of $1,907.41 per patient due to earlier discharge.

    It is noted that a large and growing number of joint replacement surgeries today are performed on an outpatient basis in surgery centers. These outpatient centers typically discharge patients the same day; therapy still generally begins on day #0 or day #1 post-op but at home or in another venue.

    The location and setting of the patient and therapy equipment is not considered the key element of this inpatient pilot study. Rather, the key element was the timing of the delivery of the ROM3 therapy—i.e. in the days immediately following TKA.

    With this in view, it is expected that the savings generated by use of the ROM3 Rehab System immediately post-TKA will naturally accrue to whatever entity is responsible for the cost of therapy within the respective healthcare model, regardless of the location or setting. Under a fee-per-service model, payors may reap the benefit in the form of a reduced reimbursement. In a bundled payment model, the organization responsible for reducing the number of therapy sessions will be rewarded. Cash patients will pocket the savings themselves.

Outpatient Rehabilitation Pilot Study

Goals of the Study

The three main goals of the study were:

  1. To determine if the ROM3 Rehab System is usable by TKA patients with joint pain and limited range of motion in outpatient therapy.
  2. To determine if use of the ROM3 Rehab System in outpatient therapy beginning 3-5 weeks after TKA has a significant effect on patients’ range of motion.
  3. To determine if use of the ROM3 Rehab System in outpatient therapy affects speed of recovery and/or number of therapy visits needed to reach full recovery.

Description of Sample

The pilot study consisted of 29 outpatient therapy cases—15 in the ROM3 group (eight male, seven female) and 14 in the comparison group (four males and ten females). All of the patients had single TKAs performed at Kansas City Orthopaedic Institute, a leading orthopaedic hospital.

After surgery and prior to the pilot data collection, each patient in both groups had received therapy during their inpatient stay in the hospital, followed by 2-4 weeks of in-home therapy.

Next, beginning 3-5 weeks after surgery, each patient received outpatient physical therapy per current rehabilitation protocols at Kansas City Orthopaedic Institute, when the pilot data was collected. For patients in the ROM3 group, use of the ROM3 Cycle for a period of 8-15 minutes was substituted for the usual therapy protocol. All other procedures were kept the same for both groups.

All patients in both groups received therapy from the same therapist only, and all outcome measurements for both groups were conducted by a single therapist, minimizing variables and ensuring uniformity of measurement technique.

Results & Analysis, Outpatient Rehabilitation Study

  1. Ability to use the ROM3 Cycle. 100% of the patients in the ROM3 group were able to use the ROM3 during their initial visit and in all subsequent visits.

    All patients from both groups had continuing joint pain and indicated that excessive flexion or extension of the affected joint increased pain exponentially. Nevertheless, patients from the ROM3 group indicated they could comfortably use the ROM3 Cycle without prohibitive pain.

    Several from the ROM3 group had very limited range of motion at the beginning of therapy—too limited to perform a single revolution on a stationary bike—but were still able to use the ROM3 Cycle. One patient had severely limited range of motion, with only 47° of knee flexion at initial visit. This patient was likewise able to pedal the ROM3 Cycle on the first visit and on all subsequent visits, and showed significant improvement in range of motion.

    Once again, this is a very important finding since usability by all patients is vital. It is commonly observed that a substantial percentage of TKA patients continue to have limited range of motion for weeks post-op—including some at 4-6 weeks post-op. A device for the purpose of assisting patients with limited range of motion would be of little value if their limited range of motion prevented them from using it.

    These results indicate that the ROM3 Rehab System is usable in one of its primary intended uses—enabling therapeutic, productive motion for virtually any medically stable TKA patient at several weeks post-op.

  2. Effect on Range of Motion. The data from the two groups were compared examining the active range of motion (AROM) from initial exam to discharge. The two groups were compared on the gain in AROM.

    The mean AROM gain for the ROM3 group was 25.67° versus 17.79° for the comparison group. (See Figure 1.)

    ROM3-AROM2

    The ROM3 group’s results included superior gains in both knee flexion and extension. All but two ROM3 group patients reached 0° extension, while in the comparison group, 9 out of 14 did not achieve 0° by discharge.

  3. Speed of Recovery, Number of Visits. The ROM3 group had significantly fewer visits until discharge compared to the comparison group, t(27) = 2.16, p < .039. The ROM3 group required an average of 9.54 visits until discharge, while the comparison group required an average of 15.71 visits.

    This is impressive by itself as the ROM3 patients not only achieved a greater average range of motion, but did so in 40% fewer visits. (See Figure 2.)

    ROM3-AROM

    Due to faster recoveries, patients in the ROM3 group saw a reduction in necessary therapy visits by an average of 6.17 fewer visits per patient. Assuming an average charge of $100 per visit, this implies a $617 average savings per patient, and with better outcomes.

Conclusions

The results of the pilot studies provide preliminary indications that the ROM3 is an effective apparatus for use with patients who completed TKAs. In summary, the major results of the pilot study indicate that:

  1. Patients, including those with joint pain and severely limited range of motion, are able to comfortably and safely use the ROM3 after TKA surgery, including as early as the day of surgery and the day after surgery.
  2. TKA patients who use the ROM3 Rehab System, whether immediately after surgery or several weeks later, either inpatient or outpatient, reach greater levels of range of motion faster and recover earlier.
  3. TKA patients who use the ROM3 Rehab System immediately after surgery have shorter hospital stays (or fewer therapy sessions, depending on healthcare model). This alone can save an average of more than $1,900 per patient in cost of care.
  4. Patients who use the ROM3 Rehab System during outpatient physical therapy required an average of 6.17 fewer visits than those in the comparison group, a 40% reduction in therapy visits, and an additional cost savings of $617 per patient.
  5. The tremendous gains seen in the pilot work indicate considerable improvement over the current state-of-the-art TKA rehabilitation treatment.

The results of the two pilot studies provide a very useful examination of the potential of using the ROM3 for TKA rehabilitation. Patients find the device usable immediately after surgery, their progress is more rapid, and their lengths of stay and/or number of visits for rehabilitation are significantly fewer.

Large-scale data with more evaluation points are expected to provide even stronger and clearer results. Pilot data, being smaller in size, generally provide encouraging, but statistically insignificant results1.

The results from both the Inpatient and Outpatient Pilot Studies indicate that the ROM3 is not only an effective device in the rehabilitation of total knee replacement, but is also quite useful in reducing the cost of such rehabilitation.

When one factors in these results with the fact that more than one million patients undergo TKAs annually2, the difference in savings by using the ROM3 Rehab System both immediately after surgery and later in outpatient therapy could be in excess of $2.5 billion dollars per year.

The volume of TKAs is forecasted to reach 3.5 million per year within 14 years3, suggesting this savings could reach more than $8.8 billion dollars annually.

Pressure to reduce healthcare costs is extremely high and rising. It is safe to assume that both providers and payors will be interested in such a savings.

Increased Use

As stated, these studies examined data from patients who each had less than a dozen uses of the ROM3 Cycle, either for just 4 days immediately after surgery, or not beginning until 3-5 weeks post-op. The question arises as to whether an increased use of the ROM3 Cycle, such as on a daily basis throughout the recovery process, might produce even faster recoveries, better outcomes, and greater cost savings.

Certain healthcare providers have begun combining both inpatient and outpatient use of the ROM3 Rehab System, and added home use of the ROM3 Cycle between discharge and outpatient therapy. Under this structure, patients use the ROM3 Rehab System regularly from date of surgery through 5-10 weeks after—some 35-75+ uses. Tracking and analysis of outcome data from this thorough rehabilitation protocol is imminent; it appears to offer even quicker recoveries, fewer visits required, and greater cost savings.

It will require randomized controlled trial studies with larger sample sizes before the ROM3 will be argued to be the next generation of accepted protocol for total knee replacement rehabilitation. However, the pilot data and results presented in this paper provide a glimpse of the power of the results that the ROM3 Rehab System produces.


 

1 A Note on Small Sample Sizes and Statistical Significance:

Statistical significance when examining two or more groups involves an estimate of variability due to between group differences and an estimate of variability due to within group differences. Between group differences occur as a function of differences between groups. The ROM3 Rehab System produces significantly shorter time in rehabilitation, for example. The means for the ROM3 are smaller in terms of the number of rehab visits or length of stay in an inpatient unit. However, there are going to be individual differences within each group. Some people are going to respond to rehab faster than others. This is why it is important to randomly assign individuals to groups as the researcher will not know these individual characteristics of patients prior to treatment. To generate significant results, the ratio of between-groups and within-groups variability is determined. If the differences between groups, between-group variability, is larger than the variability between patients, within-group variability, the result will be statistically significant.

The between-group variability between the treatment and comparison groups must be much larger than the variability that naturally exists between individuals within a group. When this occurs, the ratio of between- group versus within-group variability becomes larger, suggesting that there are real and important differences between the groups.

The larger the sample size the greater the probability that significant results will occur when there are real differences. Conversely, the smaller the sample size the less probable that significant results will occur, due to the lack of power to find real differences, even if they exist.

The fact that the differences between the ROM3 and comparison groups were so robust that significant results were found in the pilot studies suggests two things: 1. that using the ROM3 Rehab System produces clinically significant results that can be seen even in small samples, and 2. that it is more probable that those differences are real differences. As a result, it is expected that the results from large-sample-size studies will be even more convincing.

Larger sample sizes generally produce less within group variability as the samples become better estimates of the populations they are representing. Thus the ratio becomes increasingly larger. It is anticipated that the results from further research with larger sample sizes will produce more impressive results. Such studies are now commencing.

2 Gittins M(1), Doucette D. Total joint arthroplasty: tips for improving efficiency. Am J Orthop (Belle Mead NJ). 2014 Mar;43(3 Suppl):S1-4. PubMed PMID: 24911640.

3 Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am. 2007 Apr;89(4):780-5. PubMed PMID: 17403800.

Warrior Mace

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Incidence of Diastasis Recti Abdominis During the Childbearing Year

Jill Schiff Boissonnault, Mary Jo Blaschak
Published July 1988

Abstract

This study was conducted to determine 1) the incidence of diastasis recti abdominis among women during the childbearing year and 2) the location of the condition along the linea alba. Clinicians have long noted its presence, prenatally and postnatally, but the magnitude of the problem is currently unknown. A cross-sectional design was used to test 71 primiparous women placed in one of five groups, based on placement within the childbearing year. A commonly accepted test for diastasis recti abdominis was performed. Palpation for diastasis recti abdominis at the linea alba was performed 4.5 cm above, 4.5 cm below, and at the umbilicus. Diastases were observed at all three places, but most often at the umbilicus. A significant relationship (p < .05) was found between a woman’s placement in her childbearing year and the presence or absence of the condition. Diastasis recti abdominis was observed initially in the women in the second trimester group. Its incidence peaked in the third trimester group; remained high in the women in the immediate postpartum group; and declined, but did not disappear, in the later postpartum group. These findings demonstrate the importance of testing for diastasis recti abdominis above, below, and at the umbilicus throughout and after the childbearing year

Effects of exercise on diastasis of the rectus abdominis muscle in the antenatal and postnatal periods: a systematic review

Read the full article

Abstract

Background

Diastasis of the rectus abdominis muscle (DRAM) is common during and after pregnancy, and has been related to lumbopelvic instability and pelvic floor weakness. Women with DRAM are commonly referred to physiotherapists for conservative management, but little is known about the effectiveness of such strategies.

Objectives

To determine if non-surgical interventions (such as exercise) prevent or reduce DRAM.

Data sources

EMBASE, Medline, CINAHL, PUBMED, AMED and PEDro were searched.

Study selection/eligibility

Studies of all designs that included any non-surgical interventions to manage DRAM during the ante- and postnatal periods were included.

Study appraisal and synthesis methods

Methodological quality was assessed using a modified Downs and Black checklist. Meta-analysis was performed using a fixed effects model to calculate risk ratios (RR) and 95% confidence intervals (CI) where appropriate.

Results

Eight studies totalling 336 women during the ante- and/or postnatal period were included. The study design ranged from case study to randomised controlled trial. All interventions included some form of exercise, mainly targeted abdominal/core strengthening. The available evidence showed that exercise during the antenatal period reduced the presence of DRAM by 35% (RR 0.65, 95% CI 0.46 to 0.92), and suggested that DRAM width may be reduced by exercising during the ante- and postnatal periods.

Limitations

The papers reviewed were of poor quality as there is very little high-quality literature on the subject.

Conclusion and implications

Based on the available evidence and quality of this evidence, non-specific exercise may or may not help to prevent or reduce DRAM during the ante- and postnatal periods.

The Effects of an Exercise Program on Diastasis Recti Abdominis in Pregnant Women

Chiarello, Cynthia M. PT, PhD1; Falzone, Laura A. PT, MS2; McCaslin, Kristin E. PT, MS3; Patel, Mita N. PT, MS4; Ulery, Kristen R. PT, MS5

Abstract

Ms Falzone, Ms McCaslin, Ms Patel, and Ms Ulery were enrolled the the Master of Science Degree in Physical Therapy at Columbia University at the time data was collected for this study.

This research was presented at Combined Sections Meeting of the APTA, Boston, MA, 2002 and received the 2002 Research Award from the Section on Women’s Health.

Approvals: This project was reviewed and approved by the Columbia University and Columbia Presbyterian Institutional Review Board, #9906.

Background: Diastasis Recti Abdominis (DRA), a separation of the 2 bellies of the rectus abdominis at the linea alba, may occur in more than half of all pregnancies. Due to hormonal changes and a growing uterus, the abdominal muscles become over‐stretched and weak, compromising posture, trunk stability, respiration, trunk motion, and vaginal delivery. Exercise to strengthen the abdominal musculature during pregnancy may affect the presence and size of DRA, however, no research has specifically examined this relationship.

Purpose: The purpose of this project was to determine the effect of an abdominal strengthening exercise program on the presence and size of DRA in pregnant women.

Study Design: A 2 group, between subjects, quasi‐experimental post‐test design.

Methods: Subjects were comprised of 8 pregnant women participating in an abdominal exercise program and 10 non‐exercising pregnant women. Diastis recti abdominis was measured using a digital caliper at 3 marked sites along the midline of each subject’s abdomen: 4.5 cm above the umbilicus, at the umbilicus, and 4.5 cm below the umbilicus. Two measurements were taken at each site, and the average was used for statistical analyses. Descriptive statistics were generated, and independent t‐tests were performed on each subject characteristic. An analysis of covariance was computed with the number of previous pregnancies as the covariate to control for the difference between the subject groups.

Results: Ninety percent of non‐exercising pregnant women exhibited DRA while only 12.5% of exercising women had the condition. The mean DRA located 4.5 cm above the umbilicus was 9.6 mm (± 6.6) for the exercise group and 38.9 mm (± 17.8) for the non‐exercise group. The mean DRA located at the umbilicus was 11.4 mm (± 3.82) for the exercise group and 59.5 mm (± 23.6) for the non‐exercise group. The mean DRA located 4.5 cm below the umbilicus was 8.2 mm (± 7.4) for the exercise group and 60.4 (± 29.0) for the non‐exercise group.

Conclusions: The occurrence and size of DRA is much greater in non‐exercising pregnant women than in exercising pregnant women. Because of the integral role the abdominal muscles play in functional activities we recommend examining pregnant and postpartum women for the presence of DRA.

The Immediate Effects on Inter-rectus Distance of Abdominal Crunch and Drawing-in Exercises During Pregnancy and the Postpartum Period

Authors: Patrícia Mota, PT, PhD1, Augusto Gil Pascoal, PT, PhD1, Ana Isabel Carita, PhD1, Kari Bø, PT, PhD2

Affiliations:
1Faculty of Human Kinetics, University of Lisbon, Lisbon, Portugal.
2Department of Sports Medicine, Norwegian School of Sport Sciences, Oslo, Norway.

The study was approved by the Review Board of the University of Lisbon, Faculty of Human Kinetics. This study is part of the research project “Effects of Biomechanical Loading on the Musculoskeletal System in Women During Pregnancy and the Postpartum Period” (PTDC/DES/102058/2008), supported by the Portuguese Foundation for Science and Technology. This study was also supported by the International Society of Biomechanics Dissertation Grant. The authors certify that they have no affiliations with or financial involvement in any organization or entity with a direct financial interest in the subject matter or materials discussed in the article.

Address correspondence to Dr Patrícia Mota, Faculdade de Motricidade Humana, Universidade de Lisboa, Estrada da Costa, Cruz Quebrada 1495-688 Lisboa, Portugal. E-mail: patimota@gmail.com
Published: Journal of Orthopaedic & Sports Physical Therapy, 2015 Volume:45 Issue:10 Pages:781–788 DOI: 10.2519/jospt.2015.5459

Journal of Women’s Health Physical Therapy:
Spring 2005 – Volume 29 – Issue 1 – p 11–16
Research Study

http://www.jospt.org/doi/abs/10.2519/jospt.2015.5459

Post Surgery: Knee Rehabilitation

PEER REVIEWED BY THE AMERICAN CHIROPRACTIC REHABILITATION BOARD

Effects on Athletic Performance with Three Seperate Injuries and Three Surgeries Over a 16 Year Period

By: Robert Pruni, D.C.,
3035 Five Forks Trickum Road
Lilburn, GA 30047
www.flexbuilding.com
Phone: 404-831-1400

Case Study

A blow out of the knee is what is referred to as an unhappy triad, terrible triad, horrible triangle or O’Donoghue’s triad. It is an injury to the anterior cruciate ligament, medial collateral and medial meniscus. Originally, O’Donoghue’s triad did not include the lateral meniscus, which is an oddity among athletes as there is always an associated tear to the lateral meniscus with a me- dial meniscus tear. Tears to the lateral meniscus are far more common than the medial meniscus with sprains to the ACL. The skeletal com- ponents in the unhappy triad are the patella, femur and bia. There are no muscles directly involved in this injury; however, muscular atrophy takes place quickly in the quadriceps, and is a necessary component in rehabilitation as well as addressing the neurological components of proper motor coordinated patterns and the effect of Neurological Crossover. 2) The unhappy triad we are discussing, which you will see in this case study as well as many other cases, is very rare and typically caused by a compression with torsion. The injuries damage both femurobial compartments as well as the ACL and the PCL. Therefore, it has been suggested by Friden T, Zatterstrom R, Lindstrand A, Moritz U (1995) that this entity should be replaced by the “unhappy compression injury.” The medial collateral ligament, lateral collateral ligament, the posterior cruciate ligament and the anterior cruciate ligament are the four primary ligaments of the knee.

Symptoms associated with the unhappy triad are pain in the affected knee with an inability to move the knee through its full range of motion.

The affected knee has soreness and swelling.

The affected knee will also catch or lock. There is a sensation of the knee “giving out” and instability with twisting or side to side movements. Often, there is a swelling behind the knee of the popliteal bursa or a Baker’s cyst. This is not a true cyst as communication with the synovial sac is often maintained.

History

Patient is a 34 year old male, high level athlete: Various sports, Body Building, Competive obstacle running and rugby.

This case study is about my own knee, and the initial damage that occurred as well as the effects on high level athletic performance 16 years following the first ACL reconstruction to the right knee. The injury occurred while jumping a bike in motocross. The bike was approximately 15’ in the air. The bike pulled back too far and I let go of the bike; I fell from the 15’ height landing with my body moving forward. Meanwhile, my leg hit the ground hyper-extending the leg in a Coxa varus genu valgus posi on with 100 degrees of counterclockwise rotation. I was on my stomach with my lower leg almost perpendicular to my femur. I rolled to my back and pulled my lower leg back into an in line position. I had no motor use of the lower leg. I noticed the effusion in the calf which was the size of a football. This is an “unhappy compression injury”.

Clinical Presentation

An ACL reconstruction was performed following an MRI, which showed the complete tear of the ACl, MCL and LCL with significant tears to the medial and lateral meniscus anterior and posterior. The post-surgical care goal, was to improve the ROM. This care started immediately following surgery in the hospital attempting to bend the leg 5-10 degrees. The Quality of pain following the surgery was different from the injury, because the symptoms resulting from the injury occurred with any movement and produced a sharp pain that was nauseating. The pain following the surgery was throbbing, deep and constant; it radiated with deep achiness into the calf. Stiffness was constant and was relieved temporarily with ice. Percocets were prescribed which were discontinued after the first day due to nausea. The Timing of the symptoms was constant with deep achiness and stiffness due to the reconstruction, which required extreme effort to move.

Inspection

Significant atrophy of the right calf and right quadriceps in particular the Vastus Medialis Oblique following surgery. Edema noted from the medial femoral condyle across to the lateral femoral condyle. The patella not as clearly defined as patella of the non-injured left knee. 3.) Palpation of the medial posterior aspect of the knee is the tendons of the sartoruis, gracilis and semitendinosus. Inflammation is noted in the common insertion of these muscles and localized inflammation of the pes anserine bursa.

Palpation

Edema and sponginess noted in the quadriceps insertion medial and lateral. Edema also palpated in the synovial bursa between the medial head of the gastrocnemius and the semi-membranosus.

Findings

Chiropractic Analysis: Limited knee internal and external rotation and flexion and extension due to post surgical edema. Overactive piri-formis, Inhibited Quadriceps, right gluteal and right hamstring. There is a weakness in the right hip flexor with difficulty performing a one leg straight leg raiser. The patient was able to perform with great effort to 60 degrees.

Muscle Testing: The primary extensors showed weakness. The quadriceps were affected. Nerve Femoral L2, L3, L4. Muscle testing was a 2 and could not perform full ROM. The primary flexor group, the hamstrings, were also affected. Semi-membranousus tibial portion of the sciatica nerve L5, Semitendinousus tibial portion of the sciatic nerve, L5 and biceps femoris bial portion of the sciatic nerve S1.

Orthopedic evaluation

Only ROM testing was performed. Orthopedic testing to the knee was not performed due to post-surgical edema.

Height 5’ 11” Weight 202 lbs BP 122/78 Respiration 12 Pulse 64

Goals

Short term goals: Reduce pain, edema and improve ROM
Intermediate goals: Improve pain free ROM, increase flexibility, Incorporate evidenced based rehabilitation protocols concurrently with CPM and isometric and eventually isokinetic rehab.
Long term goals: Improve not only the extremity ROM with full strength and a one range explosiveness, but also to repair damaged motor coordinated patterns for complex high level athletic activity.

Treatment

The post-surgical care was designed in several phases. The initial phase of treatment was designed to accelerate the post-surgical healing process while maintaining/restoring mobility as much as possible. The second phase was to restore joint stability, and finally to improve the functional strength of the injured leg to pre-injury levels. For twelve days following surgery, my treatment consisted of a cryocuff immobilizer, which I removed three times a day to perform flexion/extension exercises with a continuous passive motion machine. The first day goal was to passively move the knee joint through a 15 ̊ arc. Each day, the range motion goal was increased 10 ̊ until 115 ̊ of motion could be accomplished passively. By day 12, with daily treatment, most of the edema and inflammation were under control and the incision was closed.

The next step in my functional recovery was to begin phase one of rehabilitation. Instead of returning to my own rehabilitation clinic, I decided to obtain treatment at a physical therapy sports medicine cen- ter to see if I could pick up a few physical therapy tricks as well as introduce them to my FlexBuild- ing program; the mission was accomplished on both accounts.

The experience was a good one. In the begging of phase one, rehabilitation goals were to improve flexibility and proprioception. During the first week, in addition to my Gonstead chiropractic care to my lower back addressing chronic L4 and sacral subluxations with an accessory joint and spatulated transverse process of L5 to the ileum, this stage of care I utilized interferential prior to passive rehabilitation because of the deeper penetration and decreased skin resistance. The joint was still stiff; therefore, 30-50Hz was utilized. We followed up with multiple angle isometrics submaximal and maximal. Concurrently, I did reflex inhibition at the mid range of motion with antagonistic contractions to the quadriceps and hamstrings.

During the second and third weeks, I commenced short arc isokinetics submaximal and maximal and a modified FlexBuildingTM program, which was mid to 75% R.O.M. against gravity to light concentric modified FlexBuildingTM. In comparison to other proprioception neuromuscularfacilitation (PNF) types of stretching and rehab, the difference is that instead of the usual “stretch-relax-stretch” or “stretch-isometric contraction- stretch further” method of improving range of motion and proprioception, FlexBuildingTM disarms the splinting guarding mechanism by sending sensory afferent-stimuli to the thalamus and processing motor efferent with the immediate agonistic contraction. This full R.O.M. stretch with a full R.O.M. contraction results in improved flexibility, tone, and stabilization throughout the entire length of the muscle.

As I entered my fourth week of phase one rehab, I was already at 160 ̊ straight leg hip flexion. I was able to resist from 100 ̊ hip flexion pushing through extension to zero ̊ with partial resistance and minimal discomfort.

Other types of rehab added to the program included: balancing on the wobble board, eyes open and closed, once for 30 seconds, which could be achieved with the eyes open. I was also doing light leg press, one leg and then two starting with 8-12 reps for three sets. The sets required me to use one leg with 20lbs and two legs with 50lbs. A continual increase in weight and reps was progressed to train muscular en- durance.

The Zinovie technique commenced first because of the initial fatigue. As endurance increased, the Pyramid method was utilized to increase strength and move forward toward returning to athletic activity. Movements utilized were leg press, seated leg curl, leg extension and squats. Step ups were added concurrently which were not as difficult as a step down, backward striking the heel of the left leg. Into the fourth week of rehab, this increased functional strength the most. Strength was better with the body weight movement of stepping up and down, forward and backward with a backward step down to the heel rather than when the strength was tested immediately following with 50-80lbs high rep with 3 sets of 50 reps Leg Press. As the weeks progressed, the high rep endurance was added at the end of the Pyramid with super sets of pistol squats.

One interesting observation I made, is that I did not work during my rehabilitation process and had access to four chiropractors in my office. I had forced myself to go into my office to get adjusted following PT as I was fatigued and simply could not do it. My knee ROM therapy was always better on Lumbar L4 and sacral adjustment days. No clinical data was obtained and it was merely an observation.

4.) The core was also addressed. Weakness or lack of sufficient coordination in core musculature can lead to less efficient movements, compensatory movement patterns, strain, overuse, and injury or re-injury.

5.) Phase III, Advanced rehabilitation: Characterized by restoring normal joint kinematics, ROM, and continued improvement of muscle performance. The primary goals to be addressed during this phase are restoration of muscular endurance and strength, cardiovascular endurance, and neuromuscular control/ balance/proprioception. Criteria for progression to phase IV include: strength > 70-80% of non-involved (NI) side and demonstration of initial agility drills with proper form (e.g. avoidance of medial collapse3 5 of bilateral lower extremities, coordinated and symmetrical movement of all extremities, controlled movement of entire body).

Progression was better than anticipated. However, there was one problem. The plan that we designed failed to consider neurologic crossover.

Neurologic crossover can produce positive or negative effects. Feeding information to the side opposite the injured side, will gain benefit to the injured side by neurologic crossover. Rehabilitating opposite the injured side is important during not only phase one of rehab, but also phase one of initial healing to decrease reflex inhibition. Since positive information can be programmed through rehab therapy, conversely, negative information can also be programmed (Order).

To put this into practical context, I began to note the diminished functional capacity, motor coordination and range of motion in my non-injured leg.

To understand this effect, we must recognize that during an injury and recovery, if a non-injured area opposite the injured area is not trained, an engram resulting from neurological-crossover can develop, mimicking the injured area. “All motion, pathological or functional, can be represented by a neurological organization of a pre-programmed pattern of muscular activity devised for a specific purpose called an “engram.” The law of facilitation states that once an impulse has passed through a certain pathway to the exclusion of another, it will tend to take the same course in the future. Resistance in the path diminishes each time the impulse traverses this path. This is how basic motor learning or neural habits are formed. By nature, once an engram is developed, each additional excitation causes exactly the same activity through facilitation.

This concept can apply not only to the agonist/active muscle, but also to the facilitation of inhibition to antagonistic muscle groups. Once that pathway has been established, the transmission and end resulting motion or action becomes easier to perform and maintain. (Petruska) “Therefore, because of neurologic crossover, an engram developed in the non-injured leg. We discovered this developed in the non-injured leg almost eight weeks post-surgery.”

At this point, we were addressing the injured leg with an adequate warm-up. After which we proceeded with knee FlexBuildingTM (therapists resisted leg extension/leg curl) as well as hip abductor, adductor, and hamstring FlexBuildingTM. My straight leg hamstring FlexBuildingTM had improved to 170 ̊ after rehab. Since my goal was to return to serious weight training, I also wanted to start stimulating the “good leg.”

After a few warm-ups, I was shocked to discover that I could only straight leg raise my non-injured leg to 100 ̊ before the stiffness began to tilt my pelvis. There was no pain, but my “good side” had diminished performance capacity in comparison to the injured or “bad” side. It would appear that a negative engram had developed as a result of neurological crossover after only eight weeks. Looking back, this could have been easily avoided with minimal rehabilitation effort and focus on the non-injured side during my recovery. If this had been done, a positive engram could have just as easily been programmed, which may have diminished my recovery time. Instead, by neglecting the non-injured side for eight weeks, a negative engram resulted requiring some additional rehab to the non-injured side and a more prolonged recovery time for the injured side.

Based on these findings, remember to rehab both sides physiologically. (FlexBuilding Healthy Exercising Guide Book, Robert Pruni, Doc Talk pgs. 7-9)

At eight months post-surgical rehabilitation, there was still an 1 1⁄2″ of atrophy in the calf as well as 2” of atrophy in the quad measuring 3” above the knee. Despite the atrophy, the 40 yard dash returned to 4.9 seconds which was the pre injury time and a full squat below parallel of 405lbs and 3⁄4 squat of 595 lbs. 40” box jump both feet returned as well as a 20” box jump single leg either side was the same with no dysfunction noted. A Single leg squat to the surgical right leg and non-injured left leg were within normal limits.

It was about this time that a second injury to the ACL occurred during a skateboarding accident while doing an eight foot ramp drop in. A second surgery was performed and the rehabilitation process started again. Following this rehabilitation, the results were about the same. Athletic performance returned to the same high level. Some permanent atrophy was noted to the leg following two ACL reconstructions, but in the 15 years following there were no functional deficits noted. Athletic performance ironically and gradually continued to improve over the next 15 years. Placements in obstacle racing went from the top 15% in the athletes 20’s and 30’s, to the top 1⁄2% racing in the elite heats in the late 40’s following two ACL reconstructions.

A third injury to the same knee required a third surgery at age 48, with a crush injury to the femoral condyles, which included tearing of the medial and lateral meniscus, and tears to the ACL, PCL, medial and lateral collateral ligaments. The orthopedist described the meniscal tears as shredded.

Surgery was performed in late November and rehabilitation commenced immediately. Similar protocols were followed, and the patient competed in the qualifiers for American Ninja Warrior in May, five and one half months post-surgery.

Post rehabilitation results

All athletic performance activity, utilizing both legs, showed no functional deficit. During the rehabilitation and training process, a single leg squat could not be performed. A single leg box jump as well, could not be performed at six month post-surgery despite competing at ANW and another OCR and placing first. Training continued for another 4+ months trying to improve on the single leg strength. Almost one year post third surgery at age 49: Full squat below parallel 405lbs. A heavier 2/3 squat was not performed. The patient with continued high intensity training, still cannot perform a single leg squat. The non-injured left leg has the same 20” single leg box jump as 16 years ago. At one year post-surgical the right leg has only a single leg box jump of 7” with great effort.

Conclusion

The Neurological Crossover appears to have positive and negative engrams that can result. After 15 years, no adverse functional deficits were noted from two prior knee surgeries. Following a third surgery to the same knee, at almost one year post-surgery, it appears age and degenerative arthritic changes have little effect on the athletic performance when utilizing the entire body(two leg squat and box jumps the same as 16 years ago.) It appears that the continued decreased single leg function, is a result of disrupted motor patterns when the continually damaged side has to perform without the aid of the normal motor patterns of the opposite side. This will be a fascinating ongoing case to see, if the single leg function can return to normal with a continual rehab to both sides.

References

1.)Shelbourne K, Nitz P (1991). “The O’Donoghue triad revisited. Combined knee injuries involving anterior cruciate and medial collateral ligament tears”. Am J Sports Med 19 (5): 474–7
2.) Friden T, Zatterstrom R, Lindstrand A, Moritz U (1995) “Compression or distraction of the anterior cruciate injured knee. Variations in injury pattern in contact sports and downhill skiing” Knee Surg Sports Traumatol Arthrosc 3 (3): 144-7
3.) Hoppen eld, Stanley, Physical Examina on of the Spine and Extremi es, Appleton- Century-Cro s pp 181-182
4.) Michael Fredericson, MDa, *Tammara Moore, PTb, Muscular Balance, Core Sta- bility, and Injury Preven on for Middle and Long Distance Runners
5.) Michael P. Reiman, PT, DPT, OCS, SCS, ATC, FAAOMPT, CSCS, INTEGRATION OF STRENGTH AND CONDITIONING PRINCIPLES INTO A REHABILITATION PROGRAM

Tarlov Cysts

PEER REVIEWED BY THE AMERICAN CHIROPRACTIC REHABILITATION BOARD

Dr. Gary Tennant, Chiropractic Physician
Case Study Submission for the American Chiropractic Rehabilitation Board

Subject: Patient: RG is a 79-year-old female that has had Tarlov Cysts confirmed on her MRI.

Her presenting chief complaints in 2015 being numbness in her hip and legs. On her intake form she listed the symptoms as such:

  1. Sciatica Tingling, burning sensation in the left and right leg and feet were rated as an 8/10 on left and a 6/10 on the right
  2. Numbness in the leg that radiates down to the outer toes is rated as an 8/10 on the left and 6/10 on the right
  3. Pain in lower back 2-3/10
  4. Leg /Foot/ Toe Cramps 9/10 when they occur but have almost gone with away with this patient placing a bar of soap in the bed
  5. Bladder and bowel prolapses eight and six years respectively both of which have been treated conservatively by specialists
  6. Excruciating eye pain rated as a 10/10 sometimes. She has been treated by an ophthalmologist with limited success.

HPI (history of present illness)

PQRST

Provocative/palliative – precipitating/relieving- This patient’s pain is aggravated by walking. She also states that although she does have discomfort, her main complaints are the numbness and loss of balance.

Quality/quantity – character. Numbness and pain. Primarily into the hip on the left but also feels it on the right.

Region – location/radiation. Both hips and posterior thighs. The symptoms are worse on the left. Both feet feel numbness again with the left being worse.

Severity – constant/intermittent. The symptoms are rated an 8/10 on the right and 6/10 on the left. They are described as intermittent depending on in which activity she is engaged.

Timing – onset/frequency/duration. They are described as intermittent depending on in which activity she is engaged. She first started having symptoms twelve years ago, she thought is was sciatica.

I saw Ruth originally ten years ago. X-rays showed some degeneration and spondylolisthesis. Ruth over the years has had flexion- distraction manipulation, spinal decompression and instrument adjustments. She has also had a variety of therapies like interferential current, hot moist packs and ultrasound. These treatments sometimes seemed help but other times not very much. Nonetheless, her symptoms have not progressed dramatically. I have seen case studies where this can be the case. Sometimes a condition not getting worse is a success, albeit not the most fulfilling from a patient or practitioner’s viewpoint. I ordered an MRI which came back with the diagnosis of Tarlov cysts.

At the time I was unfamiliar with this disease. As I researched it I found out that Tarlov cysts were a fairly common finding. The quoted statistics are between 5-8% of the general population has these cysts. However, most are asymptomatic. If a practitioner like myself does some quick math, undoubtedly we have had hundreds of patients that have these cysts to one degree or another. I have had 12,000 patients over my 30-year career in chiropractic. If 5% of them have had Tarlov cysts, then the math works out to about 600 of them having this condition. I am only aware of two of my patients having the diagnosis. Unfortunately, this means that about 598 have had these and I was unaware.

Referral to a neurosurgeon: After the MRI results showed these cysts and the radiologist wrote the diagnosis, I immediately referred Ruth to a local neurosurgeon. I asked all parties if I could have permission to attend the consultation between Ruth and the neurosurgeon. I accompanied Ruth and her husband when she consulted with Dr. Martin Leukin. Dr. Leukin stated that there was no treatment for Ruth’s condition. Apparently when these cysts are operated on they refill with fluid. So he recommended conservative treatment, so the treatment fell back on me.

Anatomy and physiology: Tarlov cysts are also known as perineural or sacral nerve root cysts. They are dilations of the nerve root sheaths and are abnormal sacs filled with cerebrospinal fluid that can cause a progressively painful radiculopathy (nerve pain). They are located most prevalently at the S2, S3 level of the sacrum. They are best viewed in an MRI image or CT scan. Plain films do not pick demonstrate this abnormality due the fact that water is penetrated by the radiation of regular cathode x-rays. In that by definition water is incompressible it means that when there is fluid inside the nerve sheath, either the nerve is going to compress or the sheath will expand. This is the essence of the pathophysiology associated with Tarlov cysts.

With that mechanism known the clinical question becomes what nerves are involved and to what extent. The sacral nerve roots S2, S3 and S4 have a distribution with a dermatomal pattern into the posterior thigh and pudendal region. The viscera affected are the bladder, bowels and reproductive areas. Ruth actually has had both a prolapsed uterus and bowel, consistent with the viscera innervated by the S2-4 nerve roots.

Usually Tarlov cysts cause no symptoms and are found incidentally on magnetic resonance imaging (MRI) studies done for other reasons.

However, in some cases, the cysts expand, putting pressure on the affected nerve root. The resulting compression and nerve pressure may include sharp, burning pain in the hip and down the back of the thigh, possibly with weakness and reduced sensation all along the affected leg and foot. Tarlov cysts sometimes enlarge enough to cause erosion of the surrounding bone, which is another way they may cause back pain or sacral pain.
Mayoclinic.com

Tarlov cysts are a fairly common finding in the general population. According to radiopaedia the incidence is 5% of the population. However, in an informal survey of some of my colleagues, very few have ever heard of this disorder much less attempted to treat it. I called Dr. John Aikenhead who is a chiropractic radiologist who reads films for several MRI centers, he stated that he sees two or three films per day in which the patients’ have these cysts. This informally confirms that they are not rare and perhaps should be better understood by modern chiropractors. The treatment options listed on the Mayo Clinic website as well as the Tarlov Cyst Disease Foundation list potential treatment options from TENS Units to alkaline diet to surgery. However, none of them list rehabilitation as a treatment choice nor do they say anything against rehabilitation or exercises.

Tarlov felt that hemorrhage into the subarachnoid space caused accumulations of red cells which impeded the drainage of the veins in the perineurium and epineurium, leading to rupture with subsequent cyst formation. Four out of the seven patients in Tarlov’s 1970 article had a history of trauma. Because many of the patients with perineural cyst in their series did not have histories of trauma, Fortuna et al. believed that the perineural cysts were congenital, caused by arachnoidal proliferations within the root sleeve.

Tenderness on firm pressure over the sacrum may be present. Commonly, the symptomatology is intermittent at its onset and is most frequently exacerbated by standing, walking and coughing. Bed rest alleviates the discomfort.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2989515/

REFERENCES
1. Tarlov IM. Perineural cysts of the spinal nerve roots. Arch Neural Psychiatry. 1938;40:1067–74

Interestingly, Tarlov cysts are not mention in the radiology textbook authored by Terry Yochum.

Another resource is the National Institute of Neurological Disorders and Stroke; they have the following information:

What are Tarlov Cysts?
Tarlov cysts are sacs filled with cerebrospinal fluid that most often affect nerve roots in the sacrum, the group of bones at the base of the spine. These cysts (also known as meningeal or perineural cysts) can compress nerve roots, causing lower back pain, sciatica (shock-like or burning pain in the lower back, buttocks, and down one leg to below the knee), urinary incontinence, headaches (due to changes in cerebrospinal fluid pressure), constipation, sexual dysfunction, and some loss of feeling or control of movement in the leg and/or foot. Pressure on the nerves next to the cysts can also cause pain and deterioration of surrounding bone. Tarlov cysts can be diagnosed using magnetic resonance imaging (MRI); however, it is estimated that the majority of the cysts observed by MRI cause no symptoms. Tarlov cysts may become symptomatic following shock, trauma, or exertion that causes the buildup of cerebrospinal fluid. Women are at much higher risk of developing these cysts than are men.
(Comment: Ruth has been treated for eye pain. She has not had an MRI of other body parts, in theory they can occur anywhere. It is hypothesized that Tarlov cysts might negatively affect cerebral spinal pressure. This could cause a myriad of eye symptoms.
Is there any treatment?

Tarlov cysts may be drained and shunted to relieve pressure and pain, but relief is often only temporary and fluid build-up in the cysts will recur. Corticosteroid injections may also temporarily relieve pain. Other drugs may be prescribed to treat chronic pain and depression. Injecting the cysts with fibrin glue (a combination of naturally occurring substances based on the clotting factor in blood) may provide temporary relief of pain. Some scientists believe the herpes simplex virus, which thrives in an alkaline environment, can cause Tarlov cysts to become symptomatic. Making the body less alkaline, through diet or supplements, may lessen symptoms. Microsurgical removal of the cyst may be an option in select individuals who do not respond to conservative treatments and who continue to experience pain or progressive neurological damage.

What is the prognosis?

In some instances, Tarlov cysts can cause nerve pain and other pain, weakness, or nerve root compression. Acute and chronic pain may require changes in lifestyle. If left untreated, nerve root compression can cause permanent neurological damage.

http://www.ninds.nih.gov
National Institute of Neurological Disorders and Stroke

In that I was unfamiliar with how patients with Tarlov cysts generally present I searched f for other case studies to see if the symptoms were similar.

Another patient (not Ruth):

This 47-year-old woman presented with a 1-year history of progressive, intractable sacrococcygeal pain and numbness as well as dysesthesias of both feet. At the time, she was becoming increasingly incapacitated, although she was still able to work as a flight attendant. She rated her pain as 6 of 10 possible points on a visual analog scale. Her symptoms were aggravated by standing, walking, lifting, and climbing stairs as well as by coughing. Pain was rapidly relieved by recumbency. She had a history of renal calculi. She had no bowel or bladder dysfunction, and sensation for urination and defecation was normal.

 

Anatomy and Physiology:

Structure.—Each typical spinal nerve contains fibers belonging to two systems, viz., the somatic, and the sympathetic or splanchnic, as well as fibers connecting these systems with each other16

1. The somatic fibers are efferent and afferent. The efferent fibers originate in the cells of the anterior column of the medulla spinalis, and run outward through the anterior nerve roots to the spinal nerve. They convey impulses to the voluntary muscles, and are continuous from their origin to their peripheral distribution. The afferent fibers convey impressions inward from the skin, etc., and originate in the unipolar nerve cells of the spinal ganglia. The single processes of these cells divide into peripheral and central fibers, and the latter enter the medulla spinalis through the posterior nerve roots.17

2. The sympathetic fibers are also efferent and afferent. The efferent fibers, preganglionic fibers, originate in the lateral column of the medulla spinalis, and are conveyed through the anterior nerve root and the white ramus communicans to the corresponding ganglion of the sympathetic trunk; here they may end by forming synapses around its cells, or may run through the ganglion to end in another of the ganglia of the sympathetic trunk, or in a more distally placed ganglion in one of the sympathetic plexuses. In all cases they end by forming synapses around other nerve cells. From the cells of the ganglia of the sympathetic trunk other fibers, postganglionic fibers, take origin; some of these run through the gray rami communicantes to join the spinal nerves, along which they are carried to the blood vessels of the trunk and limbs, while others pass to the viscera, either directly or after interruption in one of the distal ganglia. The afferent fibers are derived partly from the unipolar cells and partly from the multipolar cells of the spinal ganglia.18
http://www.bartleby.com/107/208.html

The mid and lower sacral nerve root distribution is more in the posterior portion of the thighs and medially. There are branches that also innervate the pudendal region. Visceral innervation includes the reproductive organs, bladder and lower intestines. Tarlov cysts are a definite potential source of nerve root compression. However, in that they affect the sacral nerve roots there is a pattern of symptoms that differs from more common radiculopathies found in S1 nerve root lesion or L5 nerve root pathologies.

Although originally believed by Tarlov to be asymptomatic lesions, these cysts, when present in the sacral neural canal and foramina, have since been found to cause a variety of symptoms, including radicular pain, paresthesias, and urinary or bowel dysfunction.

Dermatomal distribution of the lower extremities
Dermatomal distribution of the lower extremities
Visceral Innervation from S2-4
Visceral Innervation from S2-4
underside


Pathophysiology:

Notice the swollen sacral nerve root, this photo was taken during a surgery to drain the cysts. This method generally has not offered good long term results.
Notice the swollen sacral nerve root, this photo was taken during a surgery to drain the cysts. This method generally has not offered good long term results.

General physical considerations

Ruth is a 79-year-old active female. She is 5’ 6” and weights 124 lbs. Her BMI is calculated at 20.0. Her blood pressure was measured in a seated position at 128/68 with a pulse rate of 74 and a respiration rate of 16. She is still working twenty hours a week. Her most strenuous activity is golf occasionally in the summer and she walks frequently. She is very active with her grandchild and travels frequently with her husband who is 85 years old.

Physical Examination (Pre rehabilitation):

Individual Position Examination– (Format AMA Guidelines to Impairment 5th Edition page 375)
Standing Posture
Scoliosis – Slight lean to the left
Lordosis – Slightly flattened lumbar curve
Kyphosis – None
Palpation
Muscles- Paraspinal muscles were non tender and symmetrical
Tenderness – there was slight tenderness to deep posterior to anterior pressure at the mid to lower sacral region. The coccyx was non tender
Gait – this patient has a normal gait. Her speed of gait is very good for her age.
Range of Motion – see table below
Muscle Strength
Heel-toe. The patient was able to raise up on her toes but needed to hold onto a rail for balance. Heel walking was normal.
Recumbent Supine Neurological
Sensory testing showed a numbness over L4, L5 and S1 dermatomes on both side with the left feeling more numbness than the right
Reflexes
Patellar – 2+ bilaterally, Achilles – 2+ bilaterally, Medial Hamstring – 2+ bilaterally
Strength was graded as 4/5 for the tibialis anterior, quadriceps, and hamstrings.
SLR – Normal with 80 degrees
Recumbent Prone Nerve Tension
Femoral Nerve Stretch was normal.
Individual Position (Post Rehab Program) Examination was essentially the same as the previous exam
Standing Posture
Scoliosis – Slight lean to the left
Lordosis – Slightly flattened lumbar curve
Kyphosis – None
Palpation
Muscles- Paraspinal muscles were non tender and symmetrical
Tenderness – there was slight tenderness to deep posterior to anterior pressure at the mid to lower sacral region. The coccyx was non tender
Gait – this patient has a normal gait. Her speed of gait is very good for her age.
Range of Motion – pre and post ROMs are shown in the table below
Muscle Strength
Recumbent Supine Neurological
Sensory testing showed a numbness over L4, L5 and S1 dermatomes on both side with the left feeling more numbness than the right
Reflexes
Patellar – 2+ bilaterally, Achilles – 2+ bilaterally, Medial Hamstring – 2+ bilaterally
Strength was graded as 4/5 for the tibialis anterior, quadriceps, and hamstrings.
SLR – Normal with 82 degrees. This is a slight improvement.
Recumbent Prone Nerve Tension
Femoral Nerve Stretch was normal.

Range of Motion Testing:

Motion Tested Measured ROM
9/14/15
Normal ROM Reference Percent of Normal Deficit ROM
10/12/15
Percent of Normal
LUMBAR SPINE: We used a dual inclinometer method for measuring the range of motion of the lumbar spine as outlined in the AMA Guides to Impairment:
Flexion 35⁰ 60⁰ 58% 42% 37⁰ 62%
Extension 6⁰ 25⁰ 24% 76% 12⁰ 50%
Right Lateral Bending 19⁰ 25⁰ 76% 24% 23⁰ 92%
Left Lateral Bending 21⁰ 25⁰ 84% 16% 22⁰ 88%
Lumbar Impairment 11% If this patient was to be given an impairment according to the AMA Guides to Impairment Range of Motion Method (5th Edition) 9%

Motion palpation: There was a hypermobility in the posterior to anterior direction on L4 on L5. There were slight areas of hypomobility in both sacroiliac joints, although her age of 79 might attribute greatly to this finding. Her hip range of motion in the Fabere’s position was graded as slightly restricted. This is of significance because a lack of motion in the hips can create and hypermobility on the lumbar spine as a type of compensation pattern.

Overhead squat assessment was evaluated and was essential normal. Therefore, Ruth was started on a program that mostly addressed the other functional tests (like endurance and balance as outlined below).

X-rays and MRI imaging:
Tarlov cysts may also cause diffuse poorly localized sacral pain due to pressure on adjacent periosteum and joint capsules and can also result in sacral insufficiency fractures from erosion of the sacrum. Thoracic Tarlov cysts have even been noted to cause angina-like symptoms
Initial plain radiographic examination may reveal Tarlov cysts causing erosion of the sacrum, bone scalloping, or a rounded paravertebral shadow

Below is an AP view of the lumbar spine. The first image is considered a normal or ideal film; the second one is a film of this patient.
AP view of the lumbar spine. The first image is considered a normal or ideal film; the second one is a film of this patient.
X-rays of the LUMBAR SPINE 09/03/2015
X-rays of the LUMBAR SPINE 09/03/2015

Findings: Seven views of the lumbar spine were obtained, including flexion and extension views. There is a Grade 1 Anterolisthesis of L4 on L5. This is slightly increased on flexion views. It is similar in appearance on extension views. Vertebral body heights are maintained. Alignment is otherwise normal. Narrowing of the L5-S1 intervertebral disc space. Moderate facet joint arthropathy of the lower lumbar spine.

Radiologist Report

There is significant translation forward at some of the segments listed above. Perhaps with extension stabilization there would be less and that might cause less nerve root traction and help minimize the myriad of symptoms that are related to the spine. Analysis performed by Gary Tennant, D.C. using Posture Ray Software
There is significant translation forward at some of the segments listed above. Perhaps with extension stabilization there would be less and that might cause less nerve root traction and help minimize the myriad of symptoms that are related to the spine. Analysis performed by Gary Tennant, D.C. using Posture Ray Software
Flexion Extension (Lateral) Views:
Flexion Extension (Lateral) Views

(Analysis performed by Gary Tennant, D.C. using Posture Ray software)

There are angulation abnormalities as well as translation abnormalities. These would be ratable impairments according the AMA Guide to the Evaluation of Permanent Impairment (5th Edition).
There are angulation abnormalities as well as translation abnormalities. These would be ratable impairments according the AMA Guide to the Evaluation of Permanent Impairment (5th Edition).
impressions-assessment
MRI report stated: Grade I anterolisthesis L4-L5 with approximately 3 mm of slippage. There is a moderate sized right and two smaller left sacral Tarlov’s cyst. There is also a small pernineural cyst in the left L5-S1. (Interestingly Ruth symptoms are more pronounced on the left than the right even though the cyst on the right is larger)
Lateral View of the Magnetic Resonance Image. Note the huge white spot which is the fluids inside these cysts.

MRI report stated: Grade I anterolisthesis L4-L5 with approximately 3 mm of slippage. There is a moderate sized right and two smaller left sacral Tarlov’s cyst. There is also a small pernineural cyst in the left L5-S1.<br />
(Interestingly Ruth symptoms are more pronounced on the left than the right even though the cyst on the right is larger)

Physical Performance and Functional Evaluations:

Shear Test was positive
The shear test has the patient prone with upper body supported on the table and feet on the ground. Posterior to anterior pressure is applied to the spinous processes. Then the patient lifts their legs up (toward the ceiling) while pressure is reapplied. If pain lessens then that means that there is instability and extension rehab is warranted

Side Bridge Endurance Test was tested at 32 seconds on the left and 36 seconds on the right (I used Liebenson’s Guide that less than 45 seconds was considered dysfunctional.
Rehabilitation program to use stabilization training using side bridge exercises. She was also performed stretches of her hip flexors.

Trunk Extensor Endurance Test was measured at 42 seconds (less than 60 is considered dysfunctional
Rehabilitation program to facilitate / strengthen the trunk extensors, gluteus maximus and hamstrings

Trunk Flexor Endurance was tested at 35 seconds (less than 50 seconds is considered dysfunctional).

The 2 Minute Step in Place test is part of the Senior Fitness Test Protocol used to test aerobic endurance, and is designed to test the functional fitness of seniors. This test is performed as an alternative to the 6 minute walk test for people who use orthopedic devices when walking, as well as in the case of people who have difficulty balancing.

Equipment required: tape for marking the wall, stopwatch, wall.
Procedure: The subject stands up straight next to the wall while the level corresponding to midway between the patella (knee cap) and iliac crest (top of the hip bone). The subject then marches in place for two minutes, lifting the knees to the height of the tape. Resting is allowed, and holding onto the wall or a stable chair is allowed. Stop after two minutes.

Scoring: Record the total number of times the right knee reaches the tape level in two minutes. Below is a table showing the recommended ranges for this test based on age groups (from Jones & Rikli, 2002).

Step up test scoring:

step-up

Ruth scored 82 (normal for this age group is 68-100), Ruth’s score is within the normal limits but certainly could be improved.

Endurance Training: The goals for Ruth was to improve core stability and endurance and to increase her stability on one legged stance

Lab Tests:

I did not order any outside lab tests in that the MRI is considered the definitive diagnostic procedure to use with Tarlov cysts. However, I did do a urine pH test to see if her body perhaps was acidic. Her morning urine pH was measured at 6.5. Alkaline diets are surprisingly a recommendation for treating Tarlov cysts as listed on the Tarlov cyst.org website. However, I did not instruct Ruth to start on an alkaline diet but will once this study is completed.

Differential Diagnosis

First, Tarlov cysts have a potential, but not an actual, communication with the spinal subarachnoid space and thus may exhibit delayed filling or lack of filling on myelographic examination. Meningeal diverticula, on the other hand, are in free communication with the spinal subarachnoid space and thus usually fill initially during myelography. Second, Tarlov cysts occur at or distal to the junction of the posterior nerve root and the DRG, usually in the sacral region. In comparison, meningeal diverticula occur proximal to the DRG and develop throughout the vertebral column, most often at thoracic levels. Last, Tarlov cysts occur in the perineurial space and have at least part of their wall composed of nerve fibers or ganglion cells. Conversely, meningeal diverticula have a wall lined with arachnoid mater, with or without a dural covering, and do not contain nerve fibers. Moreover, Tarlov noted that perineurial cysts, although often asymptomatic, were capable of producing clinical symptoms. whereas meningeal diverticula were more often asymptomatic. Tarlov also distinguished perineurial cysts from “unusually long arachnoidal prolongations over nerve roots,” which he asserted were of no pathological significance.

But probably the focus for a chiropractor is to use Tarlov cysts as a differential diagnosis for unrelenting sacral pain with nerve root symptoms. Less likely would be to consider these perineural cysts in the event that cauda equinae is presented in a patient.

http://journal.frontiersin.org/article/10.3389/fsurg.2014.00049/full
http://journal.frontiersin.org/article/10.3389/fsurg.2014.00049/full
normal-root-sheath

Patient Management

The following Outcome Assessment and Functional Tests to evaluate the results of treatment:

  1. Bournemouth Questionnaire: The 7 items of the Bournemouth score includes (1) pain intensity, (2) effect of work on pain, (3) effect of pain on social activity, (4) anxiety, (5) depression, (6) ability to carry out normal activity, (7) and ability to control pain.
  2. Lower Extremity Questionnaire
  3. Spinal Stenosis Questionnaire
  4. AMA Guide to Impairment Range of Motion Method
  5. The Shear Test
  6. Standing Balance Test
  7. Step Up Test
  8. Back Extension Endurance
  9. Trunk (Core) Flexion Endurance
  10. Side Bridge Endurance

Both the single leg standing balance ability and the trunk extensor have been shown to predict future back pain according to Biering-Sorenson as described in Spine Journal 1984;9:106-119 and Hides in Spine Journal 1996;21:2763-2769.

Rehabilitation and Exercises:

Exercise Purpose Functional Deficiency Test
Sitting on Exercise Ball Neurological Activation and proprioception of the core group Balance Test (Single leg stand
Ball Curl Up Activation, proprioception, strengthening and increasing endurance of abdominals Abdominal Curl Up endurance
Dead Bugs (Same as above) Back Extension Endurance
Quadraped (Bird Dogs) (Same as above) Back Extension Endurance
Back Extension Activation, proprioception, strengthening and increasing endurance of the back extensors Back Extension Endurance
Clams Part of a four exercise glut max/ med routine Single leg stance and Step up test
Side Lying leg raise (Same as above) Single leg stance and Step up test
Glute Activation Exercises (Same as above) Single leg stance and Step up test
Glute Bridges (Same as above) Single leg stance and Step up test
Side Bridges Proprioception, strengthening and increasing endurance of abdominal and back muscles, particularly the transversus abdominis, rectus abdominis, obliques and QL. Side Bridge Endurance Test
All of the above exercises were done 2 sets of 12 repetitions. Done twice a week for 4 weeks and then a reevaluation was performed
Step ups onto 10” step Increase CV endurance, balance training and to strengthen the glut max, hamstrings and calves Single leg stance and Step up test

Ruth was started on an exercise and rehabilitation protocol for strengthening extensors due to the positive Shear Test. We added some balance exercises due to the diminished time with the one leg balance test. And we added steps up to increase endurance. All of these were measured and considered with her age of 79 being kept in mind. She underwent the rehab program described below twice and week for four weeks for a total of eight rehabilitation sessions.

Cardiovascular training with concentration on strengthening the gluteus maximus– step ups for 10 minutes. She was instructed to step up onto a 10” step and had a rail available for stability.

Nutritional considerations:
In that Tarlov cysts are a fluid swelling, it was considered to prescribe a Curcumin plus other white willow bark and boswelia supplement. The effects of curcumin (turmeric) are said to be anti-inflammatory.
However, this patient has been placed on aspirin therapy to alleviate intense eye pain possibly associated with Tarlov cysts. This eye pain is thought to be due to an increase in cerebrospinal fluid pressure. It certainly is an unusual symptom to be associated with a lower back condition. With this particular patient, it actually became a concern because when she performed extension maneuvers one of the limiting factors was eye pain and pressure.

Patient education/ home care
One legged standing three times a day for two minutes. She was encouraged to continue walking and if possible to walk inclined or declined terrain.

Rationale and considerations for rehabilitation:

There were three reasons why I decided to attempt to get gains through rehabilitation

  1. Ruth was deficient in some standardized test like the one leg standing balance and endurance for back extension
  2. She also has some underlying spondylolisthesis that has some additional slippage as demonstrated on the flexion/ extension films.
  3. In any patient over 50 years old increasing balance and endurance decreases the risk of injuries and falls. Ruth has some balance issues on occasion due to the paresthesia’s in her legs.

Outcome of Care

Assessment /Test Beginning Results Ending Results Changes and comments
Bournemouth Questionnaire 36% 33%
Lower Extremity Questionnaire 16% 16% Unchanged
Spinal Stenosis Questionnaire 46% 44% 5% improvement, not significant
AMA Guide to Impairment Range of Motion Method of the Lumbar spine 11% 9% 2% improvement in an Impairment score
The Shear Test Positive Positive No change
Standing Balance Test Eyes open 8 s 10 s Normal for 70-79 years is 14.2 s There was a gain of 25% which is significant, Ruth will continue to work on this in that balance issue are a huge risk and one her main deficiencies.
Step Up Test 82 86 8% improvement
Back Extension Endurance 42 s 49s There was a significant 17% improvement in this patient’s back extension endurance.
Trunk (Core) Flexion Endurance 35 s 38 s This represents a 9% improvement in core endurance
Side Bridge Endurance
Left side
Right side
32 s
36 s
35 s
38 s
There were asymmetries in the prerehab times of 13% and post rehab of 9%. Both are still considered abnormal in that they are less than 45 and also there is a greater side-side difference of 5%

Conclusion: Mrs. G completed 8 rehabilitation sessions as outlined above. We reexamined her, had her complete the Outcome Assessments and Functional tests. Based on those criteria, we concluded that Mrs. G did not receive significant benefit in what is said to be an “untreatable condition.” She seemed to report less pain on occasion and slight increased functionality as measured by the Bouehemouth. She improved the functional tests such as the one leg balance by the following amounts 2 seconds. The examination showed minimal improvements.

Based on this one case study other practitioners might offer a clinical trial of specific rehabilitation to ascertain the possibility of offering some relief for these type of patients.

Discussion:

There were two benefits that were seen in using a specific rehabilitation protocol with this patient with Tarlov cysts. She improved in her balance and her endurance. In that she has balance and numbness complaints, she would most probably have decreased her risk of falling to some decrease. She also improved her back extension endurance. That improvement might help her to avoid progression of her back pain. However, her main complaints of leg pain and numbness did not change significantly from the beginning of the program to the end.

Dr. Gary Tennant
Chiropractic Physician
386 Forest Blvd.
Park Forest, IL 60466

Addendum:

(I am certain that the reader of this case study are familiar with the exercises that I chose for Ruth’s rehabilitation. I decided as I relooked at each exercise to reference a good source. I kept them in the paper only as an addendum. But I plan on using the following the help teach my staff about these exercises and progression. Gary Tennant, D.C.)

Stuart McGill, professor of spinal biomechanics at the University of Waterloo, Ontario, is one of the world’s leading experts on lumbar research. McGill has identified three exercises referred to as the Big 3 that focus on stabilization. The exercises are often used in clinical populations by those in chronic pain. They put minimal load on the back and focus on endurance. The benefit from any exercise is only as good as the technique applied to the exercise. McGill suggests some very specific techniques to accomplish core stability

http://www.livestrong.com/article/392341-stuart-mcgills-big-three-back-exercises/#sthash.x0SoZTbz.dpuf

Ball Exercises – the patient was told to sit on a ball and move in the different directions to increase core activation and proprioception of the lumbar spine and pelvis.

Ball Curl Up

The curl up varies from a standard crunch. There should be no movement through the lumbar spine. Hands are placed in the small of the back to monitor movement. Elbows are down to begin and elevated as a progression. Maintain the entire spine in neutral, including the neck; lift only the head and shoulders. Compared to a crunch, the curl-up involves very little curl and the upper body and neck stay elongated. There is minimal range of motion. Other progressions involve prebracing the abdominals and deep breathing during the exercise. http://www.livestrong.com/article/392341-stuart-mcgills-big-three-back-exercises/#sthash.x0SoZTbz.dpuf

Dead Bugs for strengthening of the core (2 sets of 12)

Dead Bug How To

  1. Lie on your back with your arms extended in front of your shoulders.
  2. Bend your hips and knees to a 90-degree angle.
  3. Tighten your abs and press your lower back into the floor.
  4. Take a deep breath in.
  5. As you exhale, slowly extend your left leg toward the floor and bring your right arm overhead. Keep your abs tight and don’t let your lower back arch.
  6. Slowly return your arm and leg to the starting position.
  7. Repeat with your opposite arm and leg. Continue alternating

Bird Dog 2 sets of 12

From a quadruped position, one leg is lifted and then returned, followed by lifting the opposite extended arm. To progress, both the leg and opposite arm are lifted. Making a fist can increase the tension in the extended arm. Further progressions involve drawing a square with both the foot and hand simultaneously. The exercise is performed on alternating sides
http://www.livestrong.com/article/392341-stuart-mcgills-big-three-back-exercises/#sthash.x0SoZTbz.dpuf

Back Extensions 2 sets of 12

Gluteus Medius / Maximus Routine

The progression above utilizes an 8″ mini-band to resist the gluteus medius isolated activation, gluteus maximus isolated activation, bridges and potentially a side-stepping circuit for a quick succession of exercises that progress the client from isolated activation to core integration to reactive integration for the glute complex.

http://brentbrookbush.com/gluteus-maximus-activation

Clams -Side lying with a band 2 sets of 12

The clam exercises produced EMG activity between 34-40% for both muscles.  While this is low in comparison to other exercises, the authors did not use resistance during testing.  I would still use this, especially with a resistance band around the thighs, as am early-stage or activation exercise. The authors also compared clams at 30 degrees and 60 degrees of knee flexion and showed no different in gluteus medius activity

DiStefano, L. (2009). Gluteal Muscle Activation During Common Therapeutic Exercises Journal of Orthopaedic and Sports Physical Therapy DOI: 10.2519/jospt.2009.2796

Side Lying Leg Raise-Leg abduction with hip in extension for activation of the gluteus maxami and medii.

Side-Lying Hip Abduction should be used in all people needing glut medius strengthening.  EMG activity was almost 20% higher than the next exercise

DiStefano, L. (2009). Gluteal Muscle Activation During Common Therapeutic Exercises Journal of Orthopaedic and Sports Physical Therapy DOI: 10.2519/jospt.2009.2796

(Prone): Glute Max Activation with band 2 sets of 12

Glute Max Activation:

http://brentbrookbush.com/gluteus-maximus-activation/

(Supine): Glute Bridges 2 sets of 12

How to Perform the Glute Bridge with a band Properly
How to Perform the Glute Bridge with a band Properly

Start by having the patient lying face up on the floor with arms to the side, knees bent, and heels on the ground.  Have them lift the hips off the ground until knees, hips, and shoulders are in a straight line making sure to squeeze the glutes as they reach the top of the movement. All of the weight should be balanced between your shoulders and your feet. The patients knee should flare out to activate the gluteus medius concurrently, after holding for 2-3 seconds, have the slowly lower their hips back to the ground and allow the buttocks and back to slightly touch the ground before completing another rep.

Side Bridges

The side bridge, or plank can be performed from the knees if you have limited strength or ability to engage the abdominal wall. Begin by lying on the right side supported by the right elbow, hip and knee. Using support of the left hand, press up through the hips until you are supporting your body between your elbow and your knees.

http://www.livestrong.com/article/392341-stuart-mcgills-big-three-back-exercises/#sthash.x0SoZTbz.dpuf

Training times begin at 10 second intervals. Build up endurance for stabilization with repeated short bouts, rather than increasing duration. According to McGill, once these are tolerated, progression to a more difficult version of the exercise or other exercises is justified. Bracing, rather than hollowing, during exercise enhances stabilization. To brace, avoid drawing in the navel and instead tighten the entire core, as if you were about to be thrown a punch.

I acknowledge McGill’s work on endurance times for extension, flexion and side bridge. But the standard deviations appear very wide which means there is a wide variety of data points. Expectations have to be modified in the elderly.
I acknowledge McGill’s work on endurance times for extension, flexion and side bridge. But the standard deviations appear very wide which means there is a wide variety of data points. Expectations have to be modified in the elderly.

Kan, S., Jeon, H., Kwon, O., Cynn, H., Choi, B. (2013). Activation of the gluteus maximus and hamstring muscles during prone hip extension with knee flexion in three hip abduction positions. Manual Therapy 18, 303-307

Shoulder Instability

PEER REVIEWED BY THE AMERICAN CHIROPRACTIC REHABILITATION BOARD

SUBJECT:  Shoulder instability.

I. Review of Anatomy and Physiology

The shoulder complex consists of four joints that function in a precise, coordinated, synchronous manner. Position changes of the arm involve movements of the clavicle, scapula, and humerus. These movements are the result of the combined work of the sternoclavicular, acromioclavicular, and glenohumeral joints and the scapulothoracic gliding mechanism (1).

The ligamentous and periarticular structures of the shoulder complex combine in maintaining the joint relationships, withstanding the forces applied to the joint surfaces, and stabilizing the dependent limb (1).

Due to poor osseous congruency and capsular laxity, the glenohumeral joint is very unstable, which makes it the most frequently dislocated joint in the human body. It relies on dynamic stabilizers and the neuromuscular system for its stability. (5, 6, 7)

I.I ANATOMY

GLENOHUMERAL JOINT

The glenohumeral joint is a multiaxial ball-and-socket synovial joint. The articular surfaces, the head of the humerus and the glenoid fossa of the scapula, although reciprocally curved, are oval and are not sections of true spheres. The head of the humerus is larger than the glenoid fossa. The articular surfaces are not congruent, and the joint is loose packed. Full congruence and the close-packed position are obtained when the humerus is abducted and rotated laterally (1).

The glenoid labrum is a rim of fibrocartilaginous tissue attached around the margin of the glenoid fossa. Some theories state that the labrum deepens the articular cavity, protects the edges of the bone, and assists in lubrication of the joint. The shape of the labrum adapts to accommodate rotation of the humeral head, adding flexibility to the edges of the glenoid fossa. The tendons of the long head of the biceps brachii and triceps brachii muscles contribute to the structure and reinforcement of the labrum.
The labrum seems to represent a fold of the capsule, however, and its major function may be to serve as an attachment for the glenohumeral ligaments (1).

Capsule
The capsule surrounds the joint and is attached medially to the margin of the glenoid fossa beyond the labrum. Laterally, it is attached to the circumference of the anatomical neck, and the attachment descends about a half-inch onto the shaft of the humerus. The capsule is loose fitting to the extent that the joint surfaces can be separated 2 to 3 mm by a distractive force. The capsule is relatively thin and, by itself, would contribute little to the stability of the joint. The integrity of the capsule and the maintenance of the normal glenohumeral relationship depend on the reinforcement of the capsule by ligaments and the attachment of the muscle tendons of the rotator cuff mechanism.
Anteriorly, the capsule is strengthened by the glenohumeral ligaments and the attachment of the subscapularis tendon. The latter is a major dynamic stabilizer of the anterior aspect of the shoulder. Posteriorly, the capsule is strengthened by the attachment of the teres minor and infraspinatus tendons (1).

Rotator Cuff
The rotator cuff is the musculotendinous complex formed by the attachment to the capsule of the supraspinatus muscle superiorly, the subscapularis muscle anteriorly, and the teres minor and infraspinatus muscles posteriorly. All of their tendons blend intricately with the fibrous capsule. They provide active support to the joint and can be considered true dynamic ligaments (1).

I.II PHYSIOLOGY

Stability

A number of related factors influence the stability of the glenohumeral joint.
A shallow glenoid fossa, one third of the articular surface of the humerus, creates a potential for instability. Instability in the glenohumeral joint is mostly anterior, to a lesser extent inferior, and least of all posterior (1).

According to Panjabi, there are three subsystems that works together to promote spinal stability: central nervous subsystem (control); osteoligamentous subsystem (passive); and muscle subsystem (active) (9). Hess adapted Panjabi’s model proposed for spinal segmental stability for the glenohumeral joint, which states that joint stability is based on the interaction between the active, passive and neural control subsystems, with the rotator cuff muscles, activating at different positions, compressing the convex humeral head into the concave glenoid, thus resisting the shear force experienced by the humeral head (14).

Passive stability

The passive system is composed of the glenohumeral joint, the ligaments: glenohumeral ligament and coracohumeral ligament (2).

Dynamic stability

Dynamic stability of the glenohumeral joint is assisted by the sensorimotor system, due to the presence of mechanoreceptors within the joint which influence the patterns of muscle recruitment, reflex activity and joint stiffness. Receptors within the joint capsule contribute to a reflex arc, which will cause activation of the muscles, the rotator cuff and the long head of the biceps brachialis, which overlie the joint capsule (2,15,16).
The short rotator muscles exerting a force in a downward and medial direction in abduction are critical in controlling the position of the humeral head. The posterior tilt of the glenoid fossa, together with the posteriorly tilting humeral head, provides a relationship that also counteracts the tendency toward anterior instability (1).
A glenohumeral joint with a lax capsule and ligaments might be stabilized dynamically in the end-range of motion if the glenoid concavity is maintained and the function of the external and internal rotators, which are efficient stabilizers in this position, is enhanced. (8)

Movement of the shoulder

In order to move the shoulder, first we need to extend the thoracic spine, then stabilize the scapula and the move the humerus in the glenoid fossa (18). The sequence of muscle activation during shoulder abduction begins with the stabilization of the scapula. This provides a stable base upon the glenohumeral joint abductors can ground themselves and act on the humerus. Stabilization of the scapula relies on isometric contraction of the upward scapula rotators (upper and lower trapezius and serratus anterior). With the scapula stabilized the supraspinatus activates first providing pure abduction without elevation in a linear effect directed into the glenoid fossa. Then deltoid activates pulling the humerus in abduction and elevating the arm in abduction (17).

After a luxation, active and passive stabilization systems are damaged, biomechanical alteration occurs and it leads to articular instability. A proper muscular rehabilitation should be performed in order to achieve stabilizers efficiency and avoid future instability (2).

Motor development

Development of human motor function in early childhood is genetically pre-determined and follows a predictable pattern. These motor patterns or programs are formed as the central nervous system matures, enabling the infant to control posture, achieve erect posture against gravity, and to move purposefully via muscular activity (11). In the normal motor development, the shoulder first develops mobility, the ability to move the upper extremity in space. This is referred as open chain movement. After mobility is achieved, the shoulder starts to develop stability with close chain activities (prone position on elbows and forearms, and then on hands). In these positions the shoulder is performing a weight bearing function described as the stability aspect of motor behavior. Once the infant has achieved a stable close chain position the next phase of development of stability of the shoulder is to move one arm in open chain while the other is in contact with the ground or another surface, in close chain. This is weight shifting in various weight bearing postures of the upper extremities. This is critical to develop equilibrium and tilting response. Like in the prone position, progression in shoulder stability in the supine position starts when the infant is pulled to sitting the rotator cuff muscles, cervical, trunk and hip flexors muscles exhibit active antigravity control (4).

II. History
Case presentation.
Objectives: The purpose of this paper is to report the case of a patient with chronic pain and instability on her right shoulder who was treated with chiropractic and rehabilitation care.
Subject: Patient was a 25 year old female aerial dancer with pain and instability on right shoulder, the onset was 3 months ago, falling in a rehearsal. History of trauma: while performing an exercise having the shoulder at 90° of abduction the patient fell and hyper extended the right shoulder. When she fell she felt the shoulder “went out” and she pulled back in. She noted referred pain and instability since as well as lack of strength and inability to perform her activity.

III. Physical Evaluations
Examination revealed:
Neurological testing: reflexes, myotomes and dermatomes were unremarkable; Posture: forward head posture, increased thoracic kyphosis, protracted shoulders, winging of right scapula, pelvis postures was neutral; Gait: Normal;
Ranges of motion: full range of motion of cervical spine, thoracic spine extension was limited and painful, full range of motion of shoulder (flexion, extension, abduction, adduction, internal and external rotation), pain in right shoulder between 160° and 180° flexion and abduction, and pain in internal rotation; Palpation: tightness in right upper trapezius, tenderness and pain over the greater tubercle of the right humerus; Orthopedic testing: Anterior drawer and posterior drawer of shoulder shows instability without pain. Sitting apprehension test was positive with pain. Empty can test was positive for supraspinatus. Infraspinatus test was positive; In Janda´s abduction test when performing in right shoulder abduction the right upper trapezius was the first muscle to fire, compensating the action of right supraspinatus and right deltoid.

VI. Chiropractic Assessments
VI.I Structural analysis:
Tight right upper trapezius and levator scapulae. Tight pectoralis major. Underactive middle and lower trapezius.
VI.II Static and motion palpation:
Static palpation: C2 fixed in right rotation and right lateral flexion; T4, T5 and T6 fixed posteriorly.
Motion palpation: Hypomobility in right cervical rotation; Hypomobility of mid-thoracic spine.

VII. Differential Diagnosis
SLAP lesion, Subacromial bursitis, Rotator cuff tear.

VIII. Patient Management

VIII.I Treatment
Chiropractic technique: Cervical spine: Diversified Index contact to pillar-sitting (10); Thoracic spine: Diversified Bilateral knife-edge contact to transvers processes. Patient was adjusted in every visit.
Rehabilitation: Thoracic spine mobility exercises, Shoulder stability exercises. Thoracic spine mobility exercises were performed to achieve extension; Then progressing to a Rib roll T-spine rotation. Shoulder stability exercises: Patient was first taught to hold a quadruped position. Then from four point support in a quadruped to three-point support (extending one hip, and then the other), then progress to upper limb (flexing one shoulder and then the other), and then progress to a birddog (two points support position), holding each position for 10 seconds performing 4 sets. The patient was progress then to a bear crawl position (first 4 points support and then 3 points support and then crawling forward and backward). Then the patient was started in static shoulder pulling exercises first with a double arm double leg kettlebell deadlift and then she was progressed to a single arm single leg kettlebell deadlift. And finally to chops and lifts with bands, to integrate mobility and stability exercises for the shoulder (4,11,12,13).
VIII.II Frequency: The patient was treated once a week over an 8-week time period.
VIII.III Patient education and home care: Patient was instructed in preforming the exercises daily at home. Patient was taught the exercises in the office and in each visit previous exercises were reviewed, to make sure she was doing them correctly.

VIII.IV Rehabilitative considerations: Incorporating the motor development model of the shoulder to a rehabilitation protocol: the patient was started first with thoracic spine mobility exercises (extension and rotation), then patient was progressed from static stability close chain exercises, four point support, for shoulder and scapula stabilizers, to one arm moving (open chain mobility exercise) while the other is in contact with the ground (close chain stability exercise) three point support, and then to a moving cross crawling pattern, then to a pulling movement (holding weight) and finally in a push-pull dynamic exercises (chops and lifts) to Integrate mobility and stability of the shoulder.

IX. Outcome of Care

Patient was reassessed in every visit.

Week one: Posture: forward head posture, normal thoracic kyphosis, protracted shoulders, winging of right scapula; Ranges of motion: full range of motion of cervical spine, thoracic spine extension was limited and painful, full range of motion of shoulder (flexion, extension, abduction, adduction, internal and external rotation), pain in right shoulder between 160° and 180° flexion and abduction, and pain in internal rotation; Orthopedic test: Anterior drawer and posterior drawer of shoulder shows instability without pain, sitting apprehension test was positive with pain, empty can test was positive for supraspinatus, infraspinatus test was positive.
Week two: Posture: forward head posture, normal thoracic kyphosis, scapulae were in normal position and alignment; Ranges of motion: full range of motion of cervical spine, thoracic spine extension was limited with no pain, full range of motion of shoulder (flexion, extension, abduction, adduction, internal and external rotation), pain in right shoulder between 160° and 180° flexion and abduction, and pain in internal rotation; Orthopedic test: Anterior drawer and posterior drawer of shoulder shows instability without pain, sitting apprehension test was positive with pain, empty can test was negative, infraspinatus test was negative.
Week three: Posture: Head in neutral, normal thoracic kyphosis, scapulae were in normal position and alignment; Ranges of motion: full range of motion of cervical spine, full range of motion of thoracic spine with no pain, full range of motion of shoulder with no pain; Orthopedic test: Anterior drawer and posterior drawer of shoulder shows instability without pain, sitting apprehension test was positive with pain, empty can test was negative, infraspinatus test was negative.
Week four: Patient was asymptomatic, Posture: Head in neutral, normal thoracic kyphosis, scapulae were in normal position and alignment; Ranges of motion: full range of motion of cervical spine, full range of motion of thoracic spine with no pain, full range of motion of shoulder with no pain; Orthopedic test: Anterior drawer and posterior drawer of shoulder shows instability without pain, sitting apprehension test was negative, empty can test was negative, infraspinatus test was negative.
Week five: (Same as week four) Posture: Head in neutral, normal thoracic kyphosis, scapulae were in normal position and alignment; Ranges of motion: full range of motion of cervical spine, full range of motion of thoracic spine, full range of motion of shoulder; Orthopedic test: Anterior drawer and posterior drawer of shoulder shows instability without pain, sitting apprehension test was negative, empty can test was negative, infraspinatus test was negative.
Week six: (patient was asymptomatic and shoulder was stable) Posture: Head in neutral, normal thoracic kyphosis, scapulae were in normal position and alignment; Ranges of motion: full range of motion of cervical spine, full range of motion of thoracic spine, full range of motion of shoulder; Orthopedic test: Anterior drawer and posterior drawer of shoulder negative, sitting apprehension test was negative, empty can test was negative, infraspinatus test was negative. Patient was instructed to return to physical activities (aerial dancing).
Week seven: (Same as week six) Posture: Head in neutral, normal thoracic kyphosis, scapulae were in normal position and alignment; Ranges of motion: full range of motion of cervical spine, full range of motion of thoracic spine, full range of motion of shoulder; Orthopedic test: Anterior drawer and posterior drawer of shoulder negative, sitting apprehension test was negative, empty can test was negative, infraspinatus test was negative.
Week eight: Posture: Head in neutral, normal thoracic kyphosis, scapulae were in normal position and alignment; Ranges of motion: full range of motion of cervical spine, full range of motion of thoracic spine, full range of motion of shoulder; Orthopedic test: Anterior drawer and posterior drawer of shoulder negative, sitting apprehension test was negative, empty can test was negative, infraspinatus test was negative (patient was discharged).
Follow-up: In a 2 month after discharged telephone follow-up, the patient revealed that the pain had not returned and the shoulder was stable during physical activities and daily living activities.

X. Discussion:

The classic rehabilitation of shoulder instability has consisted of: immobilization of the affected shoulder, flexibility exercises (passive range of motion, assisted flexion and abduction arm raises, pendulum exercises, cross over arm stretch, passive internal and external rotation, etc.) and strength exercises for rotator cuff (isometric and isotonic) (7,19,20,21,22). In the classic rehabilitation protocol, the muscles of the rotator cuff are treated as prime movers. We know now that the rotator cuff muscles work as shoulder stabilizers and they should be treated as so (2,9,14,15,16). Thus the rehabilitation of shoulder instability should incorporate exercises that address: mobility of thoracic spine, stability of scapulae, and mobility and stability of the glenohumeral joint all of these performed in a natural progression according to the development of human motor function.

XI. Reference

• Functional Anatomy of the Shoulder Complex. Malcolm Peat. PHYS THER. 1986; 66:1855-1865.
• Estudio de las luxaciones de hombro. Protocolos y valoración de la contingencia. Enrique Céster Balletbó.
• Essentials of Orthopedics & Applied Physiotherapy. Jayant Joshi. Elsiver
• Physical Therapy Jan S Tecklin. fourth ed. Development. Motor development in the normal child.
• Magnetic Resonance Imaging in Orthopedics and Sports Medicine, Volume II, David W. Stoller, 2007, p 1329-1338
• Current concepts in the treatment of anterior shoulder dislocations, D. Y. Wen, ‘, American Journal of Emergency Medicine, Volume 17, Number 4, 1999, p 401-407 (Level of Evidence 2A)
• ‘Non-operative Rehabilitation for traumatic and atraumatic glenohumeral instability’, K E. Wilk, L. C. Macrina, M. Reinold, North American Journal of Sports Physical Therapy, 2006, p 16-31 (Level of Evidence 1A)
• Dynamic Glenohumeral Stability Provided by the Rotator Cuff Muscles in the Mid-Range and End-Range of Motion a Study in Cadaver. Seok-Beom Lee, M.D., Ph.D.; Kyu-Jung Kim, Ph. D; Shawn W. O’Driscoll, M.D., Ph.D.‡; Bernard. Morrey, M.D; Kai-Nan an, Ph.D. J Bone Joint Surg Am, 2000 Jun; 82 (6): 849 -849.
• Panjabi MM. The stabilizing system of the spine. Part I. Function, dysfunction, adaptation and enhancement. J Spinal Disorders 1992; 5:383-389.
• Thomas Bergmann. Chiropractic Technique Principles and Procedures. First edition.
• Clinical Commentary Dynamic Neuromuscular stabilization & sports rehabilitation. Clare Frank, DPT, OCS, FAAOMPT, Alena Kobesova, MD, PhD , Pavel Kolar, PT, PhD The International Journal of Sports Physical Therapy | Volume 8, Number 1 | February 2013 | Page 62
• The Rib-Roll Stretch for Thoracic Spine Mobility. Perry Nickelston, DC, FMS, SFMA. Dynamic Chiropractic.
• The Chop and Lift Reconsidered: Integrating Neuromuscular Principles into Orthopedic and Sports Rehabilitation. Michael L Voight, PT, DHSc, OCS, SCS, ATC, CSCS Barbara J Hoogenboom, PT, EdD, SCS, ATCb Gray Cook, MSPT, OCS, CSCS North American Journal of Sports Physical Therapy august 2008 volume 3, number 3
• Functional stability of the glenohumeral joint. Hess, S. Manual Therapy, 5, 63–71.
• The synergistic action of the capsule and the shoulder muscles. Guanche, C., Knatt, T., Solomonow, M. et al. American Journal of Sports Medicine, 23, 301–306
• Sports Rehabilitation and Injury Prevention. Paul Comfort, Earle Abrahamson. Wiley-Blackwell
• Kinesiology Movement in the Context of Activity, second edition. David Paul Greene, Susan L Roberts. Elsivier Mosby. 2005
• Movement, Functional Movement Systems: Screening, Assessment and Corrective Strategies. Gray Cook. On target publications.
• Rotator Cuff and Shoulder Conditioning Program. American Academy of Orthopaedic Surgeons.
• Shoulder Instability: Management and Rehabilitation. Kimberley Hayes, PT1 Mary Callanan, MD2, Judie Walton, PhD3 Anastasios Paxinos, MD4 George A. C. Murrell, MD, PhD5
• Diagnóstico y Tratamiento del Síndrome de Manguito Rotador, Guía Rápida. Instituto Mexicano del Seguro Social.
• Tratamiento Quirúrgico de la Inestabilidad Anterior de Hombro (articulación gleno-humeral), Guía de Referencia Rápida. Instituto Mexicano del Seguro Social.

Conscious Core Stability For Low Back Pain Occurring Under Spinal Load: Queuing the Patient

Joseph W. Piwoszkin DC
Darien, IL

Review of Anatomy and Physiology

The low back, or lumbar spine, consists of five lumbar vertebrae aptly referred to as L1, L2, L3, L4, and L5. The most inferior aspect of the lumbar spine, L5, connects to the sacrum; a large spade-shaped bone that connects the spine to the iliac bones of the hip.

The cervical spine and lumbar spine both consist of a lordotic curve with no supporting osseous structures. Unlike the thoracic spine, where each vertebra has a set of ribs attached (creating a supportive thoracic cage) the cervical spine and lumbar spine rely more heavily on muscular stability.

Due to the “upright” nature of mankind, axial loading of the spinal osseous structures is common. The job of the surrounding musculature is to resist buckling of the spine under the loads of activity. Anterior/abdominal muscles used for lumbar spine stability include the internal oblique, external oblique, transverse abdominus, and the rectus abdominus muscles. Posterior/back muscles used for lumbar spine stability include the multifidus, quadratus lumborum, lumbar erector spinae, and the thoracic erector spinae muscles. For the sake of this case study, these are the muscles being referenced when referring to core musculature (1).

Background Information

Low back pain patients requiring core rehabilitation can be defined in one of several groups: the deconditioned, imbalanced muscle development ratio, or the inability to maintain co-contraction (2). All have one common aspect to their rehabilitative care; they require education in creating a co-contraction of the core musculature. Currently, there are no outlined methods of checking for this stability pattern in patients during functional activities. Therefore, a high amount of responsibility is given to the patient’s kinesthetic awareness of functional bracing patterns. The responsibility of educating the patient in these patterns occurs during baseline rehabilitative care. When instructing the lay person on proper form and firing patterns with rehabilitative exercise, communication is key. Patients with low kinesthetic awareness at baseline (i.e. difficulty producing willful abdominal wall muscle contraction laying supine with knees at 45 degrees) should not progress to more active and functional exercise until this is mastered. If the practitioner cannot evoke abdominal wall musculature contraction in the patient, progression may be limited.

These are individuals who struggle with conscious core stability. Eliciting co-contraction in these individuals will rely heavily on the skill of the practitioner and their ability to kinesthetically educate or “queue” the patient into creating the desired outcome. A common difficulty with the aforementioned patient base is activating the abdominal wall muscles: especially internal/external oblique and transverse abdominus.

When performing an exercise used to target abdominal wall musculature, without proper queuing it is possible to continue to use poor firing patterns to execute the movements (overusing hip flexors, spinal erectors, quadratus lumborum). In the subacute or chronic patient, these “abdominal” exercises performed without proper abdominal wall contraction may continue to cause pain, but in the same patient with proper queuing, may not cause pain. Granata and Marras showed that co-contraction of the core musculature increases spinal stability by 36% to 64% (3). It may be considered that this considerable change in stability may affect whether or not the patient feels pain with rehabilitation, as well as activities involving spinal load.

Psoas major, part of the hip flexor group iliopsoas, originates at the lumbar spine. A compensatory pattern of overusing the hip flexors without dispersing force into the abdominal wall during stabilization may cause difficulty in maintaining a neutral spine. A lumbar hyperextension pattern is seen in hip flexor/erector spinae dominant stabilization patterns during exercise. According to McGill, a neutral lordosis in the lumbar spine during loaded activity has been shown to minimize risk of low back injury (4). Good queuing to correct these movement patterns in early rehabilitation may have a direct effect on outcomes.

History

Ruth, a 52-year-old female, presented to clinic for examination of low back pain. She rated the intensity of her pain on a scale of zero to ten, with zero being complete absence of symptoms and ten being very severe or unbearable pain, a seven. Pain was described with the following qualifiers: dull, sharp, deep, and stiffness. Upon questioning, Ruth stated her symptoms were aggravated by activities involving sitting, sleeping and bending. She stated that some relief was obtained when standing. Denied having, or ever having, any radicular symptoms into either legs. Ruth reported that about one and a half years ago she had a cyst removed from her right ovary. Roughly 6 weeks after surgery she woke up in the morning with extreme pain. The pain was located in the right lateral hip region. Reported pain was worse in the morning but decreased to “tolerable” levels after about 2 hours. Patient received a corticosteroid injection into the right hip that helped the pain, but since that time the pain has migrated to the low back. She reports still having occasional lateral hip pain if she moves incorrectly. Ruth has had x-rays and an arthrogram of the right hip. She reports having no known trauma in either the hip or low back areas. Previous relevant surgeries included two cesarean sections, a hysterectomy, and removal of the right ovary. Ruth also reports having undergone about one month of physical therapy, thirteen visits total, immediately previous to this examination. Ruth had another corticosteroid injection scheduled six days from our initial examination. Ruth works as a secretary. No red flags were found during the initial history.

Ruth’s previous rehabilitation did not involve any core stabilizing education. She stated that she did exercises for “her back muscles” and “leg exercises” as well. During her thirteen previous physical therapy visits at another institute she reported that her pain would decrease mildly followed by severe “flare-ups” of pain. This cycle continued throughout the thirteen visits.

Physical Evaluation

Active Lumbar Spine Range of Motion
Patient showed moderate-severe restriction in standing flexion, and moderate standing extension restriction. Both standing flexion and extension produced pain. Mild-moderate restrictions in left/right lateral flexion and left/right rotation without pain, but patient was hesitant to push these boundaries.

Palpation
With the patient prone, pain was noted with palpation over the posterior superior iliac spines bilaterally. Quadratus lumborum palpation revealed trigger points in the medial fibers near the origin along the upper lumbar spine with pain elicited. Gluteus maximus muscle origins on the right were hypertonic and tender. Middle and lower thoracic erector spinae musculature was overdeveloped comparatively with noted hypertonicity.

Motion palpation of the spine revealed restricted movement in the lower thoracic and upper lumbar spine. Counter nutation restriction of the sacrum.

Neurological Examination
Lower extremity muscle strength, pain/touch sensation, and reflexes were all within normal limits. No pathological reflexes were present.

Orthopedic Examination
Negative tests include: Straight leg raise, Bragard’s, Patrick-Fabere, and Kemp’s.
Positive Yoeman’s test bilaterally with pain in the respective sacroiliac areas and low back. Hibb’s positive on the right for pain in the right sacroiliac joint, negative on the left. Milgram’s positive for severe low back pain with the inability to hold the position for any amount of time.

Functional Examination
Squat test – Patient was asked to perform a squat with no previous queuing. While attempting to squat the patient used almost exclusively knee flexion with no hip hinging/flexion. Patient described having fear avoidance in “bending forward” because of back pain. Patient was placed supine with knees at 45 degrees and the examiner attempted to provoke an abdominal wall contraction from the patient. The patient showed complete inability to willingly produce any type of muscle contraction. When placed in a dead bug position (patient unable to raise her legs on her own due to pain) the patient described moderate low back pain, and light perturbation to the raised legs produced severe low back pain.

Imaging
X-ray and MRI arthrogram reports of the right hip were requested. X-rays were performed four months prior and the MRI arthrogram three months prior to the presenting examination. X-ray impressions stated “no evidence of acute bony abnormality” and the MRI arthrogram impressions were slight fraying of the acetabular labrum, strain of the gluteus medius at its insertion upon the greater trochanter with trochanteric bursitis, associated gluteus minimus insertional tendinosis, and no bony lesions demonstrated in the pelvis.

Differential Diagnosis
Acquired Sacroiliac and Lumbar Spine Instability and/or Sacroiliitis with Lumbar Spine Facet Syndrome.
Discogenic Pain of the Lumbar Spine

Rationale for the above diagnosis is severe pain and resulting fear avoidance behavior combined with the lack of ability to engage abdominal wall musculature. Correlation with tissue and spinal palpation, positive orthopedic tests, and functional testing support these diagnoses. Consideration of the multiple abdominal wall traumas from surgical intervention were made, however, good core stability patterns may not have been present prior to these interventions.

A compilation of information put together by Bogduk and Aprill supports the aforementioned structures as being valid sources of pain (5).

Patient Management/Intervention

These guidelines are not designed as a specific practice model. They may or may not be used, as deemed necessary by the practitioner, to help elicit abdominal wall muscle firing patterns. The “language” used is intended to be easily understood by the lay person.

Screening & Queuing Co-contraction
Patient began lying supine with knees flexed at 45 degrees, feet flat.
Explain that you will be testing their ability to contract their “stomach muscles”
An example of what a muscle contraction feels like can be easily made using the biceps muscle. Most patients will understand that when “flexing” the biceps the muscle should feel firm.
“We want the same response in your stomach muscles”
Press the pads of your second, third, and fourth fingers 2’ to 4” lateral of the umbilicus. Have the patient do the same with their own hand on the other side. Your pressure while pressing against their abdomen should be similar to the deep palpation pressure you would use during an abdominal exam.
Ask the patient to “push your fingers away using their stomach”
It is important at this point to correct any excessive lumbar extension in their attempt to contract the abdominal musculature. You may queue the patient by putting your other hand under their lumbar spine and telling them to either lightly press against it or to not let their back raise away from your bottom hand when attempting to contract.
If the patient is able to achieve this, have them place both hands around their abdomen (level with the umbilicus) with their thumbs wrapping posteriorly and fingers anteriorly.
Explain that when contracting, they should feel their hands being “pushed away in all directions” as if expanding their stomach 360 degrees.
When the patient is able to achieve co-contraction at this level, progress them appropriately into your rehabilitative program. Explain that this is their foundation, and the importance of being able to consciously stabilize their core/spine.
When performing core stability exercises (i.e. Dead/Dying Bugs or Plank/Bridge positions), make sure the patient is not falling back into lumbar hyperextension and a hip flexor/erector spinae dominant bracing pattern. Otherwise, you are continuing to train a dysfunctional pattern.
If the patient is unable to comply with the above method, you may try the following:
Remain in the above mentioned position with your hand and the patient’s hand on the abdomen. Ask the patient to give you a “fake cough” or a short fast exhale. You should note their abdomen pressing out against your hand during this. Ask the patient if they felt it as well. Make sure the patient is applying the appropriate amount of pressure onto their own abdomen.
It may help to explain the muscles you are trying to contract attach the bottom of the ribs to the front of the pelvis, and that they should feel their ribs “being pulled down” or “dropping” when they cough or forcibly exhale.
Another option is to press down on the bottom of the patient’s rib cage using the thumb and forefinger of one hand, pressing lightly into the intercostal spaces roughly even with the midclavicular line on each side. Have the patient continue with the above methods as you hold this position.
Have the patient try to hold the contraction once they achieve it using the previous method. The patient may need to use this method multiple times. If so, allow the patient time to rest with a few normal cycles of respiration between multiple attempts.
If the patient can maintain an abdominal wall brace with a normal breathing cycle pattern continue with number 5 listed above.
Once the patient can consciously contract and hold their abdominal wall it is important to address an abdominal breathing pattern. If the patient cannot breathe during a held co-contraction, they should not be progressed into exercise involving core stability.

Patient Outcomes

Two visits were required before Ruth was able to create and maintain a co-contraction of core musculature while lying supine. By Ruth’s third visit she was able to progress to positioning herself and holding the dead bug position for 30 seconds without pain. Ruth presented on her fifth visit with a “flare-up” of pain. However, the pain was less than previous flare-ups and she was able to resume her previous level of rehabilitation on the next visit two days later. Ruth has continued to progress into exercises like straight leg raises, leg abductions, glute raises with feet on a BOSU, bridges/side bridges, prone hip extensions, dying bugs, standing chops, monster and crab walks. She performed the previously mentioned exercises without additional pain. By Ruth’s ninth visit she was having no morning pain, no pain with her current activities of daily living, and only “mild discomfort” while sitting in a car. Ruth also made a personal decision not to have the cortisone injection which was scheduled for six days after her presenting examination.

Discussion

Ruth was a superb example of having absolutely no conscious ability to stabilize and she required special attention to attain this firing pattern. Many patients can pick up this pattern quickly but are simply weak while others naturally create this pattern with no queuing at all.

The author would state that the importance of educating the patient of the dynamics of core exercise is equal to the ability to prescribe the appropriate rehabilitative program. It should be considered that exercise directed at the anterior abdominal wall can be ineffective if the patient is unable to use the correct muscle firing co-contraction patterns. When performing rehabilitative core exercise without first addressing how to properly stabilize the core, the risk of provoking the spine under a less than ideal stability pattern increases.

REFERENCES

Liebenson, Craig. The Role of Muscles, Joints, and Nervous System in Painful Conditions of the Spine. Rehabilitation of the Spine: A Practitioner’s Manual. 2007; Chapter 2: 31-47.
Osborne N, Cook J. Global Muscle Stabilization Training – Isotonic Protocols. Rehabilitation of the Spine: A Practitioner’s Manual. 2007; Chapter 27: 682-685.
Granata KP, Marras WS. Cost-benefit of muscle cocontraction in protecting against spinal instability. Spine 2000;25: 1398 – 1404.
McGill, Stuart M. Lumbar Spine Stability: Mechanism of Injury and Restabilization. Rehabilitation of the Spine: A Practitioner’s Manual. 2007; Chapter 5: 94-95.
Bogduk N, Aprill C. The Sources of Back Pain. Rehabilitation of the Spine: A Practitioner’s Manual. 2007; Chapter 6: 113-119.

Journal Abstracts by Scott Michael Schreiber, D.C., D.A.C.R.B

A History of Manipulative Therapy Through the Ages and Up to the Current Controversy in the United States

Joint manipulation is an ancient art and science that can trace its origins to the earliest medical and lay practitioners. Today, it is practiced principally by physical therapists and chiropractors and to a lesser degree, by osteopathic and medical physicians. Self-manipulation of both joint and soft tissues is also a common practice in those who “crack” their own knuckles and spines.

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Global Rating of Change Scales: A Review of Strengths and Weaknesses and Considerations for Design

Most clinicians ask their patients to rate whether their health condition has improved or deteriorated over time and then use this information to guide management decisions. Many studies also use patient-rated change as an outcome measure to determine the efficacy of a particular treatment. Global rating of change (GRC) scales provide a method of obtaining this information in a manner that is quick, flexible, and efficient. As with any outcome measure, however, meaningful interpretation of results can only be undertaken with due consideration of the clinimetric properties, strengths, and weaknesses of the instrument.

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Effect of workplace- versus home-based physical exercise on musculoskeletal pain among healthcare workers: a cluster randomized controlled trial

The prevalence and consequences of musculoskeletal pain is considerable among healthcare workers, allegedly due to high physical work demands of healthcare work. Previous investigations have shown promising results of physical exercise for relieving pain among different occupational groups, but the question remains whether such physical exercise should be performed at the workplace or conducted as home-based exercise. Performing physical exercise at the workplace together with colleagues may be more motivating for some employees and thus increase adherence. On the other hand, physical exercise performed during working hours at the workplace may be costly for the employers in terms of time spend. Thus, it seems relevant to compare the efficacy of workplace- versus home-based training on musculoskeletal pain. This study is intended to investigate the effect of workplace-based versus home-based physical exercise on musculoskeletal pain among healthcare workers.

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Effects of vitamin D supplementation and exercise training on physical performance in Chilean vitamin D deficient elderly subjects.

The aim was to assess the effects of resistance training and vitamin D supplementation on physical performance of healthy elderly subjects. Ninety-six subjects, aged 70 years or more with 25 OH vitamin D levels of 16 ng/ml or less, were randomized to a resistance training or control group. Trained and control groups were further randomized to receive in a double blind fashion, vitamin D 400 IU plus 800 mg of calcium per day or calcium alone. Subjects were followed for nine months.

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2016 Trends To Be Aware of

The American College of Sports Medicine (ACSM) published its annual fitness trend forecast. (November/December issue of ACSM’s Health & Fitness Journal®) ). The survey was completed by more than 2,800 health and fitness professionals worldwide, and was designed to reveal trends in various fitness environments. Read more

Acupuncture in a Multidisciplinary Setting

The purpose of this paper is to describe how acupuncture can be implemented in a multidisciplinary setting. Acupuncture can be implemented in any practice, however, this specific paper will specifically apply to how I am implementing it in my current practice. It will include a brief description of what is acupuncture, how does acupuncture work, how it applies to a multidisciplinary practice, diseases or disorders to be treated, cost structure of equipment to be used, billing and coding, safety precautions, clean needle technique, and forms to be used. Read more
Charles-bridge-Prague-city-lights-and-skyline-at-night

A Tribute to the Prague School of Rehab

Charles-bridge-Prague-city-lights-and-skyline-at-night

Yes, you read that right. The theme for our 2016 Joint Rehab & Pediatrics Council Symposium which takes place at the New York-New York Casino/Hotel in Las Vegas on March 4th – 6th, 2016 is “A Tribute to the Prague School of Rehab”. And we have great speakers who are trained in the Prague School of Rehab as well as Dynamic Neuromuscular Stabilization (DNS). Speakers such as Drs. Craig Morris, Pamela Tunnell and Maria Perri will elaborate on the historical origins of the Prague School and DNS, clinical pearls gleaned from the research and publications of Vladimir Janda, Pavel Kolar, Karel Lewit and Frantisek Vele. Janda’s postural assessment will be discussed as well as clinical highlights from the Prague School including a neuromusculoskeletal and palpatory examination of the abdomen for the lower back pain patient, the difference between reflex vs. mechanical soft tissue techniques and the pathophysiological soft tissue barrier.

In addition, an optional Friday (3/4/16) 2 hour CEU program will focus on post (minimally invasive) surgical spine rehabilitation. Drs. Jerrold Simon. Anthony Gross and George Petruska will be examining the many therapies, both surgical and non-surgical, developed to combat back and neck pain. In particular, Dr. Gross will delineate common minimally invasive spine surgical procedures such as MISS-endoscopic (non-fusion) laminotomy, foraminotomy, discectomy and laser DTA as well as MISS-fusion procedures such as XLIF, TLIF, PLIF and Anterior Cervical Discectomy Fusion (ACDF). During the second hour, Drs. Jerrold Simon and George Petruska will discuss how to go about medically clearing the post-surgical patient for spinal rehabilitation. Common categorical drugs and their cardiovascular, pulmonary or hypertensive side effects will be enumerated. Finally, the post minimally invasive functional capacity exam for both the thoraco-lumbar as well as the cervico-dorsal surgical patient will be demonstrated with focus on how to then subsequently generate proper post-surgical rehab protocols.

On Sunday, March 6th, doctor attendees will be able to choose between a Rehab track vs. a Pediatrics track. During the first two hours of the Rehab track, Dr. William Morgan will discuss modic vertebral endplate changes as documented by MRI. This will included orientation and sequencing of the MRI images as well as defining modic changes while detailing their clinical significance. During the second two hours of the Rehab track Dr. Philip Palmer will then expound upon assessing symmetry of gait, power and dynamic stability using computer models. He will also cover gait and balance training for concussed patients using the vestibular-ocular reflex, smooth pursuit pathway and the visual vestibular system. In addition on Sunday, March 6th, the Pediatrics track will feature Dr. Michelle Stafford who will lecture on the ramifications, remedies and results of pediatric tongue tie therapies. She will define and classify oral labial and lingual frenulum and expound upon the benefits of early tongue tie therapy as well as the long-term effects of untreated tongue tie. Finally, during the last two hours of the Pediatrics track, Pediatrics Council President Dr. Elise Hewitt will discuss craniosacral therapy for infants. Instruction will include demonstration on a model of an infant as well as video footage of actual patient sessions.

As you can see, our first ever Joint Rehab and Pediatrics Symposium is shaping up to be a real winner. It’s easy to be a part of this event. Simply register online by clicking on: http://www.ccptr.org/next-annual-symposium/

See you in Las Vegas,

Jerrold J. Simon, DC, DACRB
President, ACA Rehab Council

Republish of Postpartum Osteitis Pubis Treated Successfully with Shockwave Therapy: A Case Report

The purpose of this case study was to demonstrate that Extracorporeal Shockwave Therapy (ESWT) could be an adjunctive therapy for patients with postpartum osteitis pubis. Osteitis pubis is a painful, inflammatory condition that is difficult to handle without a comprehensive treatment method. A 26-year-old female patient with a notable condition of postpartum osteitis pubis participated in this case study. The treatment involved ESWT as a therapy for the patient’s groin and pubic pain due to osteitis pubis. Read more

US Chiropractors’ Attitudes, Skills and Use of Evidence-Based Practice: A Cross-Sectional National Survey

Evidence based practice (EBP) is being increasingly utilized by health care professionals as a means of improving the quality of health care. The introduction of EBP principles into the chiropractic profession is a relatively recent phenomenon. There is currently a lack of information about the EBP literacy level of US chiropractors and the barriers/facilitators to the use of EBP in the chiropractic profession. Read more

The Effectiveness of Exercise for the Management of Musculoskeletal Disorders and Injuries of the Elbow, Forearm, Wrist, and Hand: A Systematic Review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration

The purpose of this systematic review was to evaluate the effectiveness of exercise compared to other interventions, placebo/sham intervention, or no intervention in improving self-rated recovery, functional recovery, clinical, and/or administrative outcomes in individuals with musculoskeletal disorders and injuries of the elbow, forearm, wrist, and hand. Read more

Functional Movement Screen Normative Values and Validity In High School Athletes: Can the FMS™ Be Used as a Predictor of Injury?

Limited information exists regarding injury risk factors for high school athletes. The Functional Movement Screen (FMS™) has been used to identify functional movement impairments and asymmetries, making it a potential predictor of injury. Read more

An appraisal of the Functional Movement Screen™ grading criteria – Is the composite score sensitive to risky movement behavior?

To examine the relationship between the composite Functional Movement Screen (FMS) score and performers’ spine and frontal plane knee motion. Read more

Review Article of Consecutive Loops Theraband and Demonstration Videos

There are tremendous benefits to patients doing band work. For years we have had tubing, tubing with handles, Thera-bands, loops, the Stretch strap, and now the Consecutive Loop (CLX) Theraband. In my office patients are being introduced to the CLX along with bodyweight exercises before using free weights or Kettlebells. Read more

Aquatic Therapy Use in Management of Musculosketetal Dysfunction

Aquatic physical therapy is one of the fastest growing areas of physical therapy and rehabilitation. The benefits have been recognized since ancient times when whirlpools and hot springs were used to promote healing and manage medical aliments. Read more