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Low Tech Rehabilitation

Basic Protocols for Immediate Use

Low Tech Rehab Post Graduate Programs Mark Hartsuyker, D.C.

Some Background
2 year degree/training as PTA Graduated 1980 from LACC 18 years practice Ithaca, NY 3 years practice Boston, MA
Private Practice Ergonomic Consultant

October, 2002 - Logan Clinical Faculty

Structure of Content
Theory and Background Functional Anatomy Testing, Analysis & Diagnosis Hands-on practical experience

Overview of Weekend
Introduction & Testing
Basic Concepts & Foot Evaluation Manual Muscle Testing & Flexibility

Core Stability
Neck Flexors and Neck Stability Swiss Ball

Posture & Knee


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

Upper Body
Shoulder Rehabilitation Upper Extremity Rehabilitation

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

Appropriate Orthopedic, Physical, Neurological & Chiropractic Exams Differential Diagnosis

Special Tools of Assessment


Full sized pain drawing with five types of discomfort Analog Pain scale Oswestry Quality of Life Index
Neck Low Back

Role of Manipulation
Direct experience that.
Spinal manipulation is potent Chiropractic adjustment is central

Active management compliments Exercise programs do not replace the importance of manipulation

Low-Tech Rehab
What Low cost tools for rehabilitation Why Pain management, myofascial pain & long term fitness Who - Nearly all your patients How Selective techniques geared to individual need, dependent upon place in the treatment cycle

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

Managed Care
Carriers are expecting active treatment protocols Continued reimbursement based upon outcomes Appreciable improvement when active management has been instituted

Getting Paid
97110 Rehab/Exercise 97112 Neuromuscular Re-Education One unit = 8 to 25 minutes One unit = $45

The Terrible Triad


Pain interferes with patients ADLs Decreased mobility causes segmental dysfunction Dysfunction Decreased function causes muscle atrophy Lack of motion allows patient to fixate on pain Sleeplessness does not allow muscles to relax Hopelessness sets in, reinforcing cycle

Pain

Immobility

Neurological Basis - Pathways


Primary sensory afferents - to spinal cord Ascending relay neurons - spinal cord to brain stem / thalamus Thalamocortical projections Modulation: Nociceptive transmission is modified Perception: Transduction, transmission, modulation interact to create subjective emotional experience of pain

Neurological Basis - Pathways


Ascending pathways Dorsal horn

Afferents

Neurological Basis
Large scale motor activity given preference Low grade pain perceived in absence of large scale motor activity Chronic pain associated with aberrant changes in dorsal horn organization Prompt action necessary to avoid these changes!

Interlocking Systems
Cognitive Perceptual

Limbic Emotional

Motor

Codependency of major CNS systems & environment

Testing - Biomechanical Analysis


Leg length discrepancies
Functional or anatomical

Muscle strength deficiency Muscle tension, hypertonicity or shortening Foot dysfunction Recurrent patterns of segmental dysfunction Ergonomic factors

When do you start?


Active management
Immediately Gauged to patients abilities or level of function

Rehabilitation
When most acute phase has passed Pain present so keeps patient interested Before auto discharge occurs

Goals of Rehabilitation
Decreasing pain Take away the fear of movement Decreasing mechanical stress on spinal structures Strengthening weak muscles Stabilizing hypermobile segments Improved mobility Improved posture Improved fitness levels to prevent injury

Increasing Compliance
Partnership with patient Have you engaged the patient?
Why am I doing this exercise? How does it relate to my diagnosis?

Post-instructional Check
Check patients technique within 1-3 day Are they doing the exercise(s) correctly? Are they doing them at the recommended frequency? Document compliance in SOAP

Documentation
Note the time rehabilitation started and ended in date area. Briefly describe type of exercise, program, tool and why. Describe patients immediate understanding Note frequency, duration, weight used and how many times per day List any handouts given to the patient

Patient Handouts
Ease of Creation Individualized Covers various rehab tools Covers documentation Reasonably priced

Tools of the Trade


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

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

Foam Rolls
Compliments Swiss ball type activities Trunk stability Balance and coordination

Wobble & Rocker Board


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

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

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

Kinesiotaping
Provides touch to area of chief complaint Lifts skin to open lymphatic channels Increased mechanoreceptor stimulation

Wrist & Hand Devices


Selective stability across wrist Strengthening of forearm muscles Used when acute phase has passed Tools:
Dynaflex balls Wristiciser Handmaster

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Summary of Process
Examination/Analysis Diagnosis
Understand contributing factors Patient seen in wholestic manner

Formulate a treatment plan


Short term goals Long term goals

Reassess at appropriate intervals

Evaluation of Foot Biomechanics


Evaluation Biomechanics Proprioception

Low Tech Rehab Post Graduate Programs Mark Hartsuyker, D.C.

Foot Evaluation Why?


Foundational when considering:
Biomechanics/positioning Proprioception to all postural muscles

Small change inferior = large change superior Bed of proprioceptors is rich given role of feet in standing and locomotion

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Foot Dysfunction
Foot dysfunction < > foot pain Recurrent dysfunction in:
Ankle, knees, hip Sacral-iliac joints, lumbar spine Neck, headaches Shoulder diagnosis

Do symptoms increase with weight bearing activity?

Steps for Evaluation


Observe Palpate Heel Strike Test Recommendation

Leg Length Discrepancies


Functional
Pelvic unleveling Pronation Supination

Measurement Pelvic Influence


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

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Leg Length Discrepancies


Structural
Growth plate injury Trauma - Fracture Infection Poliomyelitis Cerebral Palsy

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

Palpate
Inform the patient of your intentions Hold the ankle with one hand Firmly palpate the longitudinal arch
Taut Loss of height Pes Planus Tender

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Mechanism of Heel Strike


Phases of gait:
Heel strike Stance Toe-off Swing

Heel strike moment facilitation of quadriceps group Loss of strength at this moment = inhibition at moment weight shifts to limb in stance

Heel Strike Muscle Testing


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

Heel Strike Muscle Testing


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

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

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Heel Strike Muscle Testing


With strapping no change in quadriceps? Consider joint dysfunction along kinetic chain:
Ankle Knee Hip SI joint

Aberrant Heel Strike Effects


Loss of stability across the knee
60% muscular & 40% ligamentous Recurrent knee pain with weight bearing activities

Loss of anterior stability to the ilium


Chronic recurrent SI joint instability Compensatory muscle tightening

Gait Cycle Revisited


Heel Strike Stance Phase Toe-Off Swing

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Proprioceptors
Heel Strike through Toe-Off

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

Neurological Basis
GTO signals to anterior horn of spinal cord Type 1B afferents signal inhibition Possible nocioception below threshold for perception Upon taping, possible unloading of mechanoreceptors in the plantar fascia

Proprioception & Postural Muscles


Test latissimus dorsi or neck flexors seated Test standing with & without taping More then heel strike perception may be dysfunctional Correlate findings to patients symptoms

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Recommendation
Do not need to have positive heel strike to recommend orthotics Pronation alone adequate indicator Common bilateral equal pronation off the shelf device may suffice Marked deviation with chronic foot pain podiatrist referral may be indicated

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

Types of Orthotics
Casting weight bearing Casting non-weight bearing Hard vs. soft

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

Evaluation of Muscle Function


Clinical Correlations Documentation of Soft Tissue Findings Testing Procedures
Direct or Prime Groups Antagonists
Low Tech Rehab Post Graduate Programs Mark Hartsuyker, D.C.

Stages of Assessment
Do we have stability across the region? Is there flexibility in all muscles that cross the joint or that effect the region? Is there adequate range of motion
Segmental (vertebral) Global

Exercise or general fitness level

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Muscle Testing Why?


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

Applied Kinesiology
Prior to Goodheart muscle testing existed! Muscle testing will lead to various conclusions Emphasis Relation to vertebral subluxation Weakness secondary to biomechanical factors

Role of Manipulation
Profound effects that are:
Direct Corresponding to neurological level Indirect complex proprioception mechanisms

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

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Muscle Balance & Function


Balance across structures Considerations for all testing
Hypertonicity Postural shortening Inhibition Atrophy Myofascial pain

Vladimir Janda on Joint Dysfunction


Muscle spasm is always present in area of a painful lesion. Pressure of muscle in spasm increases the characteristic pain. Muscles & fascia are common to several spinal segments & if strained may restrict several contiguous segments. Muscle fatigue = predisposing factor that decreases the force available to meet demands. Muscle tightness may influence joint position stain of soft tissue & joints even within the normal ROM.

Janda on Chronic Pain


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

Leads to:
Muscle imbalance Overstress on structures of musculoskeletal system

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Janda on Increased Muscle Tone


May arise from:
Dysfunction of the limbic system Impaired function at the segmental (interneuronal) level Impaired coordination of muscle contraction, possibly due to trigger points As a response to pain irritation

Myofascial Pain
Prime Mover - weak

Antagonists hypertonic Synergist - overworked

Active Trigger Point


Produces pain WITHOUT digital compression Very tender on palpation Characteristic pain pattern for the muscle (either with ischemic compression or without) Impedes muscular flexibility Produces muscle weakness May elicit a local twitch response with compression (or needle stimulation)

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Latent Trigger Point


Usually silent no spontaneous pain Tender on palpation Produces referred pain pattern only with ischemic compression Impedes muscle flexibility Produces muscle weakness May elicit a local twitch response with compression (or needle stimulation) Active TrP may become latent in a chronic stage May become active with microinjury/microtrauma or macrotrauma

Muscles Prone to Tightness


Gastrocnemius Soleus Tibialis Posterior Short Hip Adductors Hamstrings Rectus Femoris Iliopsoas Tensor Fasciae Latae Flexors of Upper Limb Piriformins Erector Spinae Quadratus Lumborum Pectoralis Major Upper Trapezius Levator Scapulae Sternocleidomastoid Scaleni Masticatories

Muscles Prone to Weakness


Peronei Tibialis Anterior Vastus Medialis &Lateralis Gluteus Maximus Gluteus Medius &Minimus Rectus Abdominis Extensors of Upper Limb Serratus Anterior Rhomboids Middle and Lower Trapezius Deep Neck Flexors Digastricus

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Muscle Palpation-Described
Area being palpated?
Example: Right pectoralis minor

Pressure of palpation used?


Superficial, moderate, deep

What did you feel?


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

What did the patient experience?


Discomfort, pain: mild, moderate, severe Distribution of the pain

Art of Muscle Testing


Force aligned with muscle fibers Force appropriate for length of lever arm Force appropriate for frame size Force appropriate for muscle size Match strength to strength gradually Is there a reserve after contraction against a moderate graded force? Are there fasciculations? Is there an obvious effort or recruitment?

Muscle Strength Grading


0 No contraction 1 Slight contraction, no movement 2 Full range of motion without gravity 3 Full range of motion with gravity 4 Full range of motion , some resistance 5 Full range of motion, full resistance

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Iliopsoas
L2, 3

Rectus Femoris
L2, 3, 4

Sartorius

L2-L3

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Tensa Fascia Lata


L4, 5 S1

Hip Adductors
L2, 3

Quadratus Lumborium
T12, L1-4

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Gluteus Medius
L4, 5, S1

Gluteus Maximus
L4, 5, S1

Piriformis

L5, S1 & S2

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Hamstrings

L5, S1, 2

Rectus Abdominus

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

Oblique & Transverse Abdominals

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

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Gastrocnemius/Soleus
S1-S2

Latissimus Dorsi
Thoracodorsal, C6, 7 & 8

Teres Minor & Infraspinatus


C4, C5 & C6

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Pectoralis Major
Clavicular
C5-C6

Sternal
C6-C7

Deltoids
Axillary, C5, 6

Supraspinatus
Suprascapular, C5

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Infraspinatus

C4, C5 & C6

C5-T1

Subscapularis

Rhomboids & Subscapularis


C5
C5-T1

Integrated or Functional Version

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Rhomboids

C5

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

Lower Trapezius

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

Mid-Trapezius

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Teres Major

C6-C7

Upper Trapezius

Accessory Nerve Cranial XI (spinal portion)

Deep Neck Flexors & SCM


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

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Antagonists or Reciprocal Testing


Test one muscle rapidly followed by its antagonist Dampening is short lived unless first muscle tested is excessively tight Patient must be well coached prior to testing Excellent patient education tool
Found mostly in athletic patients Stretching proven essential to outcome

Reciprocal Inhibition
Hamstring to Quadriceps (likely) Quadriceps to Hamstrings (less likely) Adductors to Abductors (likely) Abductors to Adductors (less likely)

Testing Reciprocal Inhibition


Test the antagonistic muscles singly Train the patient for test
Positioning Perform a dry run

Quickly test one group Rapidly switch to antagonist

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

Neck Flexors
Anatomy Review Syndromes and Symptoms Myofascial Pain Patterns Observation & Testing Strengthening Expectations & Charting
Low Tech Rehab Post Graduate Programs Mark Hartsuyker, D.C.

Anatomy Review Prime Movers


Longus Capitis
Anterior rami C1-C3

Longus Colli
Anterior rami C2-C6

Scalaneus Anterior
Anterior rami C4-C6

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Anatomy Review Prime Movers


Platysma

Anatomy Review Synergists


Sternocleidomastoid

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

Anatomy Review Synergists


Scalenes

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Anatomy Review - Antagonists

Suboccipitals

Anatomy Review - Antagonists

Semispinalis Capitis

Anatomy Review - Antagonists

Splenius Capitis

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Anatomy Review - Antagonists

Upper Trapezius

Anatomy Review - Antagonists

Temporalis

Spindle Cells
Rich endowment of spindle cells in:
Neck flexors Sub-occipital triangle Longus colli

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Reciprocal Inhibition Cascade


Injury, posture, VSC Neck flexor disuse atrophy

Time, adaptation & postural changes

Facilitated neck extensors

Inhibited neck flexors

Pre-Disposing Factors
History of a motor vehicle accident (or several) or other neck trauma, even if this event was many years ago Occupational flexor dominant Behavioral slumped body posture

Syndromes
Loss of the cervical lordotic curve visible on a lateral radiograph Anterior head carriage Hypertonicity of the sub-occipital muscles, levator scapula, upper trapezius, SCM's and TMJ related muscles Headaches, especially those of myofascial origin (see muscles noted above)

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Syndromes
TMJ dysfunction Inability to maintain cervical corrections Chronic tension between the shoulders

Myofascial Pain Principles


Prime Mover - weak

Antagonists hypertonic Synergist - overworked

Myofascial Pain Patterns


Levator Scapula

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Myofascial Pain Patterns


Splenius Capitus

Myofascial Pain Patterns


SCMs

Myofascial Pain Patterns

Suboccipitals

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Myofascial Pain Patterns


Temporalis

Postural Evaluation

Forward head carriage Stooped posture Loss of curve on lateral cervical

Testing - Observation
Have table at horizontal neutral Arms overhead decrease role of synergists

Instructions to patient: Please lift your head off the table.

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

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Testing Challenge
Chin tuck 15-20 degrees of flexion Two finger or hand edge resistance

Further Testing - SCM


Sternocleidomastoid

Strengthening
Guide patient to neutral head position Have the patient walk into the ball slowly. Avoid translation Instructions: Keep ear over shoulder

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Strengthening
Hands on the wall to maintain the the chestwall inter-space Keep just enough pressure to maintain the ball on the forehead

Strengthening
With guidance have the patient perform a chin tuck Do they feel an increase in pressure on the forehead?

Strengthening
Guidance can be given both during the chin tuck & flexion Always ask permission to touch

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Strengthening
Have the patient complete flexion Repeat at least several times under observation to insure correct technique

Follow-up
Insure compliance by having the patient return in 2-3 days for an exercise check Watch for lack of neutral start, translation or excessive pressure

Additional Care
Regular manual manipulation Coaching in proper ergonomics and posture Performance of gentle and regular stretching of the cervical extensor groups Soft tissue release techniques

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Expectations for Outcome


Observation = nearly full translation Testing elicits fasciculations Testing = +4 or less strength 4-6 weeks of rehabilitation may be necessary Observation = flexion occurs early during motion Testing = +4 or better strength 7-10 days may show good results

Factors Effecting Outcomes


Inhibition secondary to segmental dysfunction of the cervical spine Inhibition secondary to excessive overuse of neck extensors from poor ergonomics or posture Loss of neuromuscular higher level integration from disuse Atrophy secondary to long-term inhibition Atrophy secondary to cervical trauma (both shortterm and long-term) Applied Kinesiology factors (a separate study not within the scope of this presentation) Pathological factors possibly not uncovered during the history

Charting
Objective: What was observed? What was the results of testing? Assessment: Loss of deep neck flexor strength Plan: Strengthen with soft ball 10x twice per day Recheck patients compliance and technique within three days

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Muscle Flexibility
Testing of Key Groups

Low Tech Rehab Post Graduate Programs Mark Hartsuyker, D.C.

Vladimir Janda

Czech doctor of neurology & physical medicine Extensive contribution to understanding muscle function

Upper Cross Syndrome


Weakness of: Tightness of:
Upper Trapezius Pectoralis Major Levator Scapulae Rhomboids Serratus Anterior Middle and Lower trapezius Deep neck flexors, especially the scalene muscles.

FROM: J Manipulative Physiol Ther 2004 (Jul); 27 (6): 414420

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Upper Cross Syndrome


This syndrome produces:
Elevation & protraction-shoulders Winging of the scapula Protraction of the head

Overstress of:
Cervical cranial junction

C4-5 and T4 segments


Shoulder due to altered motion of the glenohumeral joint

Lower Cross Syndrome


Tightened Muscles:
Gastrocnemius Soleus Hamstrings Adductors Hip flexors (i.e. iliopsoas, rectus femoris, tensor fascia latae Erector spinae

Lower Cross Syndrome


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

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Lower Cross Syndrome


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

Lower Cross Syndrome


Common Movement Dysfunctions: Excessive lumbar lordosis during movements such as squatting, lunging, and overhead pressing The result of:
Tight hip flexors Erector spinae, From weakness/inhibition of the inner unit (i.e. the transverse abdominus and multifidus).

Lower Cross Syndrome


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

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Evaluation Muscle Length


Accurate positioning of the joints
Insure maximum lengthening of origin & insertion

Adequately stabilization of one end Smooth motion during stretch, especially at end range Patients perception of tightness not a reliable guide Rely on maintaining positional stability & doctors assessment of end feel

Modified Thomas Test


Support the patient on the edge of the table

Thomas Test Lay Back


Help the patient lay back flat on table

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Assess Resting Length


To what degree does the thigh go into hip extension?

Additional Flexibility - Iliopsoas


Can the thigh be extended another 1015 degrees?

Movement should occur without loss of lumbar or pelvic stabilization.

Flexibility Rectus Femoris


While still in modified Thomas test position flex the knee
Observe for patellar position: Is it superior? Is there an indentation superior to the patella?

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Flexibility Rectus Femoris Prone


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

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

Hamstring Assessment
Palpate at ASIS for pelvis movement >70 degrees flexion = marked loss of length

51

Hip Adductors
Move the non-testing leg approximately 15 degrees into abduction Cradle the leg as in assessment of the hamstrings Slowly abduct the leg, palpating for when pelvic movement sets in

Hip Adductors
Leg should be abduct to 45 degrees without pelvic movement Flexing the knee eliminates the hamstrings as a source of restriction

Assessment - Piriformis
Flex the leg to no more than 60 degrees Provide compression along the axis of the femur Adduct the thigh Internally rotate the femur Feel for smooth movement with no restriction

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Palpation - Piriformis
Mentally draw a line between the PSIS and the greater trochanter The second line is from the ischial tuberosity to the ASIS

Palpation - Piriformis
Palpation where these two lines cross Palpation is conducted with one hand reinforcing the other and is very deep

Gastrocnemius & Soleus


Patient is supine, distal one-third of the tibia/fibula not supported by the table Distract the calcaneus caudally then raise the foot into dorsiflexion It should be able to flex to 90 degrees

53

Gastrocnemius & Soleus


To eliminate the soleus and isolate the gastrocnemius Flex the knee while maintaining the calcaneal distraction If the ROM increase the gastrocnemius is the tight muscle

Pectoralis Major
Patient supine close to the edge of the examination table Stabilization of the trunk is essential Place the arm in slight external rotation at 120 degrees of abduction Palpate the muscle for tenderness while detecting the length

Upper Trapezius
Patient supine, stand at the head of the table Use your right hand on top of the right shoulder to assess elevation Use the left hand to flex the head fully, followed by lateral flexion Head rotation is to the ipsilateral side. Traction the shoulder girdle inferior

54

Levator Scapulae
With the patient supine, stand at the head of the table Flex the head while maintaining downward pressure on the shoulder Head is rotated contralateral to the side being held Depress the shoulder girdle and assess the quality of the end feel, comparing left and right sides Also palpate the insertion of the levator scapulae at the superior angle of the scapula

Active Care Patient Self Stretches


Upper trapezius Levator scapulae Iliopsoas Piriformis Pectoralis group

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

Basic Instructions

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

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Stretch - Upper trapezius

Stretch - Upper trapezius


With less stretch

Stretch - Levator scapulae

56

Stretch - Iliopsoas

Stretch - Iliopsoas

Stretch - Iliopsoas

57

Stretch Iliopsoas (supine)

Stretch - Piriformis

Stretch - Piriformis

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Stretch - Pectoralis group

Stretch - Pectoralis group

Resource
Stretching by Bob Anderson

59

Introduction to Swiss Ball & Foam Roll Exercises

Low Tech Rehab Post Graduate Programs Mark Hartsuyker, D.C.

Swiss ball offers:


Trunk Strengthening Enhanced Proprioception Mimics Real Activities & Demands FUN!

Ball Diameter User Height


75 cm. ball (29 inches) >6 ft. 0 in. tall 65 cm. ball (25 inches) 5 ft. 5 in. to 5 ft. 11in. tall
53 cm. ball (21 inches) 4 ft. 11 in. to 5 ft. 4 in. tall 42 cm. ball (16 inches) <4 ft. 10in. tall 30 cm. ball (14 inches) children 1-2 years old 20-25 cm. ball (8-10 inches) for non-sitting exercises requiring a small ball

60

Swiss Ball Safety


Padded floor foam mats No furniture in fall zone Mounting - Hand & eye on the Swiss ball Patient and doctor face each other May require safety belt around mid-section Assistant as spotter

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

General Indications
Decreased range of motion Decreased strength Decreased balance reactions Decreased coordination Decreased endurance Decreased proprioception

61

Patient Population Entry Level


Chronic low back pain (if not in acute phase) Deconditioned Increased pain with ADLs Instability i.e.: I just stepped off the curb and my low back went out.

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

Signs of Sensory Overload


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

62

Primitive People & Abs

Misconceptions
Definition < > Toned Abdominal Muscles Raw Strength vs. True Functional Tone

Reminders to Patients
Exercises take concentration Safety zone if they fall Perform exercises slowly (generally) Any exercise can be backed down

63

Reminder to Doctor
Doctor - No hard agenda on a given visit Observe Guide and encourage Advance program only when appropriate

Circles & Figures of Eight


Sit on ball Doctor Observes: Hands on inguinal How steady fold region Fasciculations Feet apart Flattening of pattern Eventual trunk & Hip movement head move contra to matched by hips contralateral torso

Abdominal Sit-Back
Feet spread apart Roll hip forward Slowly lean straight back Lean back to point can still maintain mobility

Doctor Observes: How steady? Fasciculations Maintaining balance Anterior vs. posterior pelvic tilt

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Diagonal Sit-Back
Feet spread apart Roll hip forward Slowly lean back diagonal Lean back to point can still maintain mobility

Doctor Observes: How steady? Fasciculations Maintaining balance Anterior vs. posterior pelvic tilt

One Leg Lift


Can the patient keep balance? Is there excessive torso shift or does one hip hike up?
Transverse obliques Quadratus lumborium

Contralateral Puppet
Do not advance if the one leg lift is poor! Lift leg and arm at the same time Keep torso even and balanced

65

Quadratus Lumborium
Hip pointed at ceiling Bring hip to shoulder, shoulder to hip Not a lateral leg lift alone

Bridged Supine
Lay over the ball Feet spread apart at first Arms out for stability Start with ball under mid back Slowly roll out to ball across upper shoulders Maintain flat abdominal platform

Full-Spine Roll-Out
Start seated & slowly roll out Feet wide apart Slowly stretch torso over ball Place arms at 45 degrees overhead Lay back and let neck relax Coming up start with neck curl
Contraindications: Neck pain Poor stability on less advanced exercises

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Full-Spine Roll-Out - 1

Full-Spine Roll-Out - 2

Full-Spine Roll-Out - 3

67

Full-Spine Roll-Out - 4

Gluteus Medius
Lay on side over the ball Bend bottom leg underneath Keep hip pointed at the ceiling Lift high leg towards ceiling

Gluteus Maximus
Lay prone over the ball on knees With knee bent, lift one leg Keep torso flat with no torque Do not want lumbar extensor activation

68

Increasing the Challenge


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

Swiss Ball and Athletes


Activate a myriad of motor recruitment patterns, as the ball is unstable. It never moves the same way twice in a row! Enhance both spinal and peripheral joint stability, which help to prevent injury Swiss Balls are also effective stretching aids and can be used to develop strength in both open and closed chain environments.

Swiss Ball and Athletes


High levels of nervous system activation, = greater neurological capacity in the playing environment Reduces the incidence of injury Athletes who predominately use machine training have a difficult time transferring their strength and power to the playing environment.

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

Progressive Push-Ups - 1

Progressive Push-Ups - 2

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Progressive Push-Ups - 3

Rhomboids
Face down kneeling Arm out at 45 degree to head/neck Thumb up Attempt to lift arm Doctor observe/palpate for scapular control

Rhomboids 2

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Subscapularis & Rhomboid Dips


Assume progressive push-up position Extend out only to knees esp. beginning Drop chest/upper torso through scapula Doctor directs by placing hand on sternum and/or mid thoracic spine

Subscapularis & Rhomboid Dips

Balancing Bear
Kneel on all fours on ball Maintain position Dont fall off

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

Foam Rolls
Beginners Position
Sit back on the foam roll placed vertically under the full length of your back Have your head and neck supported on the foam roll Bend your knees with your feet on the floor

Foam Roll - Stretch position:


Start with your arms at your side and then raise one, then both of them overhead Hold for 20-30 seconds

73

Foam Rolls - Prone

Have Fun!

Shoulder Rehabilitation
Anatomy Review Muscle Testing Review Common Problems Treatment

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Anatomy Review - Shoulder


Pectoralis minor
Common TOS provoker Tension rolls glenohumeral joint anterior Tightness common with forward rolled posture

Anatomy Review - Shoulder


Latissimus dorsi
Inhibited by: thoracic fixations & C1 Major posterior postural stabilizer Readily inhibited by foot dysfunction Weakness allows anterior glenohumeral displacement

Anatomy Review - Shoulder


Infraspinatus & Teres minor
Inhibited by fixation in lower cervical spine

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Anatomy Review - Shoulder


Deltoid
Anterior Middle Posterior

Fixation mid to lower cervicals will inhibit

Anatomy Review - Shoulder


Rhomboids
Inhibited by both lower cervical & thoracic fixations Inhibited by excessive flexor tone Under used by most patients

Anatomy Review - Shoulder


Supraspinatus
Inhibited by mid to lower cervical fixations

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Anatomy Review - Shoulder


Subscapularis
Tendon easily entrapped as it passes through the glenohumeral joint Increased wear & tear with advancing age

Evaluation
History Orthopedic, neurological & physical
Remember probing palpation of soft tissue structures to patient tolerance

Radiographic Chiropractic spinal analysis Selective muscle testing

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

77

Tendonitis, Capsulitis & Bursitis


Uneven balance of forces across a joint Impingement of soft tissues
Tendons, bursa & joint capsule Vascular components (TOS) Neurological entrapment

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

Myofascial Pain
Prime Mover - weak

Antagonists hypertonic Synergist - overworked

Myofascial Pain - Triggers


Pressure direct contact by leaning Stretching passively while sleeping or indirectly during activity Use contraction, especially with considerable resistance or posturally

Myofascial Pain - Treatments


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

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Trigger Points
Latissimus Dorsi
Mid-thoracic Posterior scapula Anterior shoulder Entire arm to hand

Subscapularis

Trigger Points

Frozen Shoulder Posterior shoulder Arm Wrist

Teres major

Trigger Points

Similar to latissimus dorsi Deltoid & arm pain

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Trigger Points

Deltoid
Local pain at shoulder

Trigger Points

Coracobrachialis
Similar to deltoid Arm, forearm & wrist

Trigger Points

Biceps brachii
Pain lateral shoulder Pain anterior elbow

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Trigger Points

Supraspinatus
Mimics subdeltoid bursitis Elbow, arm & forearm

Treatment Steps
Pain relief
Ice, modalities (electrical stimulation, ultrasound) Possible start trigger point release work

Passive motion Manipulation when applicable Gentle resistance within non-painful range Gradual increase in range and resistance

Passive Motion
Pendulums or Codmans arm swing

81

Passive Motion
Wall walking

Resistance Exercises
Internal Rotation
Pectoralis major Subscapularis

Resistance Exercises
External Rotation
Teres minor

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Resistance Exercises
Abduction
Supraspinatus Deltoid

Resistance Exercises
Scapular Retraction
Rhomboids Trapezius

Scapular Fixing
Subscapularis

Knee Rehabilitation
Wobble Board Resistance Bands Stretching

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

Assumptions Prior to Treatment


Detailed History of Chief Complaint Full Regional Work-up of the Knee
Standard Orthopedic Testing

What do we know?
Rule out primary pathologies Diagnosis do we treat, co-manage or refer?

Anatomy Review
Quadriceps

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Anatomy Review
Adductors

Anatomy Review
Tensa Fascia Lata

Anatomy Review
Gluteus Medius

85

Anatomy Review
Hamstrings

Anatomy Review
Gastrocnemius

Soleus

Myofascial Pain - Knee


Rectus Femoris

86

Myofascial Pain - Knee


Vastus Intermedialis

Myofascial Pain - Knee


Vastus Lateralis

Myofascial Pain - Knee


Vastus Medialis

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Feet Biomechanics
Pronation causes angular forces Supination causes contralateral stresses Poor proprioception causes abherrent muscle firing during the gait cycle

Ankle Stability & Proprioception


History of repeated ankle sprains

Rocker Board
Renewal of proprioception Progression
Two feet AP motion with control One foot - maintaining control

No looking at the feet!

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Wobble Board
Two feet AP rocking with control Two feet lateral stability One foot four point motion One foot slow circles without touching floor

Trunk Stability & Proprioception


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

Muscular Tension
Hamstrings Quadriceps Group Calf Group (soleus & gastrocnemius) Adductors Abductors Gluteal group

89

Stretching
Hamstrings

Stretching
Calf Group

Gastrocnemius

Soleus

Stretching
Quadriceps femoris

90

Reciprocal Inhibition
Hamstring to Quadriceps (likely) Quadriceps to Hamstrings (less likely) Adductors to Abductors (likely) Abductors to Adductors (less likely)

Testing Reciprocal Inhibition


Test the antagonistic muscles singly Train the patient for test
Positioning Perform a dry run

Quickly test one group Rapidly switch to antagonist

Strengthening
Quadriceps

91

Strengthening
Gluteus medius

Strengthening
Adductors

Adductors & Gluteals

Strengthening
Abductors

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Postural Awareness & Anterior Pelvic Tilt

Low Tech Rehab Post Graduate Programs Mark Hartsuyker, D.C.

McKenzie's Back Extension Exercises

Syndromes- Indicators
Facet syndrome Excessive lumbar lordosis Poor abdominal control/positioning Chronic low back pain with weight bearing Poor standing posture Runners posture

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

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Radiographic Analysis

Georges weightbearing line Sacral base angle Spondylolisthesis

Muscle Testing Facetal Jamming


Patient prone Test the hamstring strength Careful instruction performing a press-up
Keep the hips on the table Use arm strength only Extend to 2/3 to of full extension range Respect painful limit of ROM

Hamstring inhibition present?

Anterior Pelvic Tilt


Engage the patient
Explain diagnosis Explain progression Give demonstration

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

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Exercise Progression - Prone


Patient on a firm, comfortable surface Patient contacts pubic bone Place small firm object under lumbar spine Instruct them to roll pelvic so that pubic bone rolls towards the nose Hold for 3-5 count and relax

One-Third Curl
Patient can perform a good anterior pelvic tilt Cross arms over chest or behind the head Set a pelvic tilt Slowly curl 1/3 towards full sit-up Hold for a slow count of 3-5 Slowly roll back down while maintaining the pelvic tilt throughout

Wall-Tilt
If the patient shows good control during pelvic tilts and 1/3 curls Start in a low squat and perform tilt against the wall Slowly move up the wall, performing a tilt at each level If shoulders start to roll forward then patient to perform exercise at last correct level

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Standing Tilt
If the patient can work their way up the wall to nearly standing One hand low on the anterior pelvic area One hand in the lumbar lordosis Perform a pelvic tilt without shoulders rolling forward Imagine a sky hook lifting head towards the ceiling All postural changes occur from the pelvis up Goldielocks Principle for degree of tilt

Integration into ADLs


If good control with standing Patient can assume posture
Walking Running Sitting

Visual cues in regular activities as triggers

McKenzie Method
Comprehensive assessment Positions that centralize pain Committed to either flexion or extension Performance independently at home Neutral spine and dynamic muscle support of their spine

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Observation/Assessment
Patient's response to repeated, near end-range spinal motions Patients are diagnosed with either postural, dysfunction or derangement Derangement = alteration in the structure and mechanics of the intervertebral disc

Prime Patient for Extension


65-70% require extension* Maintaining extension during all ADLs Non-weight bearing extension Standing extension Repeated throughout the day

* Stats put forth by McKenzie practitioners

Low Tech Rehab


Arm Wrist Hand

Low Tech Rehab Post Graduate Programs Mark Hartsuyker, D.C.

97

Introduction
Biomechanics are considered Touch on carpel tunnel syndrome Complete work-up including:
Metabolic Cervical Disc Tumors especially apical lung Orthopedic & Neurological

Anatomy Review
Pronator Quadratus
Approximates ulna & radius Inhibited by injury
Extension of wrist

Origin-insertion STM helpful

Anatomy Review
Flexor digitorium profundus
Hypertonicity leads to medial epicondylitis

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Anatomy Review
Extensor digitorium communus
Hypertonicity leads to lateral epicondylitis Frequent source of myofascial pain syndrome

Anatomy Review
Pronator teres
Consider involvement when pronation causes pain

Anatomy Review
Median nerve

Ulnar nerve

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Myofascial Pain
Latissimus dorsi Pain in the arm, forearm & hand

Myofascial Pain
Scalenes Pain along entire upper extremity to wrist & hand Associated chest pain Post MVA

Myofascial Pain
Extensors Wrist pain Pseudo-carpal tunnel Painful weak grip Frequently associated with lateral epicondylitis

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Myofascial Pain
Finger Flexors Stiff fingers Pseudo-carpal tunnel Frequently associated with medial epicondylitis Wrist & finger pain

Myofascial Pain
Palmaris longus Hand pain Associated with Dupuytrens Contracture

Myofascial Pain
Opponens Pollicis Thumb pain

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Other Sources TPs


Scalenes

Other Sources TPs


Latissimus Dorsi

Carpel Tunnel Syndrome


Is the presentation classic
Frequent burning, tingling, or itching numbness in the palm of the hand and the fingers, especially the thumb and the index and middle fingers Some carpal tunnel sufferers say their fingers feel useless and swollen, even though little or no swelling is apparent

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Carpel Tunnel Syndrome


Not all wrist or hand pain is CTS Causes of pain
TPs of flexor or extensor muscles TPs of latissimus dorsi TPs of the scalenes Median nerve entrapment at the elbow TOS from the pectoralis minor

Carpel Tunnel Syndrome


Screen the patient for true CTS Mixed or multiple diagnosis is possible Each component of pain production must be addressed Trace the entire path of both nerve and referred pain patterning

Treatments - Passive
Spinal manipulation Extremity manipulation Ischemic compression Kinesiotaping Gentle stretching

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Manipulation - Rationale
Spinal: Consider levels of innervations to injured area Primary problem = extremity Reflex arcs will spinal segmental dysfunction Marked reduction in healing time gained

Extremity Manipulation
Is there joint instability?
Yes: may be contraindicated No: proceed as indicated

Lateral & medial radius/ulnar displacement


Analysis: tenderness of origin & insertion of pronator quadratus Spongy springiness upon medial squeeze

Ischemic compression
In belly of muscle palpate for area of:
Taut Tenderness Nodularity Possible fasciculation or involuntary twitch

Steady pressure to patient tolerance Patient takes slow deep breaths Cannot breath through pain, too much

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Kinesiotaping
Provides touch to area of chief complaint Lifts skin to open lymphatic channels Increased mechanoreceptor stimulation

Active Care: Stretching


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

Perform the stretches unilaterally Compare left to right arms


Lighter, at ease, increased sense of energy

Goal: increased compliance

Active Care: Stretching


Three basic stretches:
Extensors Flexors Thenar

Held for ten slow deep breaths Patient to pace themselves Can be done with elbow bent Excellent injury prevention for patients who use their hands a lot

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Forearm - Flexors
Outstretched arm Reach across fingers Gently pull back Can be performed with elbow bent Hold for ten slow deep breaths

Hand Stretch - Thenar


Keep hand in stop position Gently pull the thumb down towards the beltline Hold for ten slow deep breaths

Forearm - Extensors
Outstretched arm Reach across back of knuckles Gently pull back Can be performed with elbow bent Hold for ten slow deep breaths

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Compare Extremities
Kinesthetic feedback How does the stretched side compare to the unstretched side?
Lighter Warmer More at ease

Reinforces value of stretch Now stretch the opposite extremity

Dyna-Flex
Gyroscopic action provides resistance Full circle of strength training Enhanced stability across wrist

Handmaster Plus
Open

Closed

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Wristiciser
Go through all principle diagnosis

Summary
Multifactorial nature of hand, wrist and arm pain CTS may be present yet with other contributors LTR instituted only when: Through understanding of diagnosis has been reached Acute phase has passed

Knee Pain Patient


Problem Centered Orthopedic Tests and Functional Muscle Testing
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Pain Presentation
Bilateral anterior-medial knee pain with left side more troubled then the right Aggravated by squatting, prolonged sitting and extending the leg into extension Feels like the knee is going to lock when the knee is in flexion 3 months prior had a couple of acute episodes during a long inventory inspection, which called for repeated squatting & kneeling, with pain so intense the patient could not arise. Within an hour of aggravation, the knees felt fine

Pain Drawing
Primary pain quality = achy

History - Activity
50 year old male Recreational bicyclist 34X/wk for 45 minutes per session on X-country ski simulator (Nordic-Trak)

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History - Occupational
Occupation warehouse inspection, calling for sitting at a computer, repeated kneeling and squatting and standing on hard concrete floors Medical history unremarkable No trauma to the area of involvement

History - Podiatrist
Pronation corrected many years ago by orthotics

Physical Examination
Visual inspection unremarkable with no edema Q angle normal Knee ROM full & without pain Motion palpation detects a definite eccentric glide of the patella bilaterally as patient extends the knee Pain upon palpation at lateral aspects of knee, left > right

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Q-Angle (Reference)
The Q-angle (or "quadriceps angle) is formed in the frontal plane by two line segments:
from tibial tubercle to the middle of the patella from the middle of the patella to the ASIS

The q-angle in adults is typically 15 degrees. Increases or decreases in the q-angles are associated in cadaver models with increased peak patellofemoral contact pressures (Huberti & Hayes, 1984). Insall, Falvo, & Wise (1976) implicated increased q-angle, along with patella alta, in a prospective study of patellofemoral pain. Increases in q-angle are associated with:
femoral anteversion external tibial torsion laterally displaced tibial tubercle genu valgus

References: Huberti, H.H., & Hayes, W.C. (1984). Patellofemoral contact pressures: The influence of Q-angle and tendofemoral contact. Journal of Bone and Joint Surgery, 66A, 715-724. Insall, J., Falvo, K.A., & Wise, D.W. (1976). Chondromalacia patellae: A prospective study. Journal of Bone and Joint Surgery, 58A, 1-8.

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

Positive

Physical Examination
Marked tenderness of the entire iliotibial band, especially near the distal portion when mild to moderate pressure was applied No obvious muscle atrophy Circumference of thighs was symmetrical

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Physical Examination
Latent trigger point of vastus medialis

Orthopedic Evaluation
Abduction Stress Test (valgus) Indicative of a medial collateral ligament injury

Negative

Orthopedic Evaluation
Adduction Stress (varus)

Lateral collateral ligament damage

Negative

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Orthopedic Evaluation
Apleys Compression Meniscus Injury Negative

Orthopedic Evaluation
Clarkes Sign
Mildly Positive Indicative of patellar chondromalacia

Orthopedic Evaluation
Trendelenburgs Test
Suggestive of insufficiency of the hip abductor system

Mildly positive

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Muscle Testing
+5 bilateral quadriceps

Muscle Testing
Hamstrings +5 bilaterally

Muscle Testing
+4 Hip Adductors bilaterally

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Muscle Testing
+4 gluteus medius bilaterally

Muscle Testing
Poor core stability

Poor Flexibility
Hamstrings Calf musculature

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Chiropractic Findings
Gillets Test Motion Palpation L/S spine Mild extension fixation right ilium Conclusion: not a significant contributor to patients symptoms Possibly compensatory to knee pain

Your clinical impression..?

IDK

Internal Derangement of the Knee

I dont know!

Condromalacia Patella
Functional Muscle Imbalance Myofascial Pain of Vastus Medialis Iliotibial Band Syndrome

Treatment
Soft tissue release of ITB Deep pressure to tolerance for vastus medialis trigger point

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Treatment
Strengthening of:
Adductors Gluteus Medius

Treatment
Core stability strengthening Progressive Swiss Ball routines

Treatment of Trigger Point


Application of slowly increasing, nonpainful pressure over a trigger point until a barrier of tissue resistance is encountered. Contact is then maintained until the tissue barrier releases, and pressure is increased to reach a new barrier to eliminate the trigger point tension and tenderness.
Travell & Simons Myofascial Pain and Dysfunction - 2nd edition

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Treatment
Stretching :
Iliopsoas Calf group Hamstrings

Conclusions
Orthopedic testing is valuable yet has limits In the face of hard orthopedic findings, functional testing may lead to actual conservative therapy applied Multiple diagnosis may exist and all may need to be pursued Use your knowledge to understand

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