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Trigger Point Dry Needling for Lateral Epicondylitis

Today’s guest post is from Ann Wendel on trigger point dry needling and the effect of dry needling for lateral epicondylitis. Dry needling is gaining more popularity and becoming another great option when dealing with trigger points. Ann went through Myopain Seminar’s dry needling certification. I have had the pleasure to get to learn from some of the instructors of the trigger point program, including Katie Adams, and definitely recommend them if this is of interest to you.

Trigger Point Dry Needling

 

 Trigger Point Dry NeedlingDry Needling is a physical therapy modality used in conjunction with other interventions to treat myofascial pain and dysfunction caused by trigger points. Myofascial trigger points (MTrP’s) are defined as hyperirritable nodules located within a taut band of skeletal muscle (Simons et al., 1999). Palpation of a MTrP produces local pain and sensitivity, as well as diffuse and referred pain patterns away from the affected area. Painful MTrP’s activate muscle nociceptors that, upon sustained noxious stimulation, initiate motor and sensory changes in the peripheral and central nervous systems. (Shah et al., 2008).

Trigger point dry needling can be used to achieve one of three objectives. First, trigger point dry needling can confirm a clinic diagnosis by relieving the patient’s pain or symptoms of nerve entrapment. Second, inactivation of a MTrP by needling can rapidly eliminate pain in an acute pain condition. Third, inactivation of the MTrP through needling can relax the taut band for hours or days in order to facilitate other therapeutic approaches such as physical therapy and self stretching (Dommerholt and Gerwin, 2006).

Universal precautions are always followed when utilizing dry needling in patient care. During the procedure, a solid filament needle is inserted into the skin and muscle directly at the myofascial trigger point. The trigger point is penetrated with straight in and out motions of the needle. The needle can be drawn back to the level of the skin and redirected to treat other parts of the trigger point not reached in the first pass (Dommerholt and Gerwin, 2006). During this procedure, it is essential to elicit twitch responses in the muscle. The local twitch response (LTR) is an involuntary spinal reflex contraction of muscle fibers within a taut band during needling. Research shows that biochemical changes occur after a LTR, which correlate with a clinically observed decrease in pain and tenderness after MTrP release by dry needling (Shah and Gilliams, 2008).

Trigger Point Dry Needling for Lateral Epicondylitis

Trigger point dry needling is an effective treatment modality for numerous acute and chronic musculoskeletal issues. One condition that responds favorably to dry needling is lateral epicondylitis. Therapists know that this problem has usually become chronic by the time the patient seeks treatment, and progress is usually frustratingly slow for both the patient and the therapist.

When dry needling is incorporated into the treatment plan, results are often seen after 2 or 3 visits. The entire forearm is easily treated with the patient supine on the treatment table, and multiple TrP’s can be treated in a matter of minutes. After a thorough history and physical exam, the therapist assesses the forearm for taut bands and trigger points. Muscles commonly involved in symptoms of lateral epicondylitis include: triceps, brachioradialis, extensor carpi radialis longus (and sometimes brevis), extensor digitorum, anconeus, and supinator. As always, the therapist should screen the neck and shoulder region for MTrP’s. Muscles that may refer pain to the lateral epicondyle include: supraspinatus, infraspinatus, teres major and scalenes.

The needling treatment is completed when all LTR’s are eliminated or the patient requests to stop the treatment. The needle is discarded in a sharps container and hemostasis is applied to the area to decrease bruising. The therapist provides manual therapy with a local stretch to the taut band, myofascial release and therapeutic stretch. The patient is taught a self stretch for home, and the treatment can be concluded with ice or heat to the area. The patient is instructed to stretch the area throughout the day and apply heat/ice as needed. It is not unusual to have some increased soreness at the needling site that may last for up to 48 hours. After 48 hours, most patients report a significant decrease in pain, increase in range of motion and some return of strength.

In conclusion, trigger point dry needling can be used in conjunction with other interventions to treat myofascial pain. At the current time, each state has made its own ruling with regard to the physical therapist’s ability to utilize dry needling. The therapist would be best served by reading the State Practice Act for the state in which they practice to determine their ability to use this modality. I went through 100 hours of classroom and practical training in dry needling and successfully passed both a written and practical exam to become a Certified Myofascial Trigger Point Therapist through Myopain Seminars. I highly recommend this course and I find dry needling to be a very effective part of my practice.

Mike’s Thoughts

Great article Ann, thanks.  Dry needling is something I have been exploring and integrating into my practice.  I’d love to hear form others about their experiences as well, so please comment below.  What works?  What technique do you use?  What diagnoses respond best?

Here is a video from Youtube for the extensor pollicis brevis.  This technique is more aggressive in nature, utilizing and “in and out” pattern of needling rather than just different needles.  Different groups teach it differently:

Dry NeedlingAnn is a graduate of Myopain Seminars program, which is great, but I also recommend Dr. Ma’s Integrated Dry Needling approach.  They are both different models.  Myopain is based on the trigger point theories of Janet Travell.   Dr. Ma’s Integrative Dry Needling, Orthopedic Approach™ is a contemporary dry needling therapy developed by Dr Yun-tao Ma and based on the works of Dr Janet Travell, Dr Chan Gunn, clinical evidence, evidence-based research and Dr Ma’s own 40 years of clinical and research experience and neuroscience training.

Click the below links for more information:

References

  • Dommerholt, J. and Gerwin, R., Trigger Point Needling Course Manual, The Janet Travell, MD Seminar Series, 2006
  • Shah JP, Gilliams EA. Uncovering the biochemical milieu of myofascial trigger points using in vivo microdialysis: an application of muscle pain concepts to myofascial pain syndrome. J Bodyw Mov Ther. Oct 2008;12(4):371-384
  • Simons, D.G., Travell, J.G., Simons, L., 1999. Myofascial Pain and Dysfunction: The Trigger Point Manual. Williams & Wilkins, Baltimore.

About the Author

Ann Wendel, PT, ATC, CMTPT holds a B.S. in P.E. Studies with a concentration in Athletic Training from the University of Delaware, and a Masters in Physical Therapy from the University of Maryland, Baltimore. She is a Certified Athletic Trainer (ATC) licensed in Virginia, a Licensed Physical Therapist, and a Certified Myofascial Trigger Point Therapist (CMTPT). Ann received her CMTPT through Myopain Seminars and utilizes Trigger Point Dry Needling as a treatment modality for many pathologies, including lateral epicondylitis.

 

Thoracolumbar Fascia – An Area Rich with Activity

Today’s guest post is about the thoracolumbar fascia from Patrick Ward.  I have been reading Patrick’s website for a while now and have always been impressed his content, but he also has the ability to write and communicate in a fashion that fosters thought and learning.  I have been talking with him for months about sending me a guest post, so I am happy to finally have one, thanks Patrick!

Thoracolumbar fascia: An area rich with activity 

The thoracolumbar fascia can be thought of as a transitional area between the lower extremity and the upper extremity where forces are transferred in athletic and sporting movement.  For this reason, the thoracolumbar fascia plays an integral role in the movement system of the body as it connects many joint systems – hips, pelvis, lumbar spine, and thoracic spine.   Also, considering that the latissimus dorsi has attachments onto the thoracolumbar fascia and inserts onto the lesser tubercle of the humerus, the glenohumeral joint can also be thought of as ‘connected’ with the thoracolumbar fascia.  Additionally, the cervical fascia and the thoracolumbar fascia are continuous, so this fascial structures effect can be seen into the cervical and potentially even the cranial regions.

For this reason, the thoracolumbar fascia can be an important area for treatment both in instances of injury/pathology or when developing a recovery/regeneration treatment protocol for certain athletes.

 

Three layers of Thoracolumbar Fascia

Thoracolumbar FasciaThe thoracolumbar fascia can be thought of as having three layers which help to separate the muscles in this region into compartments:

  • Anterior layer – Attaching to the anterior aspect of the lumbar transverse processes and the anterior surface of the quadratus lumborum.
  • Middle layer – Attaching to the medial tip of the transverse processes and giving rise to the transverse abdominus
  • Posterior layer – Covering all of the muscles from the lumbosacral region through the thoracic region as far up as the splenii attachments.  Additionally, this posterior layer attaches to both the erector spinae and gluteus maximus aponeurosis.  It is in this posterior layer that the gluteus maximus and contralateral latissimus dorsi attach with each other and coordinate together to allow for pendulum like movements between the upper and lower extremity that make walking and running possible.

 

Together, the muscles that connect into the three layers of the thoracolumbar fascia help to provide both a stabilizing and biomechanical role for the body.  Additionally, the vast amount of mechanoreceptors in this region hint to the importance of the thoracolumbar fascia’s sensory role, making it a potentially rich target for hands on therapy.

Photo from Wikipedia

 

A Stabilizing Role 

The transverse abdominus, internal oblique, and quadratus lumborum all invest themselves into portions of the thoracolumbar fascia.  According to Neumann (2010), the transverse abdominus provides anticipatory/feed-forward stabilization of the lumbo-pelvic region via a tensioning of the thoracolumbar fascia and an increase in intrabdominal pressure.  The connection that the thoracolumbar fascia has with the posterior ligaments of the lumbar spine allows it to assist in supporting the vertebral column when it is flexed by developing fascial tension that helps control the abdominal wall (Gracovetsky, 1981) and it may also provide some sensory function to the body aid in both postural and protective reflex activity (Yahia, et al., 1992).

The biomechanical role of the thoracolumbar fascia is generally understood by individuals in the strength and conditioning and rehabilitation professions.  Exercise programs or “core training” programs are typically designed to elicit some sort of stabilization activity to the muscles in this region.  However, insight into the myofibroblasts and mechanoreceptors of the thoracolumbar fascia may require us to look a bit deeper if we wish to make larger changes to the function of the human body.

 

Myofibroblasts

Myofibroblasts are cells that have a sort of dual function, being part fibroblast and part smooth muscle.  It is because of these smooth muscle properties that the myofibroblasts can contract on their own – like other smooth muscles cells – placing them under the control of the autonomic nervous system and allowing the autonomic nervous system to potentially regulate fascial pre-tension independently of muscular tone.  Thus, the fascial system is an adapting organ which almost has a “life of its own.” 

Schleip and colleagues (2006) showed that the lumbar fascia, via its myofibroblasts, has the ability to contract in situations of either chronic tissue contractures, such as tissue remodeling, or during more smooth muscle-like contractions, which may help to influence low-back stability.  Furthermore, Yahia et al. (1993) showed that the thoracolumbar fascia had the ability to spontaneously contract when the tissue was stretched and held at a constant length repeatedly, causing the fascia to slowly begin to increase resistance.  This information could be potentially beneficial in understanding pathologies where increased myofascial stiffness is present.  However, influencing the system to make a change in this stiffness is a more difficult question.

 

Does it Come Back to Breathing?

Given the smooth muscle properties and the control that the autonomic nervous system may have over the fascial network, perhaps a potential window into effectively dealing with increased myofascial tone can circle around to breathing.

Respiratory function is on aspect of the autonomic nervous system that we actually have direct control over.  We can change our breathing and help to elicit a parasympathetic response to allow for greater relaxation and potentially less overall tissue tone/tension, hopefully leading to more of a comfortable state of being a decreased threat perception.  Additionally, the role of the diaphragm in stabilizing the lumbar region cannot be overlooked and the fact that it shares a fascial connection with the quadratus lumborum (as well as the psoas major) and the transverse abdominus fibers invest themselves into part of the diaphragm means that the diaphragm is in a potentially prime position to have an influence over the thoracolumbar fascia, since both of these muscles invest into layers of that fascial structure.

 

Manual Therapy of the Thoracolumbar Fascia

The thoracolumbar fascia is richly innervated with mechanoreceptors providing it with a strong sensory role and making it a target for manual therapy.

There are many ways to address the body with manual/touch therapy.  The idea of treating “fascia” has been a hot topic as of late and oftentimes therapists are doing similar things however explaining them in different ways, leading to large semantics debates.  With regard to treating fascia I believe that it is important to not leave out the nervous system, as the goal of any manual hands on treatment is to somehow effect the brain to create an environment that is ripe for healing – one which decreases overall threat perception, decreases fear avoidance, and opens a window for the individual to perform some sort of non-painful movement that increases confidence, and create relaxation (again, helping to achieve a parasympathetic response).

Several types of receptors have been found in connective tissue (not just the thoracolumbar fascia) such as pacini and paciniform corpuscles, ruffini organs, interstitial receptors, and golgi receptors.  Different receptors are responsive to different sorts of techniques and forms of therapy.  For example, pacini receptors are responsive to pressure changes and vibrations, while ruffini receptors are responsive to sustained pressure and tangential forces such as a lateral stretch.

 

Practical Applications

The thoracolumbar fascia plays an important role in human movement as it not only serves as an attachment site for numerous muscles in the lumbar, thoracic, and sacral regions, but also is an important area of transition between the upper and lower extremities where forces are transferred to allow for coordinated function.

Understanding the implications that the thoracolumbar fascia has over the body will help therapists to develop both exercise programs and manual therapy/hands on treatment programs for either rehabilitation or recovery (to help increase relaxation in this area between competitions and prevent overuse or excessive strain which is common in sport).

The smooth muscle properties of the thoracolumbar fascia (and all fascia of the body) indicate a potential role of the autonomic nervous system in regulating fascial tone.  For this reason, understanding the individual athlete and levels of stress as well as their individual stress resistance can be helpful in managing overall fascial tension.  The pH of the body plays an important role in fascial tension, as greater levels of alkalinity create vasoconstriction and increased muscle tone.  The pH of the body can be influenced by increased levels of threat and changes in breathing, which cause alterations in expired CO2.  Thus, breathing, relaxation, and/or meditation, may be potential ways in which the fascial system can be influenced in a training or therapy session.  Managing stress using a variety of recovery modalities in between competitions can be help to keep athletes healthy and performing well.

Finally, the high number of mechanoreceptors found in the thoracolumbar fascia (and in all fascia) indicate that the fascial system provides an important sensory role for the body.  Various manual/hands on therapies can be utilized to influence the sensory system (and the brain) to help decrease tone/tension, improve proprioception and awareness to the area being treated, decrease threat perception, increase relaxation, and provide a window into the parasympathetic nervous system which can potentially create an optimal environment for healing.

Taking all of this into consideration, when assessing an athlete it is important to look at the entire body and keep in mind that the thoracolumbar fascia shares a connection with many structures and its influence can be seen as far up as the cervical region and into the extremities.  With that in mind the thoracolumbar fascia may be a potential area for therapy when attempting to influence other parts of the body.

 

About the Author

Patrick WardPatrick Ward, MS, CSCS, LMT is a certified strength and conditioning specialist and licensed massage therapist.  He owns Optimum Sports Performance (www.optimumsportsperformance.com), a sports conditioning and soft tissue therapy company which provides training, treatment, and consulting to professional, amateur, and high school athletes.  He writes excellent articles on his website OptimumSportsPerformance.com.

 

References

  • Chaitow L, Delany J. Clinical Application of Neuromuscular Techniques – Volume 2: The Lower Body. Churchill Livingstone. Philadelphia, PA. 2002.
  • Benjamin M.  The fascia of the limbs and back – a review. Journal of Anatomy 2009; 214: 1-18.
  • Neumann D. Kinesiology of the hip: A focus on muscular actions. J Ortho Spors Phys Thera 2010; 40(2): 82-94.
  • Schleip R, Klinger W, Lehmann-Horn F. Fascia is able to contract in a smooth muscle-like manner and therby influence musculoskeletal mechanics. Proceedings of the 5th World Congress of Biomechanics, Munich, Germany. 2006. 51-54.
  • Hammer WI. Functional Soft-Tissue Examination and Treatment by Manual Methods. Jones and Bartlett Publishers. Sudbury, MA.  2007.
  • Schleip R. Fascial Plasticity: A new neurobiological explanation part 1. Journal of Bodywork and Movement Therapies 2003; 7(1): 11-19.
  • Schleip R. Fascial Plasticity: A new neurobiological explanation part 2. Journal of Bodywork and Movement Therapies 2003; 7(2): 104-116.
  • Yahia L, et al. Sensory  innervation of human thoracolumbar fascia: An immunohistochemical study. Acta Orthop Scand 1992; 63(2): 195-197.
  • Hoheisel U, et al. Nociceptive input from the rat thoracolumbar fascia to lumbar dorsal horn neurones. Euro J Pain 2011; 15: 810-815.

Fascial Manipulation

Today’s guest post is written by Larry Steinbeck, PT.  Larry and I have been talking about Stecco and his Fascial Manipulation book for some time now.  I have both books and must say they are fascinating.  It is a great way to look at the body and to combine the thought process of the kinetic chain and manual therapy.  For those familiar with Anatomy Trains, this is pretty similar.  I find that Anatomy Trains is a bit more geared to the clinical application side, while these books are geared more towards deeper understanding of fascia.  If you have read and enjoyed Anatomy Trains, this is the recommended next book for you.

imageA month ago I had the opportunity to participate in a course presented by the Fascial Manipulation Association in Italy. They present coursework based on the studies and research of Luigi Stecco, PT. This was the first time that the full course was presented in English. Over the past several years this group has presented twice at the the Fascia Research Congress, 2007 in Boston and 2009 in Amsterdam. They have published on fascial research, histology and treatment with 35 indexed articles. I stumbled on their research while continuing my studies on trigger points and myofascial sources of pain. 6 months or so ago I contacted Mike to see if he had read any of Fascial Manipulation. The book describes a unique biomechanical model for movement assessment and treatment of dysfunction.

The Myofascial Unit

imageTheir theoretical concepts have moved away from a strictly muscle insertion and origin viewpoint where a muscle moves a bone/joint, towards a function of a myofascial unit. A myofascial unit is described as group of motor units that activate mono and biarticular fibers that can move a body segment in a specific direction. This includes the joint moved, the nerves and circulatory system and the fascia that connect it all. They look at fascia as more than just a containment vessel, but looking at past and present research, fascia has a role in movement perception and force transmission.

As an example, they cite studies that show that up to 40% of force generated by a muscle contraction is not directed toward the origin and insertion of the muscle, but rather is transmitted to agonistic and antagonistic muscles through endo-, epi- and perimysium. It has been speculated that this force transmission coordinates motor function by stimulation of muscle spindles. Stecco has postulated that the force transmission through the fascia has centers of coordination, where vector forces converge in a given movement pattern. Through his practice and study he noted that many of these centers have commonality with myofascial trigger points as described by Travell, as well as, correlation to acupuncture points.

Fascial Manipulation

clip_image004This method presents an evidence based framework for symptoms associated with myofascial pain, as well as, developing an assessment based on myofascial continuity and centers of coordination.

The assessment and treatment are quite thorough and logically based, and are quite unique. The past several years we have read in PT literature about “regional interdependence”. This model takes that concept to the next level. Movement is looked at locally as well as globally with each assessment. They have demonstrated in their studies the fascial continuity between upper limbs, trunk and lower limbs in a way unique to them. Whether it was their original intent or not, I see how other concept/model can be explained even deeper through the eyes of fascial manipulation biomechanical model-this includes my experience with studying Travell, Elvey/Butler, Lewit/Janda, Mulligan and Knott/Voss. The concepts may take a while to understand and conceptualize. It is definitely worth a look at their texts, articles or even one of their courses. As for me, I am looking forward to be heading back to Italy in September for the second of three courses in the series.

Case Studies

I would like to present 2 recent cases that hopefully will give a more practical representation of the theories presented by Stecco and the Fascial Manipulation Association.

The Fascial Manipulation Association places a great deal of emphasis on history taking. This will include present site of pain, any other present pain (things that I normally would brush off like a patient who comes to the clinic with a diagnosis of cervical arthritis, but also notes knee pain on their intake form). History taking also ask about historical injury/pain-pain that may not be at present, but may have occurred in the past and may have not healed in a normal physiologic time frame,( i.e. a sprained ankle “took months to get over”). There is interest in movements that cause the present pain. History will be taking on past surgeries-anywhere, past fractures, visceral problems, and any parasthesias. (A headache might be considered a parasthesia.) They use this history to develop a hypothesis for segments/myofascial units that might be involved and to establish movement assessment that needs to be undertaken. Below are two recent cases in our clinic that were previously treated in other clinics with no resolution of symptoms.

Case Study 1 – Hip Causing Neck Pain

imageFemale, age in the mid 40’s with 6 month duration right sided cervical pain.  She had received 7 visits over 4 weeks of PT consisting of moist heat, electrical stimulations, cervical, and thoracic manipulations. Symptoms overall had not changed. Primary complained of pain while talking on the phone and turning head to look out rear window in the car. Limitation with cervical sidebend and rotation to the right, but some symptoms to the left as well. No other present pain reported at this time. She had a history of L hip “bursitis” that persisted for 6 months prior to resolution.  Prior treatment had included 2 injections and 6 PT visits. No other history reported.

Fascial manipulation in this case would be directed to look at 2 segments – cervical and hip. Assessment will be made through all planes in both segments. In this case there was a limitation in strength and mobility of the left hip abductors only. The assessment leads one to believe that there is consistent limitation in mobility, either strength or range of movement, in the frontal plane. Based on this finding, treatment would be directed to the myofascial units involved in hip abduction and cervical side bending to the right.  The theory would be that the older injury can quite possibly cause compensation in other areas of the fascia system, and that these compensations may lead to pain/dysfunction. For this reason, the hip was addressed first. Treatment to the hip myofascial units for abduction, resulted in 75% decrease in pain during right cervical sidebend.

Treatment was next direct to the cervical segment for sidebend right. This resulted in 90% decrease in pain with right sidebend.  One week later symptoms were still 75% improved. Each visit a new assessment was made to determine segment and the unit to be treated. Visits were planned for 1 week apart. After 3 visits there was a 95% improvement. Limitation persisted with”tightness” for looking out the car rear window, but no pain with activities.

Case Study 2 – Ankle Cramps and Back Pain

72 year old female with 3 year history of bilateral leg pain,”sciatica”, with a diagnosis of lumbar degenerative disc disease and spinal stenosis. She had been treated medically with NSAIDs, and an epidural injection, as well as traction and HVLA manipulation from a local chiropractor. Primary complaints pain worse at night, “cramps in both my calves.” Also has pain in central lumbar/sacral junction, and in right buttock. Pain is reported as intermittent, worse with activity, primarily with ascending stairs. No other concomitant pain noted. No history of surgeries or fractures.

Based on movements that patient reported as painful and the body areas reported as painful, hypothesis was made to look individually at the lumbar spine, pelvis and both ankles (lower leg). Movement assessment was made for three planes of movement in each segment. Calf pain and low back pain were reproduced with movement test for the posterior myofascial units of the calves.  Low back pain was reproduced with the test for posterior myofascial units. These movements were on the same plane, so treatment was directed to the posterior components. The patient thought that she had the “cramps” in both her calves “years” before she ever had any low back pain.

Treatment was directed to the calves first. Movement assessment following the treatment to the claves resulted in no symptoms present in the lumbar region or pelvis and no pain with the movement reassessment.  The patient was given a home program. At the one week follow up visit, she reported no cramps since initial visit, but still had 1/10 low back pain. No change in ability to ascend stairs without increasing low back pain. Reassessment demonstrated continued problem in the post myofascial unit in the lumbar region, but also in the anterior hip myofascial unit. Treatment was directed toward the posterior lumbar and anterior hip components (the same planes of movement). No symptoms in lumbar region following treatment.

During the follow up one week later, no pain in lumbar region with general activity was noted, no further occurrence of night cramps, but still has pain with ascending stairs. Reassessment revealed limitation in ant hip myofascial unit. Treatment directed here along with progression of home exercises. One week later, no symptoms reported with ascending stairs, no low back pain with general activity, and no night cramps.

With this patient’s history and diagnosis, I would have previously most likely considered traction and unweighted gait training, lumbar “stabilization” program, and maybe another attempt at HVLA manipulation or graded joint mobilization.

More Information

This method provided another means to assess dysfunction through a logical, well thought out, and reproducible method. If this method piques your interest, I would recommend reading both of Luigi Stecco’s books, Fascial Manipulation for Musculoskeletal Pain and Myofascial Manipulation: Practical Part,

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About the Author: Lawrence (Larry) Steinbeck, PT is a physical therapist at the Atlanta Falcons Physical Therapy Center in Jasper, GA.

The McKenzie Method – Part 2 – Syndrome Classification and Treatment

In part 1 of this series, we discussed the misconceptions of the McKenzie Method.  Part 2 of the this guest post series by Christie Downing will review the three main mechanical syndromes and focus on treatment advice and some words of wisdom based on Christie’s experience.  Be sure to go back to Part 1 to learn about the basics of Mechanical Diagnosis and Therapy (MDT) if you haven’t read it already.

Syndrome Classification in MDT

There are three main syndromes in MDT – Derangement, dysfunction, and posture.  Each one will be discussed.

Derangement Syndrome

imageSimply put, this is a disruption in the normal articulation of a joint. There are several characteristics that make this syndrome unique including: it can be rapidly reversible, it can be acute or chronic, it can produce distal or local pain, there is loss of movement, it may display a “directional preference” and is the only syndrome to demonstrate “centralization” of symptoms…the hallmark of the disorder.

Possible mechanism: Tissue obstructing movement (i.e., disc protrusion)

Analogy for the patient: A pencil stuck in the door jam…it won’t open or close all the way until you wiggle the door around and get the pencil out of the way.

Dysfunction Syndrome

imageIt exists as both an articular or contractile tissue dysfunction. I will focus on articular because it is the easiest to understand. For those somewhat familiar with MDT, adherent nerve root is also a type of dysfunction, but I will not focus on this today. Basically, dysfunction is shorted and adapted tissues that when stretched or loaded, produce pain. There are several characteristics that can help one identify a dysfunction: it is always chronic, it only produces local pain (except adherent nerve root), it is consistent (the same activity always produces pain), there is loss of movement, it is not rapidly reversible and pain is always intermittent.

Possible Mechanism: restricted tissues that when stretched/loaded produce pain (i.e., a knee flexion contracture)

Analogy for the patient: someone who has been immobilized in a cast. The joint is stiff and each time it is stretched, it produces pain.

Posture Syndrome

imageIn this syndrome, it is faulty postures and positions that place undue mechanical strain on otherwise normal tissue. It’s actually somewhat rare to see this patient in the clinic. Often times, they figure out on their own what needs to be done, namely, posture correction. However, anecdotally, patients with this syndrome are typically teenagers who sit in a slumped position. Often times, a worried parent accompanies the patient to therapy, concerned that a more troublesome diagnosis exists. However, in these situations, the patient is pain free upon activity and only experiences the pain with prolonged sitting or standing with slouched posture. Movement is full and pain free. Education is very important, first, to reduce stress and ease worry; second, to educate about behavioral modification required.

Possible mechanism: deformation of mechanoreceptors with prolonged postures and/or temporary ischemia to joint capsules, ligaments and other soft tissues.

Analogy for the patient: Bend your finger backwards to demonstrate how prolonged stresses can cause pain, but that upon release of the prolonged position, the finger returns to full pain free range of motion.

Treating the derangement syndrome

There are a few pearls I have picked up over the years. Some I’ve learned as part of advanced clinical training and others on personal experience. I’m going to share a few with you that may help you understand how to proceed with the mechanical clinical reasoning.  Since the Derangement Syndrome is so common, we’ll use this syndrome as a model.

When it comes down to it, treatment of dysfunction and posture syndromes are really simple: increase tissue extensibility and educate (respectively for each).  Truth be told, the literature on these two syndromes in not as well versed, but as far as dysfunction syndrome, therapists can take their knowledge from sources outside MDT regarding connective tissue properties in order to effectively treat dysfunction.

Really Listen to Your Patient

Patients often tell me in their subjective history how to best treat them. They can give you clues not just about what syndrome they have, but how to best treat it.

  • Does your patient report that certain movements and positions sometimes hurt and other times do not? This is highly suggestive of derangement syndrome. Patient often need to be reassured that variability is common, as many think they are “crazy” because “one time I bend over and it hurts, and other times I can do it just fine.”
  • Do they tend to feel better with certain activities that suggest a directional preference? Is your patient typically better walking and lying prone and worse with sitting and bending? This highly suggests an extension bias. For the acutely injured patient or those with high fear avoidance belief questionnaires, avoiding repetitious motion testing into flexion, in this case, can result in getting to the answer faster while sparing the relationship with your patient.
  • Do they need a loaded or unloaded force? While we typically start motion testing in standing, for those who tell me that both standing and walking, but so does sitting while lying is quite comfortable, I may defer a lot of unnecessary testing in standing and go right to the supine or prone position after a general ROM baseline assessment.

Not only will you hopefully arise at a provisional diagnosis before the exam has even begun, but summarizing to the patient that you’ve really listened to them is a great way to establish a rapport: “Based on what you’ve told me, your body want to move in this way in order to help it heal…you were very clear about this in what you told me. The examination only confirmed what you told me…”

Use the “Traffic Light” Guide

Simply stated, this is a way to determine if you need to progress your force or consider an alternative.

  • Green light: The more a patient moves in a particular direction results in abolition of pain, lessening of pain, centralizing of peripheral symptoms and/or a rapid mechanical improvement (ie, more range of motion, lessening of neurogenic signs, etc). In this case, continue on with the current regimen. If it’s giving you the desired response, no need to change it.
  • Yellow light: Proceed with caution. This happens when one experiences an equivocal response. An example could be someone who is better during a movement, but does not remain so afterwards. It could also mean someone who is worse during a movement, but does not remain so afterwards. Yellow lights mean a force progression. This could mean more time and repetition, giving extra pressure to a movement (ie, mobilization)….or in some cases less pressure. The novice McKenzie practitioner often fails to recognize that force progression is a continuum of treatment in the same direction, but with variable levels of force. An example could be someone who needs to start with mid range extension in lying before proceeding to end range extension in lying.
  • Red lights: Stop! This one is obvious: motions that increase or produce symptoms that weren’t there before and/or result in peripheralizing symptoms that remain worse even after the maneuver. Red lights require a force alternative, usually a change in direction and/or loading strategy. This could be someone who is worse with repeated extension in lying who need to have a lateral component entered into the equation.

The traffic light guide is a very simple tool to not only guide clinical reasoning, but is also helpful for patients. I use it even in cases of non-mechanical pain. In treating those with a sensitized pain state, it gives them a guide to know how much to do, how much pain is allowable, what should happen afterwards and when they should “back off.” Giving patients permission to evaluate and respond to their own symptoms is highly empowering! It’s also a good chance to educate them about pain…pain does not always mean harm!

Watch for Mechanical Changes

Watch for mechanical changes when the symptomatic complaint does not seem to change. Novice McKenzie practitioners frequently forget this. For someone with painful and restricted motion, a rapid increase in range of motion in the face of an equivocal symptomatic response is still a green light. In my opinion, this is most easily observable in the cervical spine and extremities. Someone who has painful right rotation who, after doing repetitions of retraction and extension, still has painful right rotation that has improved from 20 degrees to 50 is still a green light. Keep going! Be patient!

I hope this series has helped to shed some light on the usefulness of the McKenzie Method and MDT principles.  Are you MDT trained?  What other advice would you offer? 

image_thumb[5]Christie Downing, PT, DPT, Dip. MDT, ICLM  Christie works at Alexian Brothers Rehabilitation Hospital in Elk Grove Village,  IL.  She specialize in musculoskeletal care as well as lymphedema management.  She is a MDT credentialed provider and student in the Diploma level of MDT, focusing primarily in MDT in both spine and extremity problems.

The McKenzie Method – Part 1 – Clearing Misconceptions about MDT

imageThis week features a 2-part guest post discussing the McKenzie Method of Mechanical Diagnosis and Therapy (MDT) by Christie Downing.  Christie is a frequent contributor to this site.  I think this is a great series to “clear the air” about some of the misconceptions regarding MDT, and more importantly, to share some of Christie’s experience and pearls of wisdom.  If you are unfamiliar with MDT, take this as an opportunity to get to learn more about the method.  While Christie discusses that MDT is not all about extension exercises, it does fit into my reverse posturing theory to an extent.

The McKenzie Method – Clearing the Air

What is your gut reaction when you hear “McKenzie Method?” I predict you are either excited or just rolled your eyes. If it is the later, I hope you will give this post due diligence. For it is my observation that those who despise it have not been fully informed about it. It’s one of the most researched physical therapy approaches, yet is fraught with misconceptions. For those interested in the research, the McKenzie Institute International maintains a database of the most relevant research. However, rather than discuss the literature, my objective will be to clear up misconceptions of what the McKenzie method entails and to give some brief “Pearls of Wisdom.” This first post will entail a brief overview of the McKenzie Method, otherwise known as Mechanical Diagnosis and Therapy (or MDT).

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Mechanical Diagnosis and Therapy – MDT

Due to long standing misconceptions, much has been inaccurately portrayed regarding MDT. When describing MDT to another practitioner, it is sometimes easier to first discuss what it is not. MDT is/does not:

  • A series of exercises
  • Only about derangement
  • Only extension
  • Only about the intervetebral disc
  • Only about repeated end range movements
  • Ignore biopsychosocial issues
  • Without the use of manual therapy
  • Only about spinal conditions

I will address each of these issues point by point to more accurately portray what MDT is:

MDT is not a series of exercises: Although some exercises are common, MDT is an assessment process and problem solving paradigm. One takes clues from the history about the effects of specific loading strategies on one’s symptoms. At the history, the therapist begins to formulate a differential diagnosis. First, is it a problem with a mechanical influence, a medical influence, a biopsychosocial influence or any combination of the above? Second, if mechanical, which of the syndromes are likely at play: derangement, dysfunction, posture or “other?” Then, the examination includes a series of loading strategies to confirm or refute the postulated diagnosis.

imageMDT is not only about derangement: Although found widely, derangement syndrome is not the holy grail of MDT. Muscular or articular restrictions (dysfunctions) and postural syndromes are part of the “main” three mechanical syndromes. However, stenosis, chronic pain state (i.e., centrally/periperhally sensitized pain), SIJ dysfunctions, s/p traumatic states, etc. are all recognized by MDT clinicians.

MDT is not just extension: Although a common treatment recommendation, all planes of movement can be considered in both the assessment and treatment recommendations.

MDT is not just about repeated end range movements: static positioning and mid range movements are all part of the spectrum of force progressions.

MDT is not just about the intervertebral disc: Although it serves as one model of joint derangement, other postulated mechanisms are frequently discussed including: joint inclusions, fat pads, loose bodies, capsular impingements, etc for both the spine and peripheral joints as applicable.

MDT does not ignore biopsychosocial influences: Although a positive mechanical response (such as centralization) can sometimes trump “yellow flag” indicators, fear avoidance behaviors and other biopsychosocial influences are always considered and dealt with by education and graded exposure to movement where necessary.

MDT does not exclude manual therapy: Although we take a “hands off” approach first, mobilization and manipulation are all part of the continuum of force progressions. We focus primarily on education and self directed treatments first in order to reduce dependency and empower the patient to control their symptoms; however, sometimes patients are not successful in reducing their own pain in the initial stages. It is at this time we consider the use of our hands. However, use our hands in order to foster greater success of the patient treating themselves. We put our hands on, only to take them off again.

MDT is not just about the spine: The concepts of assessment and classification can be applied to the peripheral joints as well.

As a brief summary, MDT is a classification system. It seeks to differentiate between mechanical and non-mechanical influences of pain and functional limitation by using mechanical loading strategies and assessing both the patient’s subjective response and any mechanical changes.

The main 3 mechanical syndromes are derangement, dysfunction and postural syndromes.

Although the intervertebral disc serves as one model for mechanical influences of spinal pain, other influences are recognized. MDT focuses on patient education and empowerment in order to promote self directed treatment, reduce fear, and promote function.  In part 2 of this series, we will describe the syndromes in more detail and offer “Pearls of Wisdom.”

imageThanks Christie, great post!  One thing that I wanted to also mention was a book that you can read for more information, Rapidly Reversible Low Back Pain.  The book has been discussed here in the past, is a quick read, and I think is pretty cheap (~$10) on Amazon.  I thought it did a good job talking about MDT, including it’s origin.  My favorite story was the discovery of extension exercises for low back pain, check it out if haven’t already.

Have you heard these misconceptions? Did this post surprise you? What other questions do you have about what MDT is?

imageChristie Downing, PT, DPT, Dip. MDT, ICLM  Christie works at Alexian Brothers Rehabilitation Hospital in Elk Grove Village,  IL.  She specialize in musculoskeletal care as well as lymphedema management.  She is a MDT credentialed provider and student in the Diploma level of MDT, focusing primarily in MDT in both spine and extremity problems.

Photo credit toyourhealth

A Day with Anatomy Trains Author Tom Myers

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A couple of months ago I was lucky enough to spend a morning with Tom Myers, author of the amazing book Anatomy Trains.  Tom came to speak to my staff to review his research and theories on fascia and the anatomy trains concept.  We had an amazing day and learned a lot about Tom’s works.

He has a very unique understanding of how the muscles relate to one another as he has personally dissected many cadavers to specifically asses the fascial system.   One of the many take home messages that I took away that day included:

Muscles are only separate in photos in anatomy books.  In real life they are connected spiraling fascial tissue.

That is a great way of thinking about it.  Muscles are separated for simplicity when we discuss and learn about their function.  However, we really don’t learn the anatomy well when we look at the body from this simple approach.  This is an area that we need further research to better understand, but the next thought we should be focusing on is not just what happens at a joint when muscle contracts, but what happens to the surrounding and connecting muscles and soft tissue.

The other interesting point that stuck out to me, among the many, was Tom’s comment that:

Movement becomes habit, which becomes posture, which becomes structure

That’s a great way of putting the chronic soft tissue dysfunction that we are developing over time do to our poor postures and habits.

IMG_0044But we did more than just talk about fascia and the Anatomy Trains concept, we also practiced some soft tissue techniques.  Considering we have been talking about the pec minor so much the last few months (best pec minor stretch and new pec minor stretch, I wanted to share a techniques from Tom.  This is more of a deep tissue release but it’s all in the positioning.  With the patient supine, get down low next to the table with your forearm actually touching the table.  This will position you so that you force is directed inward but also superiorly up along to the rib cage.  You should then be able to slide your fingers in deep underneath the pec major to palpate and release the pec minor.  Pretty good approach.

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If you haven’t read the Anatomy Trains book, time to get on board and learn how muscles throughout the body interact.  Also, be sure to check out the anatomy trains website and Tom Myers’s own blog for more details.  Here is a quick video on some more info on the anatomy trains concepts:

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Anatomy Trains

Soft Tissue Adhesions

Today’s guest post is a real thought provoking piece on adhesions by Chris Lofquist.  Interesting thoughts Chris, appreciate the contribution to the site and the nice article.

Adhesions

Let me start by saying this is by no means an exhaustive explanation of the pathology of adhesion or scar tissue, but a brief overview. When the phrase scar tissue is mentioned, most people think of external scarring or scars formed from surgery, when this is only a specific type of what could more generally be termed as adhesion formation. Scar tissue or adhesion is most commonly recognized as the fibrous connective tissue that is formed over a damaged area as the body attempts to repair this damaged tissue. The more commonly overlooked sources of adhesion, beyond acute injury, are microtrauma and hypoxia, which will also be discussed.

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The Connective Tissue Healing Process

The healing process in connective tissue has four components, the formation of new blood vessels, the migration and proliferation of fibroblasts, the deposition of extracellular matrix and the maturation and reorganization of fibrous (scar) tissue. This last step, the remodeling process, when left on its own can take as little as 3 days, but typically takes 30 days to 2 years, and in some cases never truly reorganizes in a proper pattern.

Scar tissue or adhesions lead to a variety of symptoms such as:

  • Reduced Range of Motion
  • Muscle Weakness
  • Pain
  • Compensation patterns which cause problems in seemingly unrelated areas
  • If a nerve is entrapped it can cause numbness, burning or tingling

Soft Tissue Dysfunction

Adhesion is one of the most common causes of soft tissue restriction, and the breakdown of adhesion appears to be a very feasible explanation behind how so many soft tissue treatment techniques work. When this adhesion is broken down, normal loading patterns are more easily established. When tissues are loaded in the manner in which they are designed and do not exceed their ability to recover, complete healing is allowed to take place.

Adhesion can form between any two surfaces within the body and can cause a decrease in global and segmental ranges of motion, as well as affect the speed and quality of those motions. These tests are not specific for adhesion, so a full assessment, including palpation to determine if adhesion is present and its specific location is required. This adhesion between two surfaces or within a structure itself can be a result hypoxia, microtrauma, or macrotrauma as mentioned before. Unfortunately we currently do not have reliable technology to run a diagnostic test for the presence of adhesion. This means detection relies on skilled palpation and having a keen eye for biomechanical dysfunction and compensation. Pain can be helpful, but as we all know, pain is a liar.

The Effect of Hypoxia

Hypoxia causes not only cell death, but also fibroblastic proliferation and free radical proliferation. Free radical proliferation then leads to the production of fibrous adhesion. Fibrous adhesion via fibroblastic activity is an often overlooked cause of musculoskeletal dysfunction. The reason this is often overlooked seems to be lack of exposure to the pathology itself. Simply put, a healthcare provider will never find a pathology they do not look for, or they don’t know exists. As a side note, Dr. William Brady has an excellent in depth description of this pathway at his blog.

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Microtrauma induced scar tissue formation occurs in a similar pathway as macrotrauma, however if damage is continually induced in an area, collagen cannot remodel itself in an efficient pattern. With this repetitive damage there is also a risk of the myofibroblast rearing its ugly head in a chronic nature. The myofibroblast is a specialized contractile type of fibroblast. In normal situations, the myofibroblast allows for opposition of the separated areas in a damaged site, the myofibroblast exhibits contractile ability, allowing it to help close down this gap. After this gap has closed the myofibroblasts leave the area. If abnormal stresses are left in place without proper remodeling, the myofibroblast will remain active, inhibiting the normal range of motion in a tissue until these abnormal stresses are resolved. It is important that these abnormal stresses are addressed and soft tissue is permitted to remodel itself in conjunction with the surrounding tissue through manual therapy, stretching and exercises.

References

Special thanks to Dr. William Brady and Dr. Mike Leahy for helping me to understand these pathways and their implications.

  1. Kumar V & Ramzi Cotran. Robbins Basic Pathology 7th ed. Elsevier; pp 69-77.
  2. Falanga V, & Kirsner RS. Low oxygen stimulates proliferation of fibroblasts seeded as single cells. J of Cellular Physiology. 1993 Mar; 154(3):506-10.
  3. Leahy PM, Active Release Techniques: Soft Tissue Management System. 2nd Ed. 2008; pp 8-16.
  4. Hinz, B. The myofibroblast: paradigm for a mechanically active cell. J of Biomechanics 2010 Jan 5;43(1):146-55.
  5. Wipff, P & B Hinz, Myofibroblasts work best under stress. J of Bodywork & Movement Therapies 2009 Apr; 13(2):121-7.

Dr. Lofquist is a chiropractor and manual therapist practicing at Trenton Chiropractic & Rehab in Findlay, Ohio. He graduated with a Bachelor of Science in Athletic Training from Heidelberg University in Tiffin, OH and graduated from Logan University in St. Louis, MO with his Master of Science in Sport Science and Exercise Rehabilitation and his Doctorate in Chiropractic. He is a certified athletic trainer and is a consultant for several area collegiate athletic training departments.

Subscapularis Release for Loss of External Rotation

image We have a great guest post today from my friend Trevor Winnegge.  Trevor wrote a nice article last year on complications following distal radius fractures that ranked as my number 1 guest post in 2009!  This time, he presents the results of really nice case series on restoring external rotation ROM using subscapularis release massage techniques.  Great idea and some common manual techniques that I use as well with all of my patients.  Thanks Trevor!

The Role of Soft Tissue Mobilization to Subscapularis to Improve External Rotation in a Type II SLAP Repair-A Case Series

Our clinic is a smaller clinic and doesn’t have the time or resources for a full research study but we did have the opportunity to perform a very small pilot study/case series. I decided to contribute this information because I think it is an underutilized technique and is valuable in assisting our post operative shoulder patients.

We looked at the role that subscapularis has on limiting external rotation (ER) in a post operative shoulder patient. Given that subscapularis is an internal rotator and also assists with some adduction, it is stretched with abduction and ER of the shoulder[1]. Many shoulder surgeries place the patient in a sling in the internally rotated position to some degree. Standard Type II SLAP repair protocols limit the passive range of motion (PROM) into ER to anywhere from 0-30 degrees for the first four weeks, limiting the ability of the subscapularis to stretch[2]. Therefore, we felt if we could perform soft tissue mobilization to the subscapularis in the initial post operative period while range of motion is limited, then they would be less stiff once they were allowed to progress into ER. To my knowledge there has been only one study to date looking at the role of soft tissue mobilization to subscapularis on improving ER and that was published in JOSPT in December of 2003[3]. In that study, conducted by Godges et al, they excluded any patient that was in the immediate four week post operative healing phase. We felt that this immediate healing phase is when we can be most successful at preventing excessive subscapularis tightness by performing soft tissue mobilization, thereby improving ER ROM once they are allowed to progress past 30 degrees of ER.

Research Design

We took four patients (two males, two females) between the ages of 17 and 26 who had undergone primary Type II SLAP repair and randomly assigned them into two groups. The first group received standard ROM treatment for all motions and had ER ranged only to 30 degrees per the doctors protocol. The second group had the same exact treatment, however also received five minutes of subscapularis soft tissue mobilization[4]. Soft tissue mobilization was performed while the patient was in sidelying for the first one or two treatment sessions until the patient had enough abduction ROM to allow for good access to subscapularis in a supine position. The technique was using thumb or fingertips to hook inside the lateral border of the scapula and dig deep down between the scapula and ribs. A combination of deep pressure and soft tissue mobilization were performed for a total of five minutes. Every patient in each group was seen at the one week post operative timeframe and was seen twice a week for the next three weeks.

Video Demonstration

I do have two videos of the soft tissue techniques. The first is for the immediate post op patient while patient is in sidelying. The second video is while the patient is in supine. This video also incorporates the soft tissue technique with some elevation ROM.

Results

The results were as we had expected. The group that received the soft tissue mobilization had about twenty five more degrees of ER ROM (measured with goniometer in 45 degrees of abduction while supine) at the four week mark than did the group that did not receive the treatment.

Control Group-ER ROM

 1 week post op4 weeks post op
Subject 110 degrees40 degrees
Subject 215 degrees38 degrees

Intervention Group- ER ROM

 1 week post op4 weeks post op
Subject 112 degrees64 degrees
Subject 215 degrees63 degrees

I understand that these results should be taken with a grain of salt, as strong conclusions can not be made with such a small sample size. As I previously stated we simply do not have the time or resources in our clinic to perform a large scale study. It is my hope that someone reading this who works in a much larger center can take this information and use it as a stepping stone to a full blown research study. Clinically, I use these techniques on a daily basis and achieve great results. I truly feel the results of a larger study would be quite similar. What was also interesting is that shoulder elevation was also improved in the soft tissue mobilization group. This is likely due to the close proximity of the latissimus dorsi to the subscapularis, it is hard to truly isolate the subscapularis. We focused on SLAP repairs, but Bankart repairs could also benefit from this as well as rotator cuff repair patients who require sling use for extended amounts of time, provided a subscapularis repair wasn’t performed. I think the possibilities for research in this area are endless and I would love to see it published as a large research study. Please give me any feedback if you currently use this technique, or tried it after reading this. It really works well.

clip_image001Trevor has been practicing PT for over 9 years. He graduated from Northeastern University with a bachelors in PT and a master of science degree. He also graduated from Temple University with a Doctor of physical therapy degree. He is a board certified specialist in orthopedics and also a certified strength and conditioning specialist. He is adjunct faculty at Northeastern University, teaching courses in orthopedics and differential diagnosis. He is currently the Clinical Coordinator of Rehabilitation at Sturdy Orthopedics and Sports Medicine Associates in Attleboro MA.


[1] Palastanga, et al. Anatomy and Human Movement. Boston MA:Butterworth Heineman; 1993.

[2] Wilk K, Reinold M, Andrews J. Postoperative Treatment Principles in the Throwing Athlete. Sports Medicine and Arthroscopy Review. 2001;9:69-95.

[3] Godges et al. The Immediate Effects of Soft Tissue Mobilization with Proprioceptive neuromuscular Facilitation on Glenohumeral External rotation and Overhead reach. JOSPT. 2003; 12: 713-718.

[4] Travell J, Simons D. Myofascial Pain and Dysfunction: The Trigger Point Manual. Baltimore MD:Williams and Wilkins; 1983.