Cce5 LTR PPT

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
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

Is there a loss of strength? Double strapping across arch & ankle Retest strength Proprioception is aberrant
No loss of strength? Biomechanics alone a factor Consider orthotics on other factors
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With strapping no change in quadriceps? Consider joint dysfunction along kinetic chain:
Ankle Knee Hip SI joint
Aberrant Heel Strike Effects

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

Chronic recurrent SI joint instability Compensatory muscle tightening
Gait Cycle Revisited

Heel Strike Stance Phase Toe-Off Swing
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Proprioceptors
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
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
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
Semispinalis Capitis
Splenius Capitis
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Upper Trapezius
Temporalis
Spindle Cells
Rich endowment of spindle cells in:
Neck flexors Sub-occipital triangle Longus colli
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Reciprocal Inhibition Cascade

Injury, posture, VSC 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
Myofascial Pain Patterns

Levator Scapula
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Splenius Capitus

SCMs
Suboccipitals
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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
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

Weakened/Inhibited Muscles:
Posterior & anterior tibialis Gluteus maximus Gluteus medius Transverse abdominus Internal oblique Multifidus
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Common Joint Dysfunctions:
Subtalar joint Proximal tibio-fibular joint Tibio-femoral joint Iliofemoral joint Sacroiliac joint Lumbar facet joints

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

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

Accurate positioning of the joints
Insure maximum lengthening of origin & insertion
Adequately stabilization of one end Smooth motion during stretch, especially at end range 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
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Hip Adductors
Move the non-testing leg approximately 15 degrees into abduction Cradle the leg as in assessment of the hamstrings Slowly abduct the leg, palpating for when pelvic movement sets in
Hip Adductors
Leg should be abduct to 45 degrees without pelvic movement Flexing the knee eliminates the hamstrings as a source of restriction
Assessment - Piriformis
Flex the leg to no more than 60 degrees Provide compression along the axis of the femur Adduct the thigh Internally rotate the femur Feel for smooth movement with no restriction
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Palpation - Piriformis
Mentally draw a line between the PSIS and the greater trochanter The second line is from the ischial tuberosity to the ASIS
Palpation - Piriformis
Palpation where these two lines cross Palpation is conducted with one hand reinforcing the other and is very deep
Gastrocnemius & Soleus

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

To eliminate the soleus and isolate the gastrocnemius Flex the knee while maintaining the calcaneal distraction If the ROM increase the gastrocnemius is the tight muscle
Pectoralis Major
Patient supine close to the edge of the examination table Stabilization of the trunk is essential Place the arm in slight external rotation at 120 degrees of abduction Palpate the muscle for tenderness while detecting the length
Upper Trapezius
Patient supine, stand at the head of the table Use your right hand on top of the right shoulder to assess elevation Use the left hand to flex the head fully, followed by lateral flexion Head rotation is to the ipsilateral side. Traction the shoulder girdle inferior
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Levator Scapulae
With the patient supine, stand at the head of the table Flex the head while maintaining downward pressure on the shoulder Head is rotated 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
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Stretch - Iliopsoas
Stretch - Iliopsoas
Stretch - Iliopsoas
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Stretch Iliopsoas (supine)
Stretch - Piriformis
Stretch - Piriformis
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Stretch - Pectoralis group
Stretch - Pectoralis group
Resource
Stretching by Bob Anderson
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Introduction to Swiss Ball & Foam Roll Exercises
Swiss ball offers:

Trunk Strengthening Enhanced Proprioception Mimics Real Activities & Demands FUN!
Ball Diameter User Height

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

Padded floor foam mats No furniture in fall zone Mounting - Hand & eye on the Swiss ball Patient and doctor face each other May require safety belt around mid-section Assistant as spotter
Global Evaluation
Relative function of muscle groups Weakness or hypertonicity Compensatory mechanisms Neurological deficit Synergetic movement Lack of balance
General Indications
Decreased range of motion Decreased strength Decreased balance reactions Decreased coordination Decreased endurance Decreased proprioception
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Patient Population Entry Level

Chronic low back pain (if not in acute phase) Deconditioned Increased pain with 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
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Primitive People & Abs
Misconceptions
Definition < > Toned Abdominal Muscles Raw Strength vs. True Functional Tone
Reminders to Patients
Exercises take concentration Safety zone if they fall Perform exercises slowly (generally) Any exercise can be backed down
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Reminder to Doctor
Doctor - No hard agenda on a given visit Observe Guide and encourage Advance program only when appropriate
Circles & Figures of Eight

Sit on ball 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
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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
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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
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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
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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
74
Anatomy Review - Shoulder

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

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

Infraspinatus & Teres minor
Inhibited by fixation in lower cervical spine
75

Deltoid
Anterior Middle Posterior
Fixation mid to lower cervicals will inhibit

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

Supraspinatus
Inhibited by mid to lower cervical fixations
76

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
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
78
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
79
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
80
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
External Rotation
Teres minor
82
Abduction
Supraspinatus Deltoid
Scapular Retraction
Rhomboids Trapezius
Scapular Fixing
Subscapularis
Knee Rehabilitation
Wobble Board Resistance Bands Stretching
83
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
84
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

Vastus Intermedialis

Vastus Lateralis

Vastus Medialis
87
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!
88
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
92
Postural Awareness & Anterior Pelvic Tilt
McKenzie's Back Extension Exercises
Syndromes- Indicators
Facet syndrome Excessive lumbar lordosis Poor abdominal control/positioning Chronic low back pain with weight bearing Poor standing posture Runners posture
Assessment
Lateral lumbar radiographs Standing postural analysis Muscle testing for facetal jamming
93
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
94
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
95
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
96
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
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
98
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
99
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
100
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
101
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
102

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

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
103
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
104
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
105
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
106
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
107
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
108
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)
109
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
110
Q-Angle (Reference)
The Q-angle (or "quadriceps angle) is formed in the frontal plane by two line segments:
from tibial tubercle to the middle of the patella from the middle of the patella to the ASIS
The q-angle in adults is typically 15 degrees. Increases or decreases in the q-angles are associated in cadaver models with increased peak patellofemoral contact pressures (Huberti & Hayes, 1984). Insall, Falvo, & Wise (1976) implicated increased q-angle, along with patella alta, in a prospective study of patellofemoral pain. Increases in q-angle are associated with:
femoral anteversion external tibial torsion laterally displaced tibial tubercle genu valgus
References: Huberti, H.H., & Hayes, W.C. (1984). Patellofemoral contact pressures: The influence of Q-angle and tendofemoral contact. Journal of Bone and Joint Surgery, 66A, 715-724. Insall, J., Falvo, K.A., & Wise, D.W. (1976). Chondromalacia patellae: A prospective study. Journal of Bone and Joint Surgery, 58A, 1-8.
Orthopedic Evaluation
Thomas Test - indicative of a flexion contracture involving the iliopsoas musculature
Positive
Marked tenderness of the entire iliotibial band, especially near the distal portion when mild to moderate pressure was applied No obvious muscle atrophy Circumference of thighs was symmetrical
111
Latent trigger point of vastus medialis
Abduction Stress Test (valgus) Indicative of a medial collateral ligament injury
Negative
Adduction Stress (varus)
Lateral collateral ligament damage
Negative
112
Apleys Compression Meniscus Injury Negative
Clarkes Sign
Mildly Positive Indicative of patellar chondromalacia
Trendelenburgs Test
Suggestive of insufficiency of the hip abductor system
Mildly positive
113
Muscle Testing
+5 bilateral quadriceps
Muscle Testing
Hamstrings +5 bilaterally
Muscle Testing
+4 Hip Adductors bilaterally
114
Muscle Testing
+4 gluteus medius bilaterally
Muscle Testing
Poor core stability
Poor Flexibility
Hamstrings Calf musculature
115
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
116
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
117
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
118

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Low Tech Rehabilitation

Basic Protocols for Immediate Use

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

October, 2002 - Logan Clinical Faculty

Posture & Knee

Appropriate Orthopedic, Physical, Neurological & Chiropractic Exams Differential Diagnosis

Special Tools of Assessment

The Terrible Triad

Neurological Basis - Pathways

Neurological Basis - Pathways

Codependency of major CNS systems & environment

Testing - Biomechanical Analysis

When do you start?

Tools of the Trade

Wobble & Rocker Board

Wrist & Hand Devices

Formulate a treatment plan

Reassess at appropriate intervals

Evaluation of Foot Biomechanics

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

Foot Evaluation Why?

Do symptoms increase with weight bearing activity?

Steps for Evaluation

Leg Length Discrepancies

Measurement Pelvic Influence

Leg Length Discrepancies

Mechanism of Heel Strike

Heel Strike Muscle Testing

Heel Strike Muscle Testing

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

Heel Strike Muscle Testing

Aberrant Heel Strike Effects

Loss of anterior stability to the ilium

Gait Cycle Revisited

Proprioception & Postural Muscles

Evaluation of Muscle Function

Exercise or general fitness level

Muscle Testing Why?

Muscle Balance & Function

Vladimir Janda on Joint Dysfunction

Janda on Chronic Pain

Janda on Increased Muscle Tone

Antagonists hypertonic Synergist - overworked

Active Trigger Point

Latent Trigger Point

Muscles Prone to Tightness

Muscles Prone to Weakness

Pressure of palpation used?

What did you feel?

What did the patient experience?

Art of Muscle Testing

Muscle Strength Grading

Tensa Fascia Lata

Oblique & Transverse Abdominals

Teres Minor & Infraspinatus

Rhomboids & Subscapularis

Integrated or Functional Version

Accessory Nerve Cranial XI (spinal portion)

Deep Neck Flexors & SCM

Antagonists or Reciprocal Testing

Testing Reciprocal Inhibition

Quickly test one group Rapidly switch to antagonist